Manfred S. Green
Manfred S. Green
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I voted against the third COVID-19 vaccine dose. Here’s why

Before we introduce shots haphazardly, we need a comprehensive data review to establish clear policy for when, how, and to whom the boosters should be given
(210101) -- TEL AVIV, Jan. 1, 2021 (Xinhua) -- A medical worker prepares a vaccine against the COVID-19 at a municipality vaccine center in Tel Aviv, Israel, Dec. 31, 2020. (Gideon Markowicz/JINI via Xinhua) Jewish News
A medical worker prepares a vaccine against the COVID-19 at a municipality vaccine center in Tel Aviv, Israel, December 31, 2020. (Gideon Markowicz/JINI via Xinhua, Jewish News)

As part of Israel’s panel of experts weighing in on how Israel should approach its COVID-19 crisis, I voted against immediately administering a third dose of the vaccine. That vote may be counterintuitive to some. Why would I be against offering a way for people with depleting antibodies to refresh their supply so their body can properly combat the virus?

In actuality, I’m not against the booster shot as a concept. However, Israel should have a clear policy in place before it starts administering a third dose to the general public. Even if it is restricted to the elderly, such an action  can unleash a Wild West of sorts, where anyone with low antibodies — or someone who simply believes they’re entitled to a third dose — will demand and expect one.

This is simply not how things should be done.

As of now, the vaccine is given in two doses with a 21-day break in between. The early data showed that the vaccine is at least 90 percent effective and those taking it will have only about a 2% chance of being hospitalized. As such, the vaccine is very effective. Vaccinated people who have been infected, by and large, have had mild symptoms. This, by all accounts, is a public health success story.

However, in the face of the rapidly spreading Delta variant, six months after the second dose, those numbers change; the vaccine has been reported to be around 39% effective, although it still prevents serious illness in about 80%.

This begs two serious questions: Do we administer a third dose? And, if so, to whom and when?

The decision, then, needs to rest on three important factors; the morbidity rates after the second dose, for those who have been vaccinated, the number of those severely ill after receiving the second dose, and evidence of a decline in antibodies since the second dose.

What we need are clear policy options for administering a third dose.

Instead of simply deciding that we should administer a third dose, we need to make some important decisions. The most important is whether the current vaccine is best given in a three-dose schedule, based on our current knowledge. And, if so, which age groups should be targeted for that three-dose schedule? Additionally, what should be the optimum timing between doses (for example, 0, 3 weeks and 6 months)?

Another option we were given to consider was to immediately offer a third dose to all those over 60. This does not seem to me to be a sound policy option. For example, should someone who received their second dose one month ago, receive a third dose?

Finally, should the three-dose schedule be given to the whole population? This will depend on the accumulated data, but could be considered after deciding on the policy for the elderly population.

Of course, selecting the right course is not easy as there are several other factors to consider. Specifically, we must take into account the side effects that may occur with a third dose, although in the elderly population it is likely that serious side-effects would be rare.

There is, of course, a possibility that a more effective vaccine that better protects against the  Delta variant is on the horizon. Do we immediately administer to those who have already received a third dose?

Another possibility to consider is that we may need even more doses in the future, but that should be determined based on accumulated data on morbidity.

While it may be tempting to simply green light a third dose, for all the reasons stated above, this is a decision we cannot afford to make lightly. Giving a third dose in an ad hoc fashion will not only cause chaos, but can interrupt the progress we have made in what has been a generally orderly and effective vaccine rollout.

Moreover, Israel was one of the first countries to vaccinate on a large scale. In that sense, the world is watching what we do. A panicked rush to administer a third dose without a strategy is not the example we want to set for the rest of the world.

A third shot may very well be necessary for many people, but it should be put into the framework of a clear policy as we do with every other vaccine.

What is needed is a comprehensive policy document that can be considered by the panel of experts. We have much of the data necessary and the policy options can be stated clearly.

Preparing such a document is not a lengthy process. Other than the data, it does not need to include much more than that which I have stated.

In the event that a third dose is offered, this should be a staged process by age group. Those vaccinated with a third dose should be closely monitored so that we can observe possible side-effects and measure the gradual decline of their antibodies.

Meanwhile, there are about a million adult Israelis who are still not vaccinated and getting jabs in their arms should be Israel’s primary goal. This will prevent disease and reduce the risks of new variants. We need to target those people.

At the same time as deciding on the need for a third dose, I would encourage the public to wear a mask in closed public places and avoid large gatherings where possible. These may seem like primitive measures in the face of modern technology, but these simple tasks can and do save lives.

About the Author
Prof. Green is the director of University of Haifa’s international MPH program and previously served as head of the University’s School of Public Health, where he is a professor in the Department of Epidemiology. He also serves as an adjunct professor at the University of Georgia College of Public Health in the United States. He previously served as head of the public health branch for the Israel Defense Forces, as well as founding director of the Israel Center for Disease Control.
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