A Blog by Jonathan Low

 

Feb 7, 2022

Why So Few Vaccinated Americans Have Gotten Covid Booster Shots

The black line is the share of the US population who have received a booster shot. The green lines are the other wealthy, developed countries with which the US is frequently compared. 

Lower booster shot rates in the US are due to a fragmented healthcare system in which the impetus is on the individual to look after their own health and the fact that US public health officials have been sadly obtuse about explaining concerns and needs. The result is lower booster shot rates despite the fact they are free and widely available. JL 

David Leonhardt reports in the New York Times:

Millions of Americans who have already received two vaccine shots — eagerly, in many cases — have not yet received a follow-up. The unboosted include many Republicans, Democrats and independents and span racial groups. The reasons: medical care in the U.S. is notoriously fragmented. Many Americans also do not have a regular contact point for their health care. As a result, preventive care — like a booster shot — often falls through the cracks. The second is that Government health officials, as well as some experts, struggle to communicate effectively. Americans were slower to put on masks and slower to be vaccinated than they could have been. The pattern is repeating itself with boosters.

The United States has a vaccination problem. And it is not just about the relatively large share of Americans who have refused to get a shot. The U.S. also trails many other countries in the share of vaccinated people who have received a booster shot.

In Canada, Australia and much of Europe, the recent administering of Covid-19 booster shots has been rapid. In the U.S., it has been much slower.

 

This is a different problem from outright skepticism of the vaccine. The unvaccinated skew heavily Republican, according to the Kaiser Family Foundation. The vaccinated-but-unboosted more closely resemble the country as a whole. Millions of Americans who have already received two vaccine shots — eagerly, in many cases — have not yet received a follow-up. The unboosted include many Republicans, Democrats and independents and span racial groups.

This booster shortfall is one reason the U.S. has suffered more deaths over the past two months than many other countries, as my colleagues Benjamin Mueller and Eleanor Lutz have explained.

 

The most urgent problem involves the unboosted elderly. (About 14 percent of Americans over 65 eligible for a booster had not received one as of mid-January, according to Kaiser.) But some younger adults are also getting sick as their vaccine immunity wears off.

A recent study from Israel, published in The New England Journal of Medicine, was clarifying. For both the elderly and people between 40 and 59, severe illness and death were notably lower among the boosted than the merely vaccinated. For adults younger than 40, serious illness was rare in both groups — but even rarer among the boosted: Of the almost two million vaccinated people ages 16 to 39 in the study, 26 of the unboosted got severely ill, compared with only one boosted person.

“Boosters reduce hospitalization across all ages,” Dr. Eric Topol of Scripps Research has said. As Dr. Leana Wen wrote in The Washington Post, “The evidence is clear that it is at least a three-dose vaccine.”

Two explanations

What explains the American booster shortfall? I think there are two main answers, both related to problems with the American health system.

First, medical care in the U.S. is notoriously fragmented. There is neither a centralized record system, as in Taiwan, nor a universal insurance system, as in Canada and Scandinavia, to remind people to get another shot. Many Americans also do not have a regular contact point for their health care.

As a result, preventive care — like a booster shot — often falls through the cracks.

The second problem is one that has also bedeviled other aspects of U.S. Covid response: Government health officials, as well as some experts, struggle to communicate effectively with the hundreds of millions of us who are not experts.

They speak in the language of academia, without recognizing how it confuses people. Rather than clearly explaining the big picture, they emphasize small amounts of uncertainty that are important to scientific research but can be counterproductive during a global emergency. They are cautious to the point of hampering public health.

As an analogy, imagine if a group of engineers surrounded firefighters outside a burning building and started questioning whether they were using the most powerful hoses on the market. The questions might be reasonable in another setting — and pointless if not damaging during a blaze.

A version of this happened early in the pandemic, when experts, including the C.D.C. and the World Health Organization, discouraged widespread mask wearing. They based that stance partly on the absence of research specifically showing that masks reduced the spread of Covid.

But obviously there had not been much research on a brand-new virus. Multiple sources of scientific information did suggest that masks would probably reduce Covid’s spread, much as they reduced the spread of other viruses. Health officials cast aside this evidence.

Tests, vaccines, boosters

Similar problems have occurred since then, especially in the U.S.:

  • Regulators were slow to give formal approval to the Covid vaccines while they waited for more data — even as those same regulators were pleading with people to get shots.
  • Regulators were slow to approve rapid tests — even as Britain and Germany were using rapid tests effectively.
  • U.S. officials were slow to tell people who had received the Johnson & Johnson vaccine to get a follow-up shot — even as some experts were persuaded enough by the data to do so themselves.

As a result, Americans were slower to put on masks and slower to be vaccinated than they could have been. The pattern is repeating itself with boosters. Across Europe, Canada and Australia, health officials are urging adults of all ages to receive booster shots. Israel and several other countries are even giving second booster shots to vulnerable people.

In the U.S., some officials and experts continue to raise questions about whether the evidence is strong enough to encourage boosters for younger adults. Two top F.D.A. officials quit partly over the Biden administration’s recommendation of universal boosters. The skeptics say they want to wait for more evidence.

I don’t fully understand why statistical precision seems to be a particularly American obsession. In the case of boosters, political beliefs seem to play a role, as is often the case with Covid debates: Some booster skeptics are bothered that rich countries like the U.S. are giving third shots before many people in poorer countries have received first shots. But discouraging booster shots in the U.S. has not helped increase vaccine uptake abroad.

Officially, the skeptics have lost the debate. President Biden and Dr. Rochelle Walensky, the C.D.C. director, have strongly encouraged all eligible people to get boosted. Still, the expert skepticism does seem to have fueled public skepticism, which in turn has led to fewer booster shots. The public skepticism, in turn, is one reason that the U.S. is suffering more Covid hospitalizations and deaths than many other countries.

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