The Biden administration wants people who got the Pfizer-BioNTech or Moderna mRNA vaccines to seek a “booster” shot several months after their second dose, if the Food and Drug Administration deems them safe and effective. (Third doses are already authorized for immune compromised people.) Notably absent from these announcements are what the 14 million U.S. residents who have received the one-shot Johnson & Johnson vaccine should do.
We think people who received the Johnson & Johnson vaccine will need a booster, and they can get one now. Pfizer’s Covid-19 vaccine recently received full approval from the F.D.A., which means that doctors can recommend a dose to their patients at their discretion, or what’s called “off-label.” Physicians should have this conversation and recommend the shots, in particular for immune compromised patients.
Health authorities have so far advocated only for additional Covid-19 doses for people who got the Pfizer or Moderna mRNA vaccines, based on multiple studies showing that these vaccines’ protection against SARS-CoV-2 wanes over time. However, we found the reluctance of organizations like the Centers for Disease Control and Prevention to recommend vaccine boosters for Johnson & Johnson recipients an unfortunate omission, one they justified by citing ongoing studies, results of which should be available soon.
However, given the spread of Delta, there are concerns over how well the Johnson & Johnson vaccine holds up. While there is no systematic data collection on vaccine breakthrough cases nationally, reports from multiple locations suggest a higher breakthrough rate for Johnson & Johnson versus the other vaccines. In the Provincetown outbreak, a higher proportion of cases occurred from Johnson & Johnson recipients than from Pfizer or Moderna recipients, when adjusting for the number of vaccines given. Among people who are immune compromised, early studies suggest that there may be notable differences between the vaccines. One recent study, which has not been peer-reviewed, found that 33 percent of Johnson & Johnson-vaccinated dialysis patients did not develop antibodies, compared with 4 percent for Pfizer and 2 percent for Moderna.
The Johnson & Johnson vaccine is certainly better than no vaccine, regardless of the variant. A recent study from South Africa found it reduced the risk of hospitalization from the Delta variant in health care workers by 71 percent relative to the unvaccinated general population. While this finding is encouraging, it does not address whether a subsequent dose of Johnson & Johnson or another vaccine might be even better.
Most vaccines used today — whether for a childhood disease like measles or an adult one like shingles — use multiple shots to strengthen the immune response. Johnson & Johnson reported on Wednesday that a second dose of its vaccine increased levels of antibodies against the coronavirus. Other data strongly suggests that an additional dose of an mRNA vaccine could improve a Johnson & Johnson recipient’s protection from disease. Multiple studies have found that an additional dose of an mRNA booster following a single dose of the AstraZeneca vaccine (a vaccine similar to Johnson & Johnson’s) produced stronger immunity compared with getting a second dose of AstraZeneca.
Experience also suggests that getting an mRNA dose after the Johnson & Johnson or AstraZeneca vaccine is safe. According to C.D.C. data, more than 90,000 Johnson & Johnson recipients have already received an additional Covid-19 vaccine dose, even though this is not yet recommended. The mixing and matching of vaccines has already been endorsed in multiple European countries. Several prominent people have shared that they have gotten an mRNA dose after their Johnson & Johnson or AstraZeneca vaccine, including Chancellor Angela Merkel of Germany, multiple infectious disease experts and various pharmaceutical company executives. So far, none of them have reported serious adverse events, nor have there been unanticipated side effects in countries using the strategy.
There are multiple studies in progress now that will further inform health authorities’ decisions about additional doses for Johnson & Johnson vaccine recipients. But until then, here’s what we think should happen now.
First, immune compromised people who received the Johnson & Johnson vaccine should be eligible for mRNA boosters at the same time as other vaccine recipients, and health authorities should clarify whether they should seek one.
Second, we believe that if the United States moves forward on expanding booster shots to other groups of people outside of the immune compromised, starting with health care workers, they should include Johnson & Johnson recipients in the same time frame as people who got the Pfizer or Moderna vaccines.
Some may view seeking additional doses of Covid-19 vaccines as unwarranted during a global vaccine shortage. As a counterargument, we feel that in settings such as ours in the United States, where there is abundant vaccine supply, doctors should do everything we can for the health of our patients while still advocating for more equitable global distribution.
It’s unfortunate that Johnson & Johnson recipients have had to endure the Delta surge with relatively little data or guidance compared with those who got other vaccines. While they may be a minority among the vaccinated in the United States, they deserve just as much attention.
Michael Z. Lin is an associate professor of bioengineering and neurobiology at Stanford University and performs research on SARS-CoV-2 antiviral drugs. Paul E. Sax is a professor of medicine at Brigham and Women’s Hospital and Harvard Medical School, where he is the clinical director of the division of infectious diseases.
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