Federal health officials made an important decision last week to recommend that immunocompromised Americans receive an additional dose of the covid-19 vaccine. Unfortunately, they neglected to include a group that is increasingly left behind when it comes to coronavirus guidance: recipients of the Johnson & Johnson vaccine.
These are the same arguments being used to justify why the 13 million people inoculated with the single-dose J&J vaccine aren’t being advised to receive a booster. But this is increasingly unacceptable as infections surge and evidence accumulates that the mRNA vaccines (Pfizer and Moderna) are more effective against covid-19 than adenovirus vector vaccines (J&J and AstraZeneca). At the very least, I believe federal health officials should allow J&J recipients to receive one dose of an mRNA booster, regardless of whether they are immunocompromised.
This is a personal issue to me. I’m one of the 13 million who received the J&J vaccine. I was glad to have gotten the shot; at the time, vaccines were in short supply and initial studies showed that J&J protected well against severe disease.
The situation has changed. Now, there is a surplus of vaccines in the United States, with millions of doses soon to expire. In addition, while the Pfizer and Moderna vaccines provide at least 90 percent protection against symptomatic disease, the J&J provides about 66 percent. Laboratory studies are inconclusive about whether the J&J vaccine is effective against the delta variant; a company-sponsored study found that it is, while an independent one did not.
Just this month, a South African trial showed that the J&J vaccine was 71 percent effective against hospitalization and 96 percent against death. This is encouraging from a global health standpoint; this vaccine, with its ease of storage and one-dose formulation, remains an excellent option for many countries in desperate need of vaccines. However, people fortunate to live where mRNA vaccines are plentiful are within their rights to ask whether they should seek a higher level of protection.
To that point, data are emerging that for people who received an initial adenovirus vector vaccine, a second dose with an mRNA vaccine would enhance immunity. While we don’t have results yet of mixing one dose of J&J with an mRNA vaccine or two doses of J&J, there are studies that examined mixing another adenovirus vector vaccine, AstraZeneca, with Pfizer. Interestingly, the mix-and-match approach elicited a stronger immune response than two doses of the same vaccine. In Germany and Britain, patients have been receiving the mixed regimen without major safety outcomes.
I believe clinicians have enough information to provide J&J recipients guidance as to whether they should get a booster. This isn’t a one-size-fits-all recommendation, but rather an individualized decision based on people’s medical circumstances and exposures. A healthy young person who is working from home and associating only with other vaccinated people could decide that the level of protection afforded by the J&J vaccine is sufficient. On the other hand, a person who is severely immunocompromised is likely not optimally protected by the J&J. The benefit of an additional mRNA dose is substantial, and though the risk is theoretically unknown since this exact combination is still being studied, it’s almost certainly lower than the risk of severe illness were they to contract covid-19.
I’d probably give similar advice to, say, an elderly patient who has serious underlying medical conditions, especially if that person lives with unvaccinated family members or has high-risk exposures. I myself have not sought out the additional dose yet, as I’m generally healthy and have already reduced my risk out of concern for my unvaccinated children, but it’s an option that I’d like to keep open. And when my patients and I do decide to seek a booster, we should be able to do so openly and easily without having to circumvent existing rules.
Two weeks ago, San Francisco’s health department became the first in the country to allow J&J recipients the option for a booster. This was the right call, and federal health officials need to take heed. The Biden administration is expected to announce its new booster policy soon. Even if it is not yet ready to say that the 13 million who received the J&J vaccine should receive another vaccine, they need to at least say that they can. After all, many people who received the J&J vaccine did so because they followed public health advice to get the first vaccine available to them. They shouldn’t be forgotten now.