NSW ministers are eyeing 90 per cent vaccination coverage to lift restrictions on the unjabbed, while masks and house visit limits could remain in Victoria after an 80 per cent double-vaccinated target is reached.
The nation's largest school system has been temporarily stopped from enforcing a vaccine mandate for teachers and other workers by a federal appeals judge just days before it was to take effect.
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The definition of full vaccination against COVID-19 has, since the winter, been somewhat difficult to nail down. It takes one dose of Johnson & Johnson, but two doses of an mRNA vaccine. The CDC counts you as fully vaccinated as soon as you get your last shot, but tells you that you won’t be fully vaccinated until two weeks after that. People have a hard time knowing exactly when it might be safe for them to venture into restaurants, wedding venues, or mask-free offices.
Now, in the age of booster shots and breakthrough cases, the phrase has gotten even murkier. Early this morning, the CDC officially backed booster shots for tens of millions of Americans who are six months past their second Pfizer dose: those over 65, those in long-term-care facilities, and all adults who have an underlying medical condition that puts them at high risk of severe COVID-19 or who are at high risk of getting sick from occupational or institutional exposure to the coronavirus.
During a two-day meeting of the CDC’s Advisory Committee on Immunization Practices this week, the CDC’s Sara Oliver advised the committee that the agency’s definition of fully vaccinated would not change—at least for now. That makes it much less useful as a category: Will some fully vaccinated people be more vaccinated than others? And it leaves open the possibility that the definition could change as more information becomes available: If you’re fully vaccinated now, could you become un-fully vaccinated a few months down the line? These questions go beyond semantics. As more and more Americans are mandated to be “fully vaccinated” in order to work—see here, here, and here, for example—continued clarity on what that category means, and who belongs in it, will be crucial.
Fully vaccinated didn’t originate with the coronavirus. The term has been used for other vaccine series that require multiple shots, such as those for measles, hepatitis B, and HPV. Currently, the CDC considers people to have achieved full vaccination against COVID-19 “2 weeks after their second dose in a 2-dose series, such as the Pfizer or Moderna vaccines, or 2 weeks after a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine.” The agency’s website does include a caveat: For the immunocompromised, being fully vaccinated might not be the same as being fully protected, so a third shot is a good idea.
Part of the problem is that the difference between full vaccination and full protection has been explained less than perfectly to the American public. The truth is, no one is 100 percent protected from the coronavirus after vaccination, regardless of how healthy their immune system is; that’s simply not how vaccines work, especially in the context of a pandemic virus that hasn’t stopped evolving. “You cannot definitively say, until we have finally beat the virus or gotten it to a point where it is no longer killing people, that you are [fully] protected,” says Ruqaiijah Yearby, a health-law expert and co-founder of Saint Louis University’s Institute for Healing Justice and Equity.
Even before booster shots were a mainstream possibility, the concept of full vaccination could lead people to develop what Saskia Popescu, an infectious-disease epidemiologist at George Mason University, calls a “Superman complex.” After getting their J&J shot or their second mRNA dose, some people feel immediately invincible, she told me, as though nothing they do is dangerous to themselves or the people around them. The ongoing discussion about boosters could be an opportunity to undo the Superman complex by adding some nuance, reminding the public that no vaccine is perfect and that we all must work together to get the pandemic under control. Such a rethinking could even go beyond COVID vaccines. “Maybe we need to reimagine how we communicate vaccines in general,” Popescu said.
A sudden injection of nuance could confuse a lot of people, though, and even discourage some from getting their first shot by making the process seem especially convoluted or onerous. For schools, businesses, and other institutions that have implemented vaccine requirements over the past few months, it would likely be a nightmare. If getting two shots doesn’t guarantee that you’re fully vaccinated, then who should be allowed to come to work? Will schools need to interview every teacher who was vaccinated before April about their medical history?
