It's time for variant-specific boosters

Vaccination was always going to be a long war

I hate to have to write about Covid policy again. During the pandemic, when we argued about masks and lockdowns and vaccine allocation, we developed a predictable rhythm for these discussions — Thomas Pueyo or Nate Silver or Matt Yglesias or whoever would suggest doing something differently, a bunch of other people would shriek at the guy to stay in his lane and trust the public health experts, and then right-wing people would come out of the woodwork to denounce the public health experts as liars and incompetents. Sometimes the suggestion would eventually become consensus or official policy (masking, vaccinating old people first), sometimes the suggestion would be discarded (“first doses first”, selective lockdowns), and either way the discussion would be memory-holed, with no one remembering the times they were wrong.

So anyway, that’s probably going to happen again here — at least if anyone bothers to pay attention to my suggestion. Hopefully others will take up the call. But, it’s time to say it anyway: We need to make and distribute boosters against specific Covid-19 variants — Delta, and whatever nastier variants come after it.

Currently, there is a debate over booster shots. But it’s a debate about giving people a third dose of the type of vaccine we already have — a vaccine that targets the spike protein of the original, un-mutated SARS-CoV-2 coronavirus. The Biden administration has a plan to administer third doses in order to shore up waning immunity in the face of the Delta variant. Vaccines confer long-lasting immunity, but it does wane a bit over time, as the initial rush of antibodies clears out of your system. Boosters would take people back to maximum in time for a possible winter wave of Delta.

Though some experts have endorsed the Biden plan, others have been pushing back on it, arguing that giving Americans third doses would rob other countries of needed vaccine shots. This seems like a weak argument to me. It conceives of vaccines as a fundamentally scarce commodity. In actuality, vaccines are a thing we can make more of if we dedicate the resources to producing more. We’ve already accomplished herculean feats in terms of vaccine production; the experts arguing against boosters are implicitly assuming that this process is maxed out, and that we should now simply think about allocation. That smacks of artificial scarcity thinking. If you want to give people boosters and also give vaccine shots to other countries, just invest more money in vaccine production.

Anyway, that’s the debate. But there’s something else we’re not doing, which we need to be doing: Releasing variant-specific boosters.

The technology to make boosters that specifically target already exists. Pfizer already has a Delta-specific shot in development. In fact, the ability to quickly and easily make boosters targeting any new variant is one of the key strengths of mRNA vaccines. And in fact, we’ve already created a regulatory regime that makes rolling out variant-specific boosters fast and easy, since they don’t have to go through full Phase III trials.

Yet all of the public discussion about boosters right now is about giving people additional shots of the original vaccine. It’s crazy that we invented this miraculous new technology with this amazing versatility, and a regulatory structure to accommodate that versatility, and then decided to simply ignore it!

In fact, there are two very important reasons we need to be rolling out variant-specific boosters: Reducing the burden of the disease in the short term, and getting back to normal in the long term.

Transmission, long Covid, the immunocompromised, and risk reduction

Current vaccines will protect you against dying from the Delta variant and other variants that have evolved to partially escape immunity against the original coronavirus. Current vaccines will significantly reduce your chances of hospitalization from Delta. But current vaccines do not stop you from transmitting Delta to others:

Eric Topol @EricTopol

Delta breakthrough infections among 62 healthcare workers vaccinated in Vietnam 1. High viral loads. Many asymptomatic infections with similar viral loads 2. Low neutralizing antibodies 3. Transmission between vaccinated individuals papers.ssrn.com/sol3/papers.cf…

Delta is a highly transmissible form of Covid — far more transmissible than the original. Without Delta-specific boosters, vaccinated people can easily spread the virus to the unvaccinated or the immunocompromised.

So why should we think that Delta-specific boosters will impede the spread of Covid? Basically, Delta evolved to evade the antibodies to the original SARS-CoV-2, but the human body is capable of creating antibodies that are highly effective against Delta. We know this because while vaccine immunity to the original SARS-CoV-2 is better than natural immunity, natural immunity to Delta is better than the immunity conferred by our current vaccines. If we make boosters against Delta, then it’s reasonable to expect that they will confer superhuman immunity against that variant.

For this same reason, Delta-specific boosters would probably offer better protection against long Covid. We tend to dismiss the risk of long-haul symptoms when talking about the costs of the pandemic, simply because there have been so many deaths that long-term morbidity seems like a secondary issue. But long Covid is truly a terrible burden on a very large number of people in our society. If you don’t believe me, read this report by Ed Yong, one of the best chroniclers of the pandemic:

After a year and a half, the risk of long COVID, for both unvaccinated and vaccinated people, is one of the pandemic’s biggest and least-addressed unknowns. The condition affects many young, healthy, and athletic people, and even now “none of us can predict who’s going to have persistent symptoms,” Lekshmi Santhosh, the medical director of a long-COVID clinic at UC San Francisco, told me. A small number of fully vaccinated people have become long-haulers after breakthrough infections, although no one knows how common such cases are, because they aren’t being tracked. Mysteries abound; meanwhile, millions of long-haulers are sick…

The Delta variant is so transmissible that it will be impossible to fully eradicate. Instead, the pandemic will end when the virus goes endemic—that is, when most everyone has some immunity, preferably through vaccination or, alternatively, through infection. The virus will still circulate, but the shield of immunity will blunt its sting for both individuals and societies. Although breakthrough cases will undoubtedly occur, they should be milder. But just ask a long-hauler what a “mild” infection can do.

Without variant-specific boosters, we’re forcing everyone in our society to expose themselves to a greater risk of this debilitating condition.

Finally, variant-specific boosters would allow people to choose their own acceptable level of Covid risk. Breakthrough deaths are rare, sure, but they do happen. We have a technology that will allow people to go through life unafraid of death from Covid, and morality dictates that we make that technology available to our people.

Preparing for the endemic

The second reason we need variant-specific boosters is that we were always going to need variant-specific boosters. As soon as Covid showed that it could evolve enough to evade vaccines, it became highly likely that we will be dealing with repeated waves of Covid for many decades to come.

And in fact, we already have a model for a virus like this: The flu. The original H1N1 “Spanish” flu rampaged through our society, and then it stopped rampaging. But now we have this thing called “flu season” every year that kills tens of thousands of Americans. The flu mutates too fast for vaccines to quell it entirely (at least until we develop a universal flu vaccine), but we have this thing called a “flu shot” that lots of us get every year, which protects us against the most common currently circulating versions.

In the same way, we’ll have yearly Covid shots. Every year or two, the vaccine companies will use the amazing technology of mRNA to cook up vaccines specific to the latest variant, the FDA will approve them quickly, and lots of people will get these shots.

Why not begin this process right now? By making variant-specific booster shots widely available, the U.S. can begin discovering and demonstrating what life will look like in the age of endemic Covid. That will allow nations all over the world to plan for a future of endemic Covid, both in terms of their vaccine manufacturing capabilities and in terms of their public health policies. And that planning will in turn create economic confidence, because businesses and consumers alike will know what the future looks like.

In other words, the faster we get variant-specific boosters, the faster the whole world gets to the post-pandemic future. Even without the imperative to protect Americans in the short term, that is a compelling moral case for ramping up our industrial capacity and creating variant-specific boosters right now.

So let’s start talking more about variant-specific boosters, instead of largely ignoring them as we’ve been doing so far.

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