Tensions emerge over redefining the fully vaccinated

A debate is emerging around what it means to be fully vaccinated against COVID-19, as some state and local officials push to change the definition to include an additional dose of a coronavirus vaccine.

Governors in two states in the past week indicated they think three shots are necessary for full vaccination, but public health experts warn such a move would result in massive confusion, and a return to the piecemeal, scattered response that marked the early days of the pandemic.

“We’ve just moved from lots of confusion where most people were not aware, could not figure out, if they were eligible for a booster,” said Jennifer Kates, a senior vice president at the Kaiser Family Foundation.

“If states move out ahead and kind of change their definition of who they’re qualifying as fully vaccinated … that could create a lot more confusion again, because you’d have these different standards all over the country,” she said. 

While just two governors have said they think the definition of fully vaccinated should include a booster shot, others could follow as concerns grow among officials about waning immunity levels.

New Mexico Gov. Michelle Lujan Grisham (D) on Nov. 17 said she thinks three doses should be considered fully vaccinated, and the state, which does not currently have any vaccine mandates, was looking into implementing some.

“We … are analyzing what we can do to create those incentives — and potentially mandates — for making sure that people are fully vaccinated, which means three vaccines,” she said.

The state’s Health and Human Services Secretary David Scrase said he anticipates a public health order will be released in the coming weeks about updating the definition.

Connecticut Gov. Ned Lamont (D) similarly said last week that he thinks booster shots are needed to qualify a person as fully vaccinated, but did not indicate any health orders would be forthcoming.

The debate over what qualifies as fully vaccinated is tied up in the controversy over boosters.

President Biden over the summer promised widespread boosters for all Americans by the end of September, well before the Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) had examined the evidence. 

While officials were careful to say the booster program was contingent on the FDA and CDC giving the green light, scientists inside and outside the government argued there wasn’t enough evidence showing protection against severe illness and hospitalization dropped to levels that warranted a booster.

In a nod to the conflicting views, officials initially authorized boosters for people over the age of 65, plus anyone at high risk because of their line of work or where they live, or those with an underlying medical condition. 

The conditions were broad, but members of the public were confused. So last week, administration officials simplified it and authorized a booster of any COVID-19 vaccine for anyone over the age of 18, with certain timing stipulations.

Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said the debate over boosters and changing what it means to be fully vaccinated just further obscures the primary purpose of the coronavirus vaccines.

“It’s first and second doses that change the trajectory of the pandemic, that protect hospital capacity. It’s not boosters. Our hospitals are not getting pressure from people who are fully vaccinated and having breakthrough infections,” Adalja said. 

Federal health officials have been encouraging every adult who has been vaccinated in the past six months to get a booster shot, but are also insisting that boosters are not required.

“The definition of fully vaccinated is two doses of a Moderna or a Pfizer vaccine, as well as one dose of a J&J vaccine,” CDC Director Rochelle Walensky said during a recent White House briefing. 

This week, the nation’s top infectious diseases doctor Anthony Fauci said that may change.

“Right now, officially, fully vaccinated equals two shots of the mRNA and one shot of the J&J, but without a doubt that could change,” Fauci told Reuters in an interview. “That’s on the table for discussion.”

In a separate interview on ABC’s “This Week,” Fauci said there needs to be more data from people who have received boosters before making any decisions.

“We’re going to see what the durability of that protection is, and as we always do, you just follow and let the data guide your policy and let the data guide your recommendations,” Fauci said.

But experts said neither states nor the federal government should have any business essentially mandating booster shots, because it sends the wrong message about the effectiveness of the initial series. 

“I don’t think there’s any scientific basis to say that somebody who’s gotten two doses of vaccines is equivalent to someone who’s not vaccinated. There’s just no science to back that up. It’s actually wrong,” Adalja said. 

Paul Offit, director of the Vaccine Education Center at Children’s Hospital in Philadelphia, said his hospital has a vaccine mandate, and thinks it would make no sense to require a booster on top of the normal series, even for those over 50 years old who may particularly benefit from additional antibodies.

“Should we then call everybody back who’s over 50 and say, you can’t work here anymore until you get a third dose, given the paucity of data that supports that? No,” Offit said. 

The third dose is “a detour away from what’s really important, which is vaccinating the unvaccinated,” Offit said.

“We’re not going to get past this pandemic by boosting people who’ve already been vaccinated. We’re going to get past this pandemic by vaccinating the unvaccinated,” he added. “That should be the focus.”