Coronavirus (Covid-19) and the vaccine: What about boosters, or, if you got Johnson and Johnson, what about getting a second shot?

Filed Under: Costs, Health plans, Patients

A number of people who received the Johnson and Johnson covid vaccine (or Astra Zeneca outside of the United States) are seeking a second shot of either Pfizer or Moderna vaccine, in the belief that the Johnson and Johnson and other vaccines may be safer with  a booster.

We heard about this from an acquaintance, and noticed that all of a sudden a lot of people are talking about this — including, most recently, Biden administration officials. Outside of the United State, the Astra Zeneca one-shot vaccine seems to be attracting interest for the possibility that a second shot — Pfizer or Moderna — may increase effectiveness.

Dr. Vin Gupta, a professor at the University of Washington’s Institute for Health Metrics and Evaluation, tweeted on June 28: “Since I’ve seen this advice be given multiple times privately:

“If you received the 1-dose J&J, go and get 1-shot of Pfizer or Moderna as a ‘booster’ when you’re able. Most I know who got J&J are doing it and are telling others the same — since two seems better than 1 re: delta.”

On July 21, Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Disease, under questioning from Norah O’Donnell at CBS News, said people who got J&J don’t need to go get Pfizer or Moderna. It’s the second question Norah O’Donnell asked him in this clip.

CNBC ran a piece about Gupta’s suggestion, including reports on “a new study from a lab at New York University Tuesday that raises serious questions about the effectiveness of J&J’s single-dose vaccine against the highly contagious delta variant. The NYU study is not yet peer reviewed, but found that the antibody levels in those who received the J&J shot may be low enough to be less protective,” CNBC said.

“CNBC correspondent Meg Tirrell interviewed the lead author of the study, Dr. Ned Landau, who told her that the study suggests, ‘one should at least consider a second vaccination, a second shot’ with the J&J vaccine, either of the same vaccine, or one from Pfizer or Moderna.”

Beyond that, in a separate issue, it is now clear that the vaccine makers (and some national health services) are recommending — or considering recommending — a third booster shot for the two-shot Pfizer vaccine for at-risk people.

Should you do it?

So what should you think? It seems obvious that the science is evolving, and that there are differing opinions among those who might be in a position to know. Meanwhile, since the vaccines are relatively new, there’s not a lot of consensus on the timeline of effectiveness. Some people don’t believe the manufacturers’ assertions of great efficacy — followed by suggestions that boosters might be needed. The two pieces don’t quite fit together.

A doctor who works with our partner at Epicenter-NYC had this to say:

“At this time, there is sufficient evidence that all three of the currently available COVID vaccines in the US provide substantial, durable protection against all currently identified variants, including the Delta variant,” said the doctor, Dr. Mark Horowitz, a family physician who practices in Manhattan

“There is little doubt, however, that the virus will continue to mutate, perhaps necessitating reformulation of the vaccines or a booster.

“In addition, there is general consensus that individuals with weakened immune systems WILL require a booster in the next 3-6 months.

“I’ll keep you informed.”

Wait … if you want it, can you even do it?

Completely separate from whether it should be done or not, a woman we know who initially got Johnson and Johnson tried to get a Pfizer shot on her doctor’s recommendation, and found it to be impossible. She has multiple pre-existing conditions that put her at high risk from Covid. She lives in a community where there is a lot of anti-vaccine and anti-mask sentiment — meaning that she cannot count on her community to be vaccinated or masked, so she has to count on herself to be safe.

She wrote: “I received the J&J shot in March and I’m interested in obtaining a booster but have not been successful. After conducting due diligence, conducting my own research and speaking to my physician, I have concluded that I would like to get a Pfizer booster, however because it is not officially approved, I have not been able to obtain one yet.

“I went to CVS and mistakenly disclosed that I have the J&J shot, so they refused to give me the Pfizer shot at that time.

“I’m assuming I should not have disclosed that information, the next hurdle is insurance. When I got my J&J shot in March I provided my insurance information. I’m assuming if I provide insurance information for a booster it will be denied and I will have to pay for it out of pocket since it is not officially approved form of medical intervention at this time. Which means if I am trying to seek a booster, I need to not only withhold the fact that I was previously vaccinated with Johnson & Johnson, but I also must withhold my insurance information.

“I have had people asking me how to get a booster as well and I don’t know what to tell them as I am presently trying to figure this out.”

Inconsistencies abound

Another vaccine-hunter friend wrote: “It is wildly inappropriate to be dishonest about her vaccination status/history vis a vis Covid in order to reinforce her immunity with a Pfizer shot. And no doctor would ever recommend she do that, and there are plenty of doctors — due to the overall communication dysfunction in this process — who are not familiar with the red tape and regulations around access to the vaccine. They are only offering their recommendation as a healthcare provider. … If she lives and works and conducts most of her life in a well-vaccinated area, then she should be very well-protected from severe illness should she contract a breakthrough case. And if a breakthrough case concerns her, she should: A. mask where appropriate, B. continue to advocate for others to get vaccinated.”

