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Pfizer booster approved for those age 65+ and at high risk, including health care workers

By Jeff Levin-Scherz, MD | September 28, 2021

As the CDC specified eligibility for the Pfizer booster, COVID-19 cases declined slightly overall, but pediatric cases are on the rise.
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About our “The COVID-19 Crisis” series

“The COVID-19 Crisis” series is a weekly update by Dr. Jeff Levin-Scherz covering the latest developments related to the COVID-19 pandemic in the U.S. Explore the entire blog series.

It’s been a confusing week on the COVID-19 vaccine booster front, but we finally have an answer as to who is eligible for a booster shot. The Centers for Disease Control and Prevention (CDC) Director, Rochelle Walensky, followed the Food and Drug Administration’s (FDA) guidance and made the following Americans eligible for booster shots, if they were vaccinated with the Pfizer vaccine at least six months ago and if they are over age 18:

  • Those age 65 and over
  • Residents of nursing homes
  • Those age 18 to 64 with medical conditions that increase risk of severe COVID-19
  • Those who are at high risk of exposure because of where they live and work including:
    • Health care workers
    • Teachers
    • Prisoners and prison guards
    • Those who live or work in homeless shelters
    • Day care staff
    • Grocery workers

In announcing this approval Walensky overturned the recommendation of a CDC advisory committee that had recommended against booster shots for those at risk of exposure based on occupation or residency. This recommendation does not apply for those who initially got the Moderna or Johnson and Johnson (J&J) vaccines, although each of these manufacturers has presented data on the antibody boost or extra protection from booster shots, and I expect we’ll see recommendations for these forthcoming.

To add to the complexity, individuals who are immunosuppressed are recommended by the CDC for a third Moderna or Pfizer vaccine four or more weeks after finishing the initial two-dose series. This is considered a completion of the initial vaccination series, rather than a booster dose.

For all the talk of booster shots, what really matters to prevent hospitalizations is the initial vaccine, not boosters. Here’s data from the CDC advisory committee meeting last week, which illustrates that primary vaccination is:

  • 10 times more likely to prevent hospitalization in the elderly
  • 22 times more likely to prevent hospitalization in young adults

We should continue to focus efforts on getting vaccines to those who are not yet vaccinated

The number of booster vaccinations (versus primary vaccinations) that will likely be needed to prevent one hospitalization is 22 times
higher for ages 18 to 29, and 10 times higher for those ages 65+.
Vaccinations needed (both primary and booster) to prevent hospitalization over six months

Source: CDC Advisory Committee on Immunization Practice. September 23, 2021.

The graphic below gives you a good idea of just how effective vaccination continues to be in preventing hospitalizations in many different age groups. The yellow line is those who are vaccinated; the purple line is the unvaccinated. The shaded area is the current Delta wave.

Depending on age, those unvaccinated are hospitalized at a rate of 13 to 23 times higher than those who are vaccinated.
Age-adjusted weekly COVID-19 hospitalization rates by age groups

Source: CDC, Advisory Committee on Immunization Practice, September 23, 2021.
*Cumulative rate ratio from January 24 – July 17, 2021. Shaded area indicates preliminary July data that does not include one site.

Implications for employers:

  • Encouraging primary vaccination (either two doses of Pfizer or Moderna or one dose of J&J vaccine) is the most important way to decrease risk of workplace exposure or business disruption due to quarantine requirements.
  • Avoid claim edits that could prevent payment for booster shots.
  • There is no imperative at this point to include booster shots in vaccine mandates, including for the immunosuppressed.

Current COVID-19 status

COVID-19 cases continue to come down in the U.S., although they remain high in many regions. Hospitals in Oregon, Alaska and parts of Montana are operating under crisis standards of care, allowing providers to triage scarce intensive care to those most likely to survive. Hawaii has released health workers from liability for rationing care.

We reached the grim milestone of more deaths than were seen in the Influenza Pandemic of 1918 (650,000), although our population is about three times larger today. Death rates are still on the rise a bit, but deaths lag behind new cases by a number of weeks so we should expect to see a decline in reported deaths soon too. Many experts believe that as we continue to increase our vaccination rate and with the large number of natural infections we won’t have nearly as bad a winter as last year. Even if we have future waves of infections, these will not be accompanied by as many hospitalizations and deaths.

The seven-day moving average was 114,413 on September 24, 2021.
Daily trends in number of cases of COVID-19 in U.S. reported to CDC

The seven-day moving average was 114,413 on September 24, 2021.
Source: CDC

The U.S. started vaccinations earlier than most of the rest of the world, and we’ve had plentiful supply for many months now. Nonetheless, many countries have vaccinated larger portions of their populations, providing them with more protection against severe cases of COVID-19.

Our nationwide vaccine rate is 56%. In comparison, France is 73%, China 72%, Israel is 62.
Fully vaccinated percentages by country

Source: Our World in Data, September 20, 2021.

Implications for employers:

  • The U.S. lackluster vaccination rate puts areas of the U.S. with lower rates at risk for continued infections and hospital-capacity problems.
  • Increasing vaccination rates among employees can lower this risk.

