From our first days in medical school to our last days in practice, physicians follow two incontrovertible mantras: “First, do no harm” and “Patients first." However, using the COVID-19 pandemic as justification, governments, schools and employers have seized the “physician” role by fiat, forcing mandates that ignore these fundamental patient-centered ethical principles. Policies and mandates are developing faster than data can emerge, potentially risking the health and safety of millions of Americans.
Lately, universities and employers are rushing out panicked booster mandates in response to Omicron. The CDC recently amended their policies to recommend boosters for ALL persons over 12 years, who have received their primary vaccination months ago. Evaluating data collected prior to Omicron, they found that boosters can additionally reduce symptomatic illness, though the effects were not particularly strong in reducing hospitalization or death. Now with the vaccine-evading Omicron accounting for more than 95% of new cases, international data demonstrates that boosters may confer a moderately protective effect – but the magnitude and durability remain in question. These ambiguities have not deterred those willing to enforce senseless mandates.
From the beginning, one of the biggest failures of our national COVID-19 strategy has been the neglect of natural immunity. Public and private decision-makers have now compounded this disaster by ignoring natural immunity's close cousin--“hybrid immunity” – those people who have been infected and who have received an initial vaccination series. Currently, more than 60 million Americans have had COVID-19 infection, and a large fraction of these persons were infected before or after vaccination. In simple terms, these people have already effectively received their booster shot. As we noted several months ago in a peer-reviewed study, persons with natural COVID-19 histories present a significantly different risk-benefit calculus and may respond differently to vaccination and boosters.
Unfortunately, the booster data that the CDC reviewed did not at all account for those with natural or “hybrid” immunity. Furthermore, there is no data on the risk/benefit of boosters pertaining specifically to Omicron in this sizable group of Americans. Likely, these “hybrid immune” persons have the strongest immunity already, and boosters would only confer risk.
Consequently, schools and employers should refrain from aggressive and irrational mandates. But at the very least, if those leaders feel compelled to have some booster policy, then they should embed prudent flexibility and latitude for exemption in those with “hybrid immunity” and/or recent vaccination.
First, those who were previously COVID-infected and then fully vaccinated, have the coveted “hybrid immunity”, that some experts have described as “superhuman”. Similarly, those who have been vaccinated earlier, but have recently tested positive with Delta or Omicron – such as college students returning home for break -- have freshly invigorated “hybrid immunity”. There is no proven value of additional boosters in this now large population, and they should be exempted from any requirement.
Second, people who were never infected, but recently completed a full vaccination series, should be exempt from boosters, until the FDA and CDC delineated window expires (five, six, and two months for Pfizer, Moderna, and J&J, respectively). It would be an egregious error for organizations to coerce persons into earlier boosters outside of CDC recommendations.
While initial vaccination mandates may have had a distinct value proposition, the slippery slope has been greased towards outright medical authoritarianism. Administrators and bureaucrats have agency toward their respective organizations, but not necessarily its individuals. They cannot be forever bestowed with universal powers over personal health decisions. We applaud the brave college students, and many others, who are fighting against this flagrant encroachment on their personal health and ask the relevant leaders to exercise poise and compassion in their policy.
Therefore, we call on organizational leaders and administrators to refrain from inflexible and heavy-handed booster mandates, in favor of efforts to encourage its members to seek individually optimized COVID-19 protection strategies. Politicians and administrators, often without medical experience, should not become de facto medical decision makers for the masses. This should be left to a person and their physician, who naturally apply “no harm” and “patient first” principles on an individual basis. The sooner we empower individuals to protect themselves from COVID-19, as we do with other medical conditions, the sooner we’ll return to normalcy.
Addendum: In this essay, we reported that over 60 million Americans have been diagnosed with COVID-19, per CDC reports. While this is the correct number of confirmed corrections, the CDC currently estimatesover 145 million Americans may have been infected overall, when including unconfirmed or asymptomatic cases. In either estimate, the burden of prior COVID-19 infection is incredibly high.
