All Adults Can Now Get a COVID-19 Booster. But Should You?

On Nov. 19, Dr. Rochelle Walensky, director of the Centers for Disease Control and Prevention (CDC), supported an advisory committee’s advice and expanded the group of people who can now get COVID-19 booster doses to include all adults over age 18.

But just because you’re now eligible for a booster shot, do you need to run out and get one? Does the booster recommendation mean your original vaccination is no longer protecting you? How urgent is the need to get that booster dose?

The CDC now says that all adults who had received the Pfizer-BioNTech or Moderna vaccine are eligible to get booster at least six months after their second dose. (The agency had already recommended boosters for all adults initially vaccinated with the Johnson&Johnson-Janssen shot.) Previously, the CDC made a distinction between those over age 65 and with underlying health conditions—who the agency said “should” get a booster shot—and those living or working in high risk settings, who “may” get a booster.
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According to a spokesperson for the CDC, the latest expansion for all adults falls into the latter category, so it makes it possible for any adult to get boosted, and leaves the choice up to the individual.

Many people are interpreting that to mean that the urgency to get a booster isn’t as great as the urgency behind the CDC’s original message to get vaccinated, and some people aren’t quite clear about how necessary the booster is. Studies show that the original doses of all three vaccines currently approved or authorized—two doses of the Pfizer-BioNTech or Moderna shots, or one dose of the J&J-Janssen shot—continue to protect people from getting severe disease and needing to be hospitalized. But the agency decided to recommend boosters because there is also growing evidence from countries like Israel, where more of the population has been vaccinated for a longer period of time than in the U.S., that infections among vaccinated people are possible, and that some of those people are sick enough to need hospitalization.

In fact, this question of how urgently boosters are needed was considered carefully by the CDC’s panel of experts, as well as the Food and Drug Administration’s (FDA) advisory committee. Initially, for example, the FDA committee decided to recommend boosters for adults who live or work in settings that put them at higher risk of getting infected, but the CDC panel opted to limit boosters to those at highest risk for severe disease—people over age 65 and those with underlying health conditions. Walensky, however, broadened the booster-eligible group to include those who also work or live in settings where they might be more likely to get exposed to SARS-CoV-2, such as health care facilities, grocery stores, prisons, homeless shelters and schools. The CDC allowed people in this group to choose whether they wanted to get a booster or not but made the option possible for them. The latest guidelines, which recommend boosters for all adults, follow this precedent that Walensky set. Otherwise healthy adults now have the option to get a booster, but they don’t have to, though the CDC encourages it.

In a press briefing on Nov. 22, Walensky said “everyone over 18 years of age is eligible to get boosted. So, if you’re 18 years and older, I encourage you to go get boosted.” But that falls short of recommending that people get boosted, says Dr. Leana Wen, professor of health policy and management at George Washington University. “The issue is whether the booster is essential vs. nice-to-have. Right now the guidance is phrased as the original vaccination provides pretty good protection, and if you want to get a little extra protection, get boosted,” she says. “That is not the case. Seeing [studies] that found protection from the vaccines declines from the high 80% to 90% to 40% after five or six months —that is not nice-to-have. The booster is not like topping up the immune protection; it’s more like game-changing.”

Dr. Anthony Fauci, the Biden Administration’s chief medical advisor on COVID-19, is equally adamant about the necessity of booster doses. He tells TIME that in his recent broadcast interviews, “I came down very strongly that I thought saying ‘should’ vs. ‘may’ has done nothing but confuse people,” he says. “If you really want people to get a booster, just tell them what to do.”

Fauci points to growing data from a number of countries, including the U.S., that support the need for boosters now. That evidence consistently indicates that infections, hospitalizations and deaths are several-fold lower in those a month after receiving a booster dose, compared to those who only received the original vaccine. In fact, early data suggest that a booster dose may lead to an enhanced level of protection in terms of higher levels of virus-fighting antibodies, as well as longer-lasting protection, than the original vaccine doses.

The question of whether boosters are necessary or a luxury comes down to what the goals of vaccination are: if you want to prevent serious disease and reduce hospitalizations, the original vaccination continues to do that pretty well. But if you want to prevent breakthrough infections, boosters are critical. “Right now we are facing more than 90,000 new infections a day [on average], we are entering the winter season, and people are gathering for the holidays,” says Wen. “We know immunity to symptomatic infection wanes substantially at the six-month mark, and immunity even to severe disease wanes too. It’s mind-blowing to me that we cannot just be straightforward with people at this point, and say it is essential to get a booster. The CDC playing around with ‘should’ vs. ‘may’ wording has further confused people.”

Wen points out that the language choice isn’t just semantics. If the CDC had said that all adults should get a booster, then the additional dose would be like the annual flu shot, and doctors would ask their patients about whether they had received a booster or not. By making it optional, patients won’t necessarily be asked or reminded about getting a booster. “That makes a huge difference,” says Wen. Leaving the decision up to individuals could diminish boosters’ protective potential, she adds.

So should you get a booster? Essentially, it couldn’t hurt. With 29 states currently recording new highs in daily COVID-19 cases—coupled with the winter season of colds, flu and other respiratory infections—having the added protection of a booster makes sense. That’s especially true if you’re planning on traveling over the holidays, and mixing with people who aren’t from your household in airports or on planes, trains or buses, and then mingling with family from different households as well. If you have small children who either aren’t yet vaccinated or are only partially inoculated, there’s even more reason to build up a cushion of immunity to surround those who are less protected.

Getting a booster is your choice, but it’s one that could affect family and friends around you. “Many people think the booster is a luxury, as opposed to something they need to get,” says Wen. “That messaging needs to change urgently.”

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