In ‘scientific close call,’ CDC director adds booster recommendation for HCWs
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CDC Director Rochelle P. Walensky, MD, MPH, issued a statement late Thursday night endorsing her vaccine advisory committee’s recommendations — made earlier in the day — on which Americans should be eligible for COVID-19 booster shots.
Then she took the uncommon step of adding a recommendation of her own.
People aged 18 to 64 years who are at an increased risk for COVID-19 in an occupational or institutional setting — a group that includes health care workers — “may” get a booster shot of the Pfizer-BioNTech vaccine, Walensky decided.
This was contrary to a 9-6 vote recorded by the Advisory Committee on Immunization Practices (ACIP) on Thursday that recommended against offering booster doses in this population.
A CDC spokeswoman told Healio that she believed it may have been only the second time a CDC director disagreed with an ACIP recommendation — the last instance coming in 2003 when then-CDC Director Julie Gerberding, MD, MPH, considered broader recommendations for smallpox vaccination in health workers.
In a White House COVID-19 press briefing on Friday, Walensky said she made her decision after listening to the ACIP and an FDA advisory committee deliberate over the data on vaccine effectiveness and the possible need for booster shots in certain populations. (The FDA authorized boosters in older Americans and people at high risk for continue exposure or severe COVID-19 based on a recommendation made by its Vaccines and Related Biological Products Advisory Committee last week.)
The ACIP meeting, held over 2 days this week, included a lot of debate about the potential usefulness of boosters, especially in younger people.
“I want to be very clear that I did not overrule an advisory committee,” Walensky said during the White House briefing. “I think you could tell by the duration of the [ACIP] meeting and the discussions that this was a scientific close call. In that situation, it was my call to make. If I had been in the room, I would have voted yes.”
In her statement Thursday night, Walensky — formerly the chief of infectious diseases at Massachusetts General Hospital — said it is her job “to recognize where our actions can have the greatest impact.”
“At CDC, we are tasked with analyzing complex, often imperfect data to make concrete recommendations that optimize health. In a pandemic, even with uncertainty, we must take actions that we anticipate will do the greatest good,” she said.
“I believe we can best serve the nation’s public health needs by providing booster doses for the elderly, those in long-term care facilities, people with underlying medical conditions, and for adults at high risk of disease from occupational and institutional exposures to COVID-19,” she added. “This aligns with the FDA’s booster authorization and makes these groups eligible for a booster shot.”
One of the ACIP members who voted against recommending boosters for younger people at occupational risk — including health care workers — said she felt the committee was being drawn into an “emotional situation” and that it needed to focus on the science, which she said has not supported the use of boosters in younger age groups.
Instead, voting yes could put doubt in the minds of people that the vaccine is effective, Lynn Bahta, RN, MPH, CPH, who advises the Minnesota Department of Heath on immunizations, said during Thursday’s meeting.
During the White House briefing, a reporter asked Walensky about another potential reaction: Could her decision to expand the ACIP’s recommendation on her own sow doubt in people’s minds about the process?
“To the extent that people are concerned about confidence, I would say they should listen to the deliberations themselves,” Walensky responded. “We did it publicly, we did it transparently and we did it with some of the best scientists in the country.”
White House COVID-19 response coordinator Jeff Zients said people could begin getting booster shots as early as Friday afternoon.
Walensky approved three other ACIP recommendations that said booster doses should be offered — at last 6 months after the primary series — to people aged 65 years or older and residents in long-term care settings; people aged 50 to 64 years with an underlying medical condition; and people aged 18 to 49 with underlying conditions, “based on individual benefit and risk.”
Infectious Disease News Editorial Board Member Jeanne M. Marrazzo, MD, MPH, said she appreciated the “heroic” efforts of the ACIP members to review evidence and make recommendations, but also welcomed Walensky’s decision.
“While I agree that health care workers should have access to boosters if they want them, I understand the ACIP's focus on hospitalizations and severe disease to prioritize the use of available vaccine supplies,” Marrazzo, who heads the division of infectious diseases at the University of Alabama at Birmingham School of Medicine, told Healio. “That said, I think most in health care, especially in the hardest-hit states, are relieved to know that the CDC director's decision may make access to a third dose somewhat easier.”
The ACIP discussed data related specifically to the Pfizer-BioNTech vaccine. According to Walensky, the ACIP will address recommendations for the Moderna and Johnson & Johnson vaccines “with the same sense of urgency,” once data become available.
Perspective
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It feels as if the vaccine booster messaging is getting clearer. It will be extremely helpful to have the FDA and CDC speaking in unison regarding the groups first in line for the Pfizer booster.
Credit to Dr. Walensky for making an understandable inclusion for the front-line workers we most need to fight the pandemic. We next hope for guidance for the Moderna and Johnson & Johnson vaccines and will await those decisions as more data are available.
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