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Americans ineligible for COVID booster shots are already snagging extra doses

August 16, 2021, 10:00 PM UTC

Ben Hallman was, by all reasonable standards, a model of responsibility in the early days of America’s COVID immunization campaign. The 47-year-old journalist, based in Huntsville, Ala., ran out to get a COVID-19 vaccine as soon as he could. He followed the prevailing advice at the time, worrying less about which brand of vaccine he was getting, and was able to receive the single dose Johnson & Johnson shot back in March 2021.

But this summer, with the Delta variant spreading quickly in Alabama, he began to worry. The state saw an 89% increase in new COVID cases over the first two weeks of August and currently ranks dead last in the country with a mere 35% COVID vaccination rate per Centers for Disease Control (CDC) data. Hallman is also a father of three young children—all under the age of 12 and therefore ineligible for a coronavirus jab in the U.S. to date.

Hallman knew that Johnson & Johnson’s vaccine had consistently been shown to be highly effective at fighting the coronavirus, especially when it comes to preventing hospitalization or death (though not quite on the same level as Pfizer’s or Moderna’s vaccines). But he couldn’t ignore the constant drip of studies suggesting that J&J’s vaccine, like Pfizer’s and Moderna’s, loses some potency over time and might benefit from an mRNA booster. He decided to take matters into his own hands.

In late July—several weeks before the FDA and CDC had authorized boosters for even a sliver of the population—Hallman went to a local Kroger’s and got a dose of Moderna. “I’d been reading some encouraging studies that showed mixing and matching the mRNA vaccines and vaccines like the J&J or AstraZeneca shot was having, like, a really good boost effect,” said Hallman. “So I started thinking about getting a booster myself.”

The debate is just beginning over COVID booster shots—and who should use which vaccine and when. But regardless of eligibility, those determined to get themselves a COVID booster can probably do it, according to individuals Fortune interviewed who have managed to get their hands on either a third mRNA vaccine dose or an mRNA booster for Johnson & Johnson’s jab. With little to stop them, at least 1 million Americans who were fully vaccinated with either Pfizer’s or Moderna’s two-dose shots had already received a third dose prior to the FDA’s and CDC’s authorization of boosters last week, according to internal CDC documents. Those documents don’t even include data on Americans with the one-dose Johnson & Johnson vaccine who may have gotten an mRNA booster like Hallman.

This data and advice gap for the more than 13 million people who received Johnson & Johnson doses further complicates matters, since regulators have mostly kept their focus on Pfizer’s and Moderna’s far more widely used mRNA shots. For instance, the FDA’s and CDC’s new booster blessing last week was expected to apply only to some 3% of America’s adult population to begin with, since it’s limited to those with vulnerable immune systems, such as organ transplant recipients or patients with conditions like cancer or an HIV infection. But the authorization’s scope is even narrower since it’s only for a third Pfizer or Moderna shot for immune-compromised people who have already received two doses of those mRNA-based vaccines. Regulators haven’t publicly mentioned what the Johnson & Johnson single-dose crowd should do.

“After a thorough review of the available data, the FDA determined that this small, vulnerable group may benefit from a third dose of the Pfizer-BioNTech or Moderna vaccines,” said acting FDA Commissioner Janet Woodcock in a statement, while emphasizing the vast majority of people don’t need boosters quite yet. “Today’s action allows doctors to boost immunity in certain immunocompromised individuals who need extra protection from COVID-19. As we’ve previously stated, other individuals who are fully vaccinated are adequately protected and do not need an additional dose of COVID-19 vaccine at this time.”

Some prominent physicians have urged a faster regulatory clip for booster authorization and suggested getting that extra dose if you can, including if you originally received a Johnson & Johnson dose, as the Delta variant wave appears to show no sign of cresting. Vin Gupta, a lung and ICU physician and University of Washington faculty member who also serves as Amazon’s chief medical officer for COVID-19, is among that group.

“Thirty percent of the country thinks that they should have the freedom to not get vaccinated, right?” said Hallman. “So maybe I’m in a growing minority of people who think they should have the freedom to get vaccinated as often as they want.”

How are pharmacies and insurance companies dealing with COVID booster line jumpers?

Different regions may have different processes for getting a COVID vaccine. One of the main methods for keeping track of who’s vaccinated and who isn’t is through health insurance, since many vaccination sites ask for insurance (if you have it, since everyone is guaranteed a COVID vaccine) when you go to get your shot. On the government side, there isn’t a universal federal database of the vaccinated. The CDC isn’t keeping tabs on every individual who gets immunized, which means the process of collecting data on the vaccinated is largely a patchwork where states are responsible for setting up the IT infrastructure to collect this data and determine how much information they want to keep. As far as the federal government goes, proof of vaccination usually falls to the patients themselves or to doctors or health clinics. This is one of the reasons for the rise of vaccine passports for proving that you have, in fact, gotten your jabs.

Americans in several different states, including New York, California, and Alabama, told Fortune that a fairly easy way to get around those safeguards is to simply not hand over your health insurance information to a pharmacist or by saying that you’re uninsured. There’s not much most pharmacies can do to deny you a shot or even know you’ve already been fully vaccinated at that point. One individual in New York who preferred not to be named said she was denied a booster for her J&J shot after handing out her insurance information to a pharmacy but able to get one at a different nearby facility by saying she was uninsured.