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Now that the CDC has recommended that a select swath of the population gets a third dose to help keep them from getting sick and spreading the virus, institutions that require full vaccination will be faced with some difficult choices. Should they demand that immunocompromised 40-year-olds get a third shot, while asking nothing more of 40-year-olds with healthy immune systems? Should they require proof of booster shots from only those who got the Pfizer vaccine, because they’re the only ones for whom boosters have been authorized so far? Or would it make more sense for companies to stick with the definition of fully vaccinated that they’ve been using to this point?
Seema Mohapatra, a visiting law professor at Southern Methodist University, told me that setting up different rules for different people probably would not create legal liabilities for the mandating party, but it could lead to “practical, administrative problems.” Restaurants and theaters, for example, have no way of verifying their patrons’ health status, so they can’t know who is in a booster-eligible category. HR departments would be hard-pressed to track which vaccine Carol from accounting received, how long it’s been since her last dose, and how that lines up with her 65th birthday.
There are also ethical problems to consider: Even if it’s legal, is it really fair to ask essential workers and immunocompromised people to get more doses than others in order to make a living, or even just to go out to eat? Given that plenty of underserved communities still have trouble accessing the shots, asking even more of the most vulnerable among us—without accompanying policies to bring them shots where they live and work, guarantee them paid time off, and offer them hazard pay—would be hard to justify.
The problem isn’t just with updates that affect different people differently, but also with constant, complicated shifts in policy, according to Jason Schwartz, a vaccine-policy expert at the Yale School of Public Health. If employers and schools update their mandates with every incremental change to the CDC’s recommendations, he told me, their tweaks could backfire and discourage vaccination. It would be better to wait for the CDC to recommend universal boosters, and then update the rules for everyone at the same time.
On the national level, mandates probably won’t change much in the immediate future. Anthony Fauci, the director of the National Institute of Allergy and Infectious Disease and Joe Biden’s chief medical adviser, told The Atlantic this week that for at least the next few weeks, “any vaccine mandates would have to go with the original vaccine regimen.” Paul Offit, who directs the Vaccine Education Center at the Children’s Hospital of Philadelphia and serves on the FDA advisory committee that recommended authorizing third Pfizer doses for a select group last week, told me that as far as a three-dose mandate goes, “I just don’t think it’s right now.”
Continued clarity over who counts as fully vaccinated wouldn’t just help employers set rules. It would also give researchers more precise language with which to investigate breakthrough infections and vaccine efficacy. Popescu pointed out that a reworked definition of fully vaccinated could allow for multiple definitions of partially vaccinated too. Are those who haven’t gotten their second mRNA dose really in the same category as those who got their second shot more than six months ago but haven’t yet gotten a booster? Should a breakthrough infection in the first group be given the same weight as one in the second, for the purposes of assessing how well the shots are working or who can safely be invited to your dinner party?
One common critique of the push for boosters is that it has no limits, that we may end up needing a fourth booster, or a fifth, or a shot every six months for the rest of our lives. “I do think that the endgame in a year or two will likely be a vaccination program that regularly updates the vaccine and is administered on a set schedule for everyone,” Schwartz said. COVID shots might even be combined with annual flu shots.
If that’s what happens, employers and schools will have new choices to make about mandates, such as whether to require shots for their employees every year and whether to provide those shots on-site. The longer we live with endemic COVID, and the more normal and predictable boosters become, the easier these conversations will be.
Katherine J. Wu contributed reporting.
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On Saturday morning, I finally rolled up my sleeve for the vaccine I’d been waiting for all summer: my annual flu shot, a technological marvel that I opt to receive every fall.
During non-pandemic times, the flu vaccine is a hot autumn commodity that holds a coveted place in the public-health spotlight. As of late, though, the shot’s been eclipsed by the prominence of its COVID-blocking cousins, fueled by debates over boosters and mandates. It’s also been a while since we’ve had to tussle with the flu directly. Thanks to the infection-prevention measures the world took to fight SARS-CoV-2 when the pandemic began, many other respiratory viruses vanished. Last winter, we essentially had “no flu season at all,” Florian Krammer, a virologist at Mount Sinai’s Icahn School of Medicine, told me. The human attention span is short; the flu’s brief sabbatical might have purged it from our minds at an inopportune time.
