The Biden administration was bracing for a bad Covid winter surge long before the Omicron variant. Now, with two competing strains and a burst of new cases, officials are rethinking what it means to be fully vaccinated — and how to steel the public for the possibility they’ll need fourth shots.
It's not just an exercise in semantics. Changing the criteria and messaging could influence how quickly workplaces and public events reopen, and how much a crisis-weary and in some cases confused population responds to pleas to get booster shots.
Discussions within the administration are focused on whether a third shot should be considered part of the original Covid-19 vaccine regimen. That would change what it means to be fully protected against the virus and immediately raise questions about the need for more shots, just as breakthrough cases are confusing many people about what vaccines can and cannot do.
There is “no doubt in anyone’s mind” that the original regimen plus a booster is ideal, especially with Omicron looming, said one health official familiar with the discussions. But “[Biden officials are] not going to change that anytime soon, because there's too many legal aspects hanging on this issue of what is fully vaccinated.”
Vaccine manufacturers are focusing on the same questions. Pfizer officials said Friday that they are exploring whether to make a booster dose part of their regimen. CEO Albert Bourla has even floated the potential need for a fourth dose, though administration officials dismiss that prospect as premature.
A White House spokesperson referred POLITICO to officials' public statements. “We are continuing to follow the science and it is literally evolving daily. And as that science evolves, we will continue to review the data and update our recommendations as necessary,” CDC Director Rochelle Walensky said Wednesday.
Officials have internally weighed the issue for months, debating what such a move would have on the broader vaccination campaign and any potential ripple effects on the economy. Major planks of President Joe Biden’s Covid-19 response are centered on whether people are “fully vaccinated,” such as travel into the U.S., guidance for reopening businesses and a series of vaccination rules for federal employees, health workers and large businesses.
The administration anticipated a bad winter well before Omicron, said the health official familiar with the discussions, with breakthrough cases among fully vaccinated people rising and new vaccinations virtually stalled. Booster rates among already-vaccinated people have been slowly building, but more than 100 million people still need third shots of the Pfizer-BioNTech or Moderna vaccines.
“All of those ingredients are very conducive to a winter surge, not even counting Omicron yet,” said the official. “We superimpose Omicron on that, and you have a serious situation.”
The CDC recorded more than 150,000 new Covid-19 cases at the end of last week. The average has steadily climbed since October, shortly after the Food and Drug Administration authorized the first booster doses from Pfizer-BioNTech.
“Everything points to a very simple message: Go get boosted,” said a senior administration official.
But while the administration positions boosters as a key tool to flattening winter case surges and possible hospitalizations, officials have to cut through public confusion over how well vaccines protect people from getting sick and questions about the wisdom of broadly boosting young and healthy Americans.
“With boosters they’re hoping to get us through this winter surge” even as a broader discussion plays out about what a complete vaccine regimen looks like, said a person familiar with the discussions within the Biden administration. “I don’t think this is a long-term solution at all,” the person added. “You cannot be getting boosters every four to six months.”
Public health officials note the vaccines still overwhelmingly protect against severe disease and death, and that most of the breakthrough cases are mild, sometimes with no symptoms. But explaining those stakes can be challenging, especially in the face of stubborn vaccine resistance among perhaps 30 percent of the U.S. population and projections that daily Omicron cases could be two to three times what was seen during the Delta variant wave.
The conversation needs to shift from cases to their severity, but “we’re not there yet,” Health and Human Services Secretary Xavier Becerra said this week during a briefing with reporters. “I think that's where we're heading — is to try to be able to tell the public that.”
In a stark warning about the winter surge Thursday, Biden focused his message on those who have yet to seek a booster.
“There’s good news,” he said, after describing a coming surge. “If you're vaccinated and you have your booster shot, you're protected from severe illness and death.”
That renewed booster push is running concurrent to deliberations about what it means to be fully vaccinated.
Changing the definition now risks upending the message and raising thorny new questions, especially for the federal mandates already at the center of high-profile legal fights. The move would also represent a major shift for the states, localities and individual businesses that have made full vaccination a standard for employment or even something as simple as access to a restaurant.
Those complications mean the administration is unlikely to greenlight such a dramatic shift in the coming weeks, instead relying on businesses and localities to make their own initial decisions on how to handle the question.
“I think the federal government is going to probably be last to go on that,” Scott Gottlieb, a former FDA commissioner and Pfizer board member, said Friday on CNBC. “They’ve tied a lot of decisions to the definition of what it means to be fully vaccinated.”
Confusion has accompanied the booster rollout from its earlier days when questions about who was eligible were blamed for sluggish uptake.
Top Biden administration officials have publicly touted the pace of booster shots since Omicron emerged, emphasizing the work they've done in recent weeks to make the shots more widely available.
Yet there’s broad concern that nearly 70 percent of U.S. adults have yet to receive boosters in the two-and-a-half months that they’ve been available. The daily pace of boosters is only just now nearing the 1 million mark. That means tens of millions of people who raced to get their initial vaccinations earlier this year and are now eligible for a booster aren't seeking that shot with the same enthusiasm.
Many within the administration blame mixed messaging. The White House initially declared that all adults would be able to get their shots by late September, only to immediately get bogged down in a fight with the Centers for Disease Control and Prevention and outside health experts over whether such widespread distribution was justified.
The CDC went on to greenlight boosters only for specific groups, such as older Americans and those at higher risk for severe Covid-19. But the process spurred uncertainty over who qualified and how urgently people should seek them out. Even among people over 65, CDC data show only about 54 percent have received a booster so far.
Biden officials who supported giving boosters to everyone from the beginning view the last two months as a lost opportunity — with several aides casting blame on the CDC and its outside advisers for slow-walking the rollout and muddling what could have been an easy directive that all adults get a booster.
The White House’s Covid-19 response team has since focused the majority of its energy on simplifying its message and trying to spark the same sense of urgency that most Americans felt back when vaccines first became available.
“There are 100 million people, roughly, who are currently eligible for a booster who have already gotten vaccinated, and so we know they’re open to this message of ‘vaccines work,’” said one official.
While the administration is working on a series of other priorities, including scaling up Covid-19 testing and deploying surge response teams, its public messaging has remained focused largely on what people can personally do to avoid a surge.
“Get boosted, get your family and kids vaccinated, wear a mask and get tested, those are the actions that people can take,” the official said.
That campaign is likely to pick up over the next several weeks, especially in the wake of more evidence that boosted individuals are far better protected against Omicron than those who have only received the initial vaccine series.
In the meantime, health experts expect a tough winter and lingering public confusion over vaccines and boosters.
“Absolutely we'll see infections and also see reinfections,” said Lawrence Gostin, a Georgetown University global health law professor. “And because we'll have more cases there will be more people going into the hospital even if it's a less serious disease.”
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