The One Thing Everyone Should Know About Fall COVID Vaccines

Paul Offit is not an anti-vaxxer. His résumé alone would tell you that: A pediatrician at Children’s Hospital of Philadelphia, he is the co-inventor of a rotavirus vaccine for infants that has been credited with saving “hundreds of lives every day”; he is the author of roughly a dozen books on immunization that repeatedly debunk anti-vaccine claims. And from the earliest days of COVID-19 vaccines, he’s stressed the importance of getting the shots. At least, up to a certain point.

Like most of his public-health colleagues, Offit strongly advocates annual COVID shots for those at highest risk. But regularly reimmunizing young and healthy Americans is a waste of resources, he told me, and invites unnecessary exposure to the shots’ rare but nontrivial side effects. If they’ve already received two or three doses of a COVID vaccine, as is the case for most, they can stop—and should be told as much.

His view cuts directly against the CDC’s new COVID-vaccine guidelines, announced Tuesday following an advisory committee’s 13–1 vote: Every American six months or older should get at least one dose of this autumn’s updated shot. For his less-than-full-throated support for annual vaccination, Offit has become a lightning rod. Peers in medicine and public health have called his opinions “preposterous.” He’s also been made into an unlikely star in anti-vaccine circles. Public figures with prominently shot-skeptical stances have approvingly parroted his quotes. Right-leaning news outlets that have featured vaccine misinformation have called him up for quotes and sound bites—a sign, he told me, that as a public-health expert “you screwed up somehow.”

Offit stands by his opinion, the core of which is certainly scientifically sound: Some sectors of the population are at much higher risk for COVID than the rest of us. But the crux of the controversy around his view is not about facts alone. At this point in the pandemic, in a country where seasonal vaccine uptake is worryingly low and direly inequitable, where health care is privatized and piecemeal, where anti-vaccine activists will pull at any single loose thread, many experts now argue that policies riddled with ifs, ands, or buts—factually sound though they may be—are not the path toward maximizing uptake. “The nuanced, totally correct way can also be the garbled-message way,” Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases, told me.

For the past two years, the United States’ biggest COVID-vaccine problem hasn’t been that too many young and healthy people are clamoring for shots and crowding out more vulnerable groups. It’s been that no one, really—including those who most need additional doses—is opting for additional injections at all. America’s vaccination pipeline is already so riddled with obstacles that plenty of public-health experts have become deeply hesitant to add more. They’re opting instead for a simple, proactive message—one that is broadly inclusive—in the hope that a concerted push for all will nudge at least some fraction of the public to actually get a shot this year.  

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On several key vaccination points, experts do largely agree. The people who bear a disproportionate share of COVID’s risk should receive a disproportionate share of immunization outreach, says Saad Omer, the dean of UT Southwestern’s O’Donnell School of Public Health.

Choosing which groups to prioritize, however, is tricky. Offit told me he sees four groups as being at highest risk: people who are pregnant, immunocompromised, over the age of 70, or dealing with multiple chronic health conditions. Céline Gounder, an infectious-disease specialist and epidemiologist at NYC Health + Hospitals/Bellevue, who mostly aligns with Offit’s stance, would add other groups based on exposure risk: people living in shelters, jails, or other group settings, for instance, and potentially people who work in health care. (Both Gounder and Offit also emphasize that unvaccinated people, especially infants, should get their shots this year, period.) But there are other vulnerable groups to consider. Risk of severe COVID still stratifies by factors such as socioeconomic status and race, concentrating among groups who are already disproportionately disconnected from health care.

That’s a potentially lengthy list—and messy messaging has hampered pandemic responses before. As Gretchen Chapman, a vaccine-behavior expert at Carnegie Mellon University, told me last month, a key part of improving uptake is “making it easy, making it convenient, making it the automatic thing.” Fauci agrees. Offit, had he been at the CDC’s helm, would have strongly recommended the vaccine for only his four high-risk groups, and merely allowed everyone else to get it if they wanted to—drawing a stark line between those who should and those who may. Fauci, meanwhile, approves of the CDC’s decision. If it were entirely up to him, “I would recommend it for everyone” for the sheer sake of clarity, he told me.

[Read: Fall’s vaccine routine didn’t have to be this hard]

The benefit-risk ratio for the young and healthy, Fauci told me, is lower than it is for older or sicker people, but “it’s not zero.” Anyone can end up developing a severe case of COVID. That means that shoring up immunity, especially with a shot that targets a recent coronavirus variant, will still bolster protection against the worst outcomes. Secondarily, the doses will lower the likelihood of infection and transmission for at least several weeks. Amid the current rise in cases, that protection could soften short-term symptoms and reduce people’s chances of developing long COVID; it could minimize absences from workplaces and classrooms; it could curb spread within highly immunized communities. For Fauci, those perks are all enough to tip the scales.

