For some of us, booster shots have finally arrived. But they’ve charted quite a meandering course to get here. First, last month, President Joe Biden announced that most Americans would be able to nab third doses of mRNA vaccines eight months after their second shots. Then, last week the FDA narrowed the eligible population, before a CDC advisory committee suggested tightening the boundaries even further. Hours after that panel shared its recommendation, the agency’s director, Rochelle Walensky, reversed course and ballooned the guidance back out to more closely align with the FDA’s much broader guidelines—though she stopped short of urging the shots for everyone.

It is all, frankly, a bit confusing. Millions of Americans are now in a sort of immunological limbo, wondering which expert advice to heed, and how soon to reroll up their sleeve, as the guidance coming from up top shifts seemingly by the day. Boosters are, at this point, offering more whiplash than protection. I spoke with Walensky today at The Atlantic Festival to see if we could make sense of some of the current situation—her unconventional move to break from the advisory committee’s guidance, and the tough choices millions of Americans face as they navigate the months ahead.

“What I want to say is, this is a ‘Walk, don’t run’ situation to go get your boost,” she told me.

Booster shots, when doled out at the right time, to the right people, are a boon. They jog the microbe-specific memories of immune cells, reinvigorating the body’s defenses against the pathogens that trouble us—a sometimes-essential shoring up, when immunity wanes, viruses shape-shift, or exposure rates soar.

But in setting the CDC’s guidelines, at least one choice, Walensky said, was “a scientific close call.”

The FDA, under advisement from an independent panel of experts, had green-lit a third shot, at least six months out from dose two, for Pfizer recipients who are over 65 or who are at high risk of getting severe COVID-19 because of health status or increased exposure to the virus. The CDC had a different job—to say who should get the shots. The agency’s Advisory Committee on Immunization Practices actively recommended them only for the 65-plus population, residents of long-term-care facilities, and those 50 and older with underlying health issues. The 18-to-49 crowd, the committee said, may opt to get shots as well if they had chronic medical issues; healthy people in high-risk occupations or living situations didn’t yet need the jabs at all.

In her decision, Walensky popped that last group back in, noting that people in exposure-heavy settings—among them health-care workers, teachers, incarcerated individuals, and people in homeless shelters—“may get a booster shot … based on their individual benefits and risks.” Again, that means that, at this point, all Pfizer recipients who are over 65, or at high risk of getting severe COVID-19, are authorized to get a booster. But only the 65-plus crowd, and those 50 and up with underlying health issues, are explicitly encouraged to—creating a befuddling tangle of advice.

In our interview, Walensky said that endorsing boosters for the oldest among us, as well as people living with high-risk health conditions, was essentially a no-brainer, and in line with what other experts have been calling for; this, she said, was where the data supporting the potential benefits of boosters were the strongest.

Putting people who are at higher risk because of their environments back into the guidance, against advice, was the tougher call, she said. That’s part of why younger people and high-risk workers within her recommendation fall under the category of “may get a booster,” rather than should. Translated practically, that means consulting an expert such as a physician or pharmacist, she said, “so you can identify whether you’re in a place that a booster is right for you.”

This type of individualistic decision making has, as my colleague Ed Yong has written, dominated much of the pandemic discourse. In prior months, Walensky herself has told the public that masks, vaccines, and more come down to personal risk-benefit analyses. She herself does intend to get a booster at some point, she told me. As a health-care worker, she qualifies, under her own recommendation. But she didn’t specify a timeline, and said that she doesn’t see herself as particularly high-risk at the moment. “Much of the government is remote,” she told me. “I want to make sure that people who are in higher-risk categories than myself, I’m not crowding them out.”

For any one person, though, gaming out who fits into that higher-risk-than-me category is tricky, precisely because risk isn’t just about the individual. Infectious diseases are, well, infectious; all danger is communal, and personal decisions affect those around us. That can be a difficult message to convey with vaccines, or most other public-health interventions, because it’s not a typical way for Americans to think. But Walensky points out that these societal metrics factored into her decision making over booster recommendations. Better defense for health-care workers and teachers, for instance, slashes the likelihood that they’ll have to be away from patients in need, or students who have already endured a year of remote learning.

Right now, the government’s booster guidance applies only to people who have gotten the Pfizer shot, which has effectively created millions of Moderna and Johnson & Johnson orphans. Official guidance on Pfizer effectively sorted these populations into groups considered “high risk”—and yet, these individuals are without federally sanctioned options to bolster their immunological defenses. (To date, the CDC’s website still says that even moderately to severely immunocompromised people, many of whom didn’t respond well to their initial immunization, who got J&J aren’t technically eligible for a boost.)

I asked Walensky how people in these seemingly forgotten groups should be taking the recent, Pfizer-specific news. Here, she backpedaled a bit. “The vaccine effectiveness is still working really quite well,” she told me. And that’s certainly true, especially if thresholds are drawn high: Across populations, the COVID-19 shots continue to stave off hospitalization and death to a spectacular degree, especially in people who are younger and healthy. But Walensky pointed to long COVID, which can unspool after initially mild infections, and noted that “even moderate disease can actually be pretty severe and debilitating.”

After “due process,” she said, the Moderna and J&J booster authorizations are coming in a matter of weeks, and will be treated with urgency. “We have not forgotten about J&J and Moderna.” The agency is moving deliberately in part to buoy public confidence in the scientific process and the data that back it, she said. Once a new round of boosters is authorized, people can, apparently, choose to move at their own pace.



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