An absent virus isn’t necessarily an extinct one, and the flu’s return was always going to be a matter of when, not if. And as the weather cools, experts are worried that skipping a season of sickness could come with costs, if we don’t raise our antiflu shields anew. Immune defenses can rust and crumble; flu viruses might return to find a slew of hosts more vulnerable than they were before, especially now that kids are back in classrooms and mask ennui continues to balloon nationwide. “I worry that we are not paying attention,” Hana El Sahly, an infectious-disease physician and vaccine expert at Baylor College of Medicine, told me. Flu shots, then, are particularly valuable this year—perhaps more so than they’ve been in quite some time.
Concerns about resurgent flu aren’t new. Back in February, when I first wrote about the lull in flu cases, experts were already warning that the bugs’ truancies could make them more unpredictable. Flu viruses, already a familiar threat to our immune system, spread less easily than SARS-CoV-2, which made them easier to stamp out with masks, physical distancing, school closures, and international travel bans, even when adherence was spotty. Cases around the globe plummeted. But “no one expected flu to go away forever,” Mary Krauland, an infectious-disease modeler at the University of Pittsburgh, told me.
Now we’re teetering on the edge of the year’s chilly turn as pandemic restrictions wax and wane. Many experts suspect that we might be in for a flu season worse than the previous one, in part because the previous one was so mild. The threshold for an outbreak this year could very well be lower. “I’m probably 60–40: 60 we will have a season, 40 we won’t,” Richard Webby, an influenza expert at St. Jude Children’s Research Hospital, in Tennessee, told me. “My gut feeling is, if it does come back, there’s going to be a little more punch.”
[Register now to join Katherine J. Wu alongside CDC Director Rochelle Walensky at the 2021 Atlantic Festival]
The flu’s absence did have positives. It spared health-care workers, hospitals, and the general population a second winter swell of sickness, atop an already overwhelming pandemic. Our not-flu season also starved the viruses of hosts in which to multiply and shape-shift and persist. Some experts are hopeful that certain lineages might have been squeezed out of existence entirely, or at the very least came close. That could mean that we have fewer flu flavors to contend with, and vaccinate against, in the future, though their disappearance isn’t yet certain.
But the previous season also left our sometimes-forgetful immune cells without an important annual reminder: Flu viruses do, in fact, exist, and can wreak serious havoc on the body. Reasonably good flu-vaccine coverage last winter certainly jogged our bodies’ memories. But without the additional alarms raised by actual illness—which during normal times hits many millions of people in the United States alone—people’s bodies might not be as tuned up as they should be. “You really need the seasonal waves to drive up population-level immunity and prevent large outbreaks,” Helen Chu, a physician and immunologist at the University of Washington, told me.
Infants and young kids might be especially vulnerable this year because a higher number of them than usual may have never met a flu virus. Schools are open again, many without mask requirements, adding risk for both children and those who interact with them. “When it comes to influenza,” El Sahly said, “children are the engines of transmission in the community.” A preview of this pattern already unfolded in the spring and summer with respiratory syncytial virus, another airway-loving pathogen that hits kids particularly hard. Like flu viruses, RSV all but evaporated last winter, but it was able to wriggle its way back into the American population around the start of April, when many COVID-19 restrictions relaxed.
[Read: The pandemic broke the flu]
Two recent models from Krauland and her colleagues at the University of Pittsburgh, posted in preprint papers last month, hint at the toll of missing out on our yearly immune boost. Flu cases and hospitalizations, the studies found, could both experience a bump this year, potentially beyond that of typical seasons—an additional burden that the pandemic-battered health-care system can little afford. That’s especially likely if COVID precautions keep falling away, or if we’re hit with an especially contagious flu strain that our bodies don’t recognize well. Worryingly, other experts pointed out, flu viruses and SARS-CoV-2 might even invade some of the same individuals at once, which could fuel very serious bouts of illness among the vulnerable.