He added: “No one administering the vaccine has consistent, official guidance about how to handle this inevitability of people wanting enhanced protection, and this will become a much more pressing question. … Part of this gets unlocked when Biden does as promised and gets vaxxes in hands of PCPs to empower them to make these decisions themselves.

“I think state and federal and local gov’t and grantors need to empower folks like us to really mobilize and educate and persuade and help vaccinators, while guidance needs to be clear and immediate to vaccine providers about folks concerned with diminished protection against Delta, and further agency given to PCPs.”

A solution, of sorts

I asked another vaccine-hunter friend about this and she said it is possible to get the Pfizer shot my friend wants, but not strictly on the up-and-up.

She has booked a number of foreign tourists for vaccines. No one in New York State is required to supply documents proving that they are New York residents or even fully documented to be in the United States. So many of these tourists go to CVS with a false identity, she said.

Obviously, we are not recommending this course of action, but reporting what we learned when we asked an experienced person how she would advise the woman who’s looking for a second shot.

Just as obviously, we do not give medical advice. Any medical decisions should be made in conversation with a health care provider.

Here’s what she said:

  • Make an appointment online via the CVS website.
  • Use a false name, birth date, address, and email.
  • Book two appointments: The CVS site requires two for the full Pfizer sequence.
  • Show up for one, and don’t show up for the second.

Perhaps this is obvious, but don’t go to a CVS where you regularly do business or fill prescriptions.

Also, this second shot should be at least 21 days from the first one.

Is this legal? Probably not. At signup, CVS asks you to check a box stating that you are answering truthfully. It’s not clear what the penalty is for lying from a quick search of the CVS site. (In the early going, the New York State vaccine-finding sites were talking about hefty financial penalties for lying.)

Who pays? Probably the federal government. The CVS site says: “The vaccines are no cost to you. We will bill your insurance provider or the appropriate federal department. So grab your insurance card(s). If you don’t have insurance, we’ll ask you to input a valid driver’s license/state ID number or Social Security number. If you don’t have this info, it’s ok to continue scheduling your vaccine.”

Is this ethical? Maybe not. But depending on your doctor’s recommendation, maybe you think it’s worth it.

Pro tip? “They will ask name and birthday at CVS so just tell her to be familiar with her fake name, and honestly I’d use my real birthday just to not get mixed up. And an easy fake name.”

Vaccine mixing is not unheard of

It’s not unheard-of for people to take different vaccines. Here’s a first-person narrative from my friend Joanne Kenen about her experience: A bad mRNA reaction led her to seeking a different solution. It was anything but easy, and she’s a science reporter, a journalist and a force of nature. So if you look at what she had to go through for her “mix and match” vaccine experience, you’ll have a sense of what my other friend is looking at.

The New York Times reported July 20 that the Johnson and Johnson vaccine may be less effective against the Delta variant. The NYU study mentioned above figured prominently in the piece; it has not yet been peer-reviewed, but raises the question of a booster.

But in other countries, this is not a huge surprise.

Two weeks ago, Israel began offering a Pfizer booster shot.

In Germany, “The German Standing Committee on Vaccination (STIKO) said Thursday that people who receive a first dose of the Oxford-AstraZeneca vaccine ‘should get an mRNA vaccine as their second dose, regardless of their age,'” CNN reported in early July. “This makes Germany one of the first countries to strongly recommend that people who have received a first dose of AstraZeneca receive either a Pfizer-BioNTech or Moderna vaccine as their second dose.”

A WHO media briefing featuring Dr. Soumya Swaminathan made the point that Astra-Zeneca followed by Pfizer seems to be supported by science, but that other “mix and match” or “booster” efforts are not yet supported by science. She pointed out that if boosters become policy in wealthy nations, the effect will be to require more vaccine worldwide. It will also cause wealthy nations to get vaccine when, in poorer nations, front-line workers, the elderly and the vulnerable have not been vaccinated.

No consistency in recommendations

It’s probably not that surprising that there is such a huge difference of opinions on this topic. Science has not caught up to the pandemic, and perhaps it will be years before it does.

The landscape is changing, clearly. On Friday, July 23, The New York Times published a story saying that Biden administration officials expect that at least some Americans will need booster shots, as Horowitz said.

Realizing that the system is not set up for that right now, the article noted: “Dr. Amanda Cohn, the chief medical officer of the C.D.C.’s immunizations division, told an advisory committee to the agency that officials were ‘actively looking into ways’ to provide certain people access to booster shots ‘earlier than any potential change in regulatory decisions.'”