Offit did tell me that he’s frustrated at the way his views have frequently been framed. Some people, for instance, are inaccurately portraying him as actively dissuading people from signing up for shots. “I’m not opposed to offering the vaccine for anyone who wants it,” he told me. In the case of the young and healthy, “I just don’t think they need another dose.” He often uses himself as an example: At 72 years old, Offit didn’t get the bivalent shot last fall, because he says he’s in good health; he also won’t be getting this year’s XBB.1-targeting brew. Three original-recipe shots, plus a bout of COVID, are protection enough for him. He gave similar advice to his two adult children, he told me, and he’d say the same to a healthy thrice-dosed teen: More vaccine is “low risk, low reward.”

The vax-for-all guideline isn’t incompatible, exactly, with a more targeted approach. Even with a universal recommendation in place, government resources could be funneled toward promoting higher uptake among essential-to-protect groups. But in a country where people, especially adults, are already disinclined to vaccinate, other experts argue that the slight difference between these two tactics could compound into a chasm between public-health outcomes. A strong recommendation for all, followed by targeted implementation, they argue, is more likely to result in higher vaccination rates all around, including in more vulnerable populations. Narrow recommendations, meanwhile, could inadvertently exclude people who really need the shot, while inviting scrutiny over a vaccine’s downsides—cratering uptake in high- and low-risk groups alike. Among Americans, avoiding a strong recommendation for certain populations could be functionally synonymous with explicitly discouraging those people from getting a shot at all.

Offit pointed out to me that several other countries, including the United Kingdom, have issued recommendations that target COVID vaccines to high-risk groups, as he’d hoped the U.S. would. “What I’ve said is really nothing that other countries haven’t said,” Offit told me. But the situation in the U.S. is arguably different. Our health care is privatized and far more difficult to access and navigate. People who are unable to, or decide not to, access a shot have a weaker, more porous safety net—especially if they lack insurance. (Plus, in the U.K., cost was reportedly a major policy impetus.) A broad recommendation cuts against these forces, especially because it makes it harder for insurance companies to deny coverage.

[Read: The big COVID question for hospitals this fall]

A weaker call for COVID shots would also make that recommendation incongruous with the CDC’s message on flu shots—another universal call for all Americans six months and older to dose up each year. Offit actually does endorse annual shots for the flu: Immunity to flu viruses erodes faster, he argues, and flu vaccines are “safer” than COVID ones.

It’s true that COVID and the flu aren’t identical—not least because SARS-CoV-2 continues to kill and chronically sicken more people each year. But other experts noted that the cadence of vaccination isn’t just about immunity. Recent studies suggest that, at least for now, the coronavirus is shape-shifting far faster than seasonal flu viruses are—a point in favor of immunizing more regularly, says Vijay Dhanasekaran, a viral-evolution researcher at the University of Hong Kong. The coronavirus is also, for now, simply around for more of the year, which makes infections more likely and frequent—and regular vaccination perhaps more prudent. Besides, scientifically and logistically, “flu is the closest template we have,” Ali Ellebedy, an immunologist at Washington University in St. Louis, told me. Syncing the two shots’ schedules could have its own rewards: The regularity and predictability of flu vaccination, which is typically higher among the elderly, could buoy uptake of COVID shots—especially if manufacturers are able to bundle the immunizations into the same syringe.

Flu’s touchstone may be especially important this fall. With the newly updated shots arriving late in the season, and COVID deaths still at a relative low, experts are predicting that uptake may be worse than it was last year, when less than 20 percent of people opted in to the bivalent dose. A recommendation from the CDC “is just the beginning” of reversing that trend, Omer, of UT Southwestern, told me. Getting the shots also needs to be straightforward and routine. That could mean actively promoting them in health-care settings, making it easier for providers to check if their patients are up to date, guaranteeing availability for the uninsured, and conducting outreach to the broader community—especially to vulnerable groups.

Offit hasn’t changed his mind on who most needs these new COVID vaccines. But he is rethinking how he talks about it: “I will stop putting myself in a position where I’m going to be misinterpreted,” he told me. After the past week, he more clearly sees the merits of focusing on who should be signing up rather than who doesn’t need another dose. Better to emphasize the importance of the shot for the people he worries most about and recommend it to them, without reservation, to whatever extent we can.