These aren’t foregone conclusions, Kyueun Lee, who led one of the studies, told me. Our social behaviors still aren’t back up to their pre-pandemic levels; even intermittent masking, distancing, and the like could put a damper on the flu’s upcoming campaign. In Australia, a nation that countries in the global North usually look to as an epidemic bellwether, flu levels have stayed fairly low, which could bode well for the United States, Ibukun Kalu, a pediatric-infectious-disease physician at Duke University, told me (although she added that the American approach to COVID containment has been “vastly different” from the Australian one). Case counts could end up between last year’s startling low and the pre-pandemic norm.
We also have an extraordinarily powerful, yet underused, tool in our arsenal: an immunity-boosting vaccine. The flu shot typically reaches only about half of the U.S. population, but Lee thinks that ratcheting up that percentage this year is essential, because it could help seal some of the cracks that COVID mitigations left in our antiflu armor. “Getting a flu vaccine this season may be particularly important,” Lynnette Brammer, who leads the CDC’s domestic influenza-surveillance team, wrote in an email. But there’s yet another catch. Normally, surveillance centers stationed around the globe are able to amass many thousands of viral genome sequences to get a good read on which versions of flu viruses are bopping around—which ones might be poised to make a resurgence if given the opportunity. Scientists mine this wealth of data when selecting strains for the yearly shot. But last winter, that genetic wellspring dried up. “It’s hard to pick if you don’t have a clear picture of what’s out there,” Krammer told me.
But there were enough data to make an informed decision, experts reassured me. “The match is always a gamble,” said El Sahly, who was a member of the committee that advised on the FDA’s final vaccine formulation. “Even having high transmission beforehand doesn’t guarantee strain selection is going to be spot-on.” Generally speaking, flu-shot effectiveness against disease tops out at roughly 60 percent. But like most other immunizations, the vaccine is stellar at curbing the severity of symptoms and keeping people out of the hospital; even a somewhat mismatched vaccine could make an enormous dent in the viruses’ impact. “No matter what, it’s going to protect you at least a little bit,” Chu said.
Flu shots are also good at hedging bets. The standard “quadrivalent” formulation contains safe, inactivated representatives from four branches on the flu tree: H1N1 and H3N2, subtypes that belong to the influenza-A family, and B/Victoria and B/Yamagata, lineages in the influenza-B family. Flu-A viruses generally shape-shift more rapidly than their B-list cousins, so those ingredients change more often. The shot I got this weekend contained two updates, compared with last year’s recipe, that will hopefully prepare me better for the flu strains du jour. (Kalu pointed out another perk: We’re still waiting for the official green light on the COVID-19 vaccines for the under-12 crowd, but the flu shot is available now for kids as young as six months old.)
Regardless of how the flu collides with us this winter, my recent vaccine is an insurance policy: Either way, I’m better protected than I was. Getting the shot was also easy. I was able to get an appointment on my first try; the injection itself, which was free and painless, took only a second at my local CVS. (Flu shots and COVID-19 shots, by the way, can be administered at the same time.) It was clearly the awakening my body needed: Within hours, my arm had swelled up a bit; eventually, so did the lymph nodes next to it, likely as they filled with hordes of grumpy, flu-sensitive immune cells, some likely roused from a two-year slumber. I felt a little achy, a little tired. I felt so much better than I had before.
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On tonight's show: lawmakers in Namibia are debating whether to accept a compensation deal from Germany. Berlin has offered to fund €1.1 billion worth of projects to atone for a four-year-long genocide that began in 1904. In Uganda, President Yoweri Museveni sets the Covid-19 vaccination goal at 10 percent of the population by the end of the year. Finally, films return to the big screen in Somalia as the National Theatre in Mogadishu hosts its first public screening in three decades.
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