Fighting misinformation

I presented during a town hall for a client earlier this week, and a few attendees posted questions based on misinformation about the COVID-19 vaccines. When you are talking to those who are vaccine hesitant, it’s best to listen carefully, provide accurate information, and avoid accidentally amplifying false claims that the vaccines are either dangerous or ineffective. Therefore, it’s best not to repeat the misinformation, and focus on the facts. Stories that are true can help, including your own personal endorsement. Here are some key points:

  • Over 6 billion COVID-19 shots have been administered globally, and we’ve been watching carefully for side effects. There have been very few side effects that last more than a day. There have been only a handful of deaths. This is one of the safest vaccinations ever developed. Those who claim that the risk of vaccination and the risk of infection are similar are simply wrong.
  • The vaccines are dramatically safer than getting natural immunity from COVID-19. Those who are vaccinated are 10 times less likely to be hospitalized if they do get infected. They are also less likely to get long COVID-19 even if they do get a breakthrough infection.
  • Vaccinated people are five times less likely to get COVID-19, and therefore much less likely to transmit it to others. Vaccinated people also clear their upper respiratory virus more quickly, so they are contagious for a shorter time. Vaccination protects you, your family and the community.
  • Vaccination saves lives. Researchers at Yale estimated that the COVID-19 vaccinations had saved 279,000 lives and prevented 1.25 million hospitalizations in the U.S. as of July 2021.

Six key takeaways to help employers make a decision regarding vaccine mandates

  1. 01

    There is no requirement to wait for the OSHA rules for vaccine mandates, or to wait until all legal challenges have been resolved.

    Our research shows that over one in five employers had a vaccine mandate in place in August, and the Equal Employment Opportunity Commission and various courts have upheld employer mandates. Since a mandate should be announced at least two months before it takes effect, delaying a mandate can increase business risk and even cost lives.

  2. 02

    Medical costs will be lower in those who are vaccinated.

    Fair Health announced yesterday that commercial costs were $75,000 on average for those who are hospitalized with COVID-19. Vaccination reduces the risk of hospitalization by about 90%. This is compelling math.

  3. 03

    Those who are vaccinated are likely to miss less work because they don’t need to quarantine if they are exposed.

    Quarantines have been a cause of business interruption. However, those who are vaccinated need not quarantine if they had an exposure and have no symptoms.

  4. 04

    Few people will leave their jobs to avoid a vaccine mandate.

    You might have seen surveys suggesting that many people will leave their jobs if subjected to a vaccine mandate. The experience with hospitals and universities so far has shown very few people have left their jobs because of these requirements, well under 1%. The Medical University of South Carolina found that just 0.0002% of its staff of 17,000 were terminated for violating the vaccine mandate, and all had violated other employer policies as well.

  5. 05

    More than half of Americans support vaccine mandates.

    Multiple surveys have shown that Americans support mandates. Many employees feel safer at a workplace where they know that almost all colleagues have been vaccinated, and many customers prefer businesses where they know staff are vaccinated. Over one in five surveyed who are unvaccinated (22%) reported supporting employer vaccine mandates.

  6. 06

    Vaccine mandates reduce business risk.

    Businesses with a vaccine mandate are less likely to have workplace outbreaks, will have lower medical expenses and be less likely to suffer business interruptions due to quarantines.

Pediatric COVID-19 cases on the rise

You’ve probably read stories about increasing pediatric COVID-19 infections. It’s true that children represent a larger portion of cases of COVID-19 now than they did earlier in the pandemic. Vaccination rates in the U.S. are 83% in the elderly, 66% in adults, and 64% among all those age 12 and over. The vaccination rate is 0% in those under age 12. Kids therefore represent an increasingly larger portion of those who are not protected by vaccination. So it’s not surprising to see them represent a growing portion of cases.

Nature reported that in the beginning of the pandemic, children represented 13% of all new cases; they now represent 22% of new cases. Nonetheless, pediatric hospitalizations remain unusual.

The following chart gives you a sense of how rare it is for children to need hospitalization (bar), intensive care (solid line) and invasive mechanical ventilation (IMV) (dotted line).

Throughout the pandemic, those under age 17 requiring ICU care or ventilation due to COVID-19 has steadily been less than 5%, often much lower.
Age 17 and under requiring ICU admission or ventilation due to COVID-19

Source: CDC Morbidity and Mortality Weekly Report, September 3, 2021

A few points about this:

  • Kids continue to be unlikely to be hospitalized even when they get COVID-19.
  • Fewer children died of COVID-19 in 2020 than died of influenza in 2019.
  • The rate of children getting infected is highly related to the overall rate of community transmission. Kids are four times as likely to be hospitalized with COVID-19 in states with low vaccination rates compared to states with high vaccination rates.
  • Pfizer has reported good safety and efficacy data for children age five to 11. We expect emergency use authorization for the Pfizer vaccine for children age five to 11 in the next month.

Implications for employers:

  • Getting employees vaccinated helps protect children.
  • We should continue to be prepared for educational interruptions this fall. These will be less likely in schools that have mask mandates.

Population Health Leader, Health and Benefits, North America

Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.

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