Health insurers, pharmacy chains, and regulators had little to say on the record about how they dealing with line-jumping for booster shots. Many declined to comment, pointed to publicly available media releases, or deferred to government agencies like the FDA and CDC, citing a fluid situation. But the practical reality is that a not-insignificant number of Americans are willing to take advantage of cracks in the booster eligibility system if they feel personally unsafe or that they may be a potential danger to others such as high-risk patients and the unvaccinated. That trend could persist if the Delta variant continues to wreak havoc and extend the pandemic, especially if people think health officials are dragging their feet on authorizing boosters for the general population.

Large pharmacy chains and smaller local facilities alike pointed Fortune to FDA and CDC recommendations when it comes to boosters, and especially when it comes to mixing up different kinds of coronavirus shots. “Our pharmacy teams follow CDC guidance in situations where interchanging vaccines may be appropriate,” wrote a CVS spokesperson in an emailed statement. “Currently, there is no CDC guidance that supports interchanging vaccines for greater protection against variants of COVID-19. Similarly, a Walgreens corporate spokesperson said the company “continues to follow federal CDC, state, and local guidelines for the administration of COVID-19 vaccines, as we have throughout the pandemic” before directing Fortune to federal regulators.

In turn, regulators noted that the booster situation is dynamic as public health experts continue to learn from real-world data and balance the best ways to triage vaccines with the overall public need. An FDA spokesperson explained that receiving an extra COVID vaccine if you’re not currently eligible shouldn’t be considered an authorized use of a booster under the agency’s policies. Officials made no mention of potential punishment or repercussions for people who ignore those policies.

But the question of liability may play out on a human level, as Hallman and others’ experience shows. Pharmacists may be confused about their own potential risk if they give a dose to someone they know is fully vaccinated and doesn’t currently qualify for a booster.

“They ran my insurance information at the pharmacy. And my insurance provider denied it, because they said that I was fully vaccinated. So that was frustrating,” said Hallman, who is covered under a Blue Cross and Blue Shield of Alabama health plan. “And she [the pharmacist] said, ‘Well, look, if your private insurance denies a claim, I can file it with the U.S. government,'” said Hallman. “Because I think the deal is everybody’s guaranteed a shot. I even offered to pay for a shot, and she told me it’s not possible. So she ran my info again, and it was approved—but then she wouldn’t do it. She said she was afraid she’d be subject to some kind of liability.”

Hallman was eventually able to get a Moderna dose from a Kroger’s down the street. Others recounted their own unpredictable experiences with seeking a booster shot. One woman, Anne, said that a local Walgreens pharmacy in California flagged her full vaccination status after she had set up an appointment for a COVID shot. By bypassing the health insurance route, she wound up getting one from a different local chain, as did multiple others who spoke with Fortune for this story.

Blue Cross and Blue Shield of Alabama declined to comment on the company’s policies in such cases. Other major insurers such as UnitedHealth Group declined to comment about their own on-the-ground policies but pointed to CDC and FDA guidance on booster shots.

Ethics, prioritization, and practicality: Should anyone be able to get a booster?

Even as some American are DIYing their own booster shots, others are asking if it is really fair that a country that’s fortunate enough to have so many available vaccines is offering anyone a third dose while billions across the world haven’t even received one.

“If I could redistribute every unused vaccine shot from my local town to the rest of the world, I would,” said Hallman. “But we know that we can’t do that. And we also know that a lot of these shots are getting disposed of. So I don’t feel like I was taking a shot from anyone. In fact, I thought maybe I was helping protect myself and my family.”

Critics of the developed world’s penchant for hoarding vaccines through exclusive supply agreements with drugmakers see things in a very different light. Among them, World Health Organization (WHO) Director-General Tedros Adhanom Ghebreyesus has been outspoken on the need to prioritize getting more people in low-income nations vaccinated over authorizing boosters in wealthier countries.

“[S]ome rich countries have announced plans to administer ‘booster’ doses to populations that have already received a full course of vaccination. Not only is this ethically objectionable, when considering the hundreds of millions of people who have not yet received a single dose in the world’s poorest countries, the scientific data to support such a major policy intervention, which will have dramatic effects on global vaccine supply, is still being gathered,” he wrote in an Aug. 12 editorial for TIME urging a moratorium on COVID-19 booster shots at least until the end of September.

“Countries with high coverage are seeing a decoupling of cases and deaths, whereas countries that cannot access vaccines are seeing high cases drive with steep rises in mortality,” Dr. Tedros explained, adding that a booster moratorium should be used to help get every country in the world to at least a 10% vaccination rate—a target that’s only been met by about half the nations across the globe so far and almost exclusively in middle- and low-income countries or those that manufacture COVID vaccines.

WHO chief scientist Soumya Swaminathan has echoed the sentiment and noted the scientific jury is still out on mixing and matching different vaccine types for an immune boost without potentially putting yourself in harm’s way. Preliminary studies such as U.K. and Spanish research on supplementing AstraZeneca’s more conventional adenovirus-based vaccine with a dose of an mRNA jab have shown promising immune responses without much in the way of serious side effects.

But there are those, including Amazon’s Gupta and noted virologists such as Angela Rasmussen of the Center for Global Health Science and Equity at Georgetown University Medical Center, who have touted a more aggressive approach given the fuzzy U.S. data on breakthrough Delta infections (not to mention recent evidence that even mRNA vaccines such as Pfizer’s may lose serious potency against the highly infectious strain) and the supply-chain hurdles of keeping doses from going to waste.

An FDA spokesperson noted that there would be enough vaccine supply to meet demand as COVID booster shots become available (or at least officially available) to wider swaths of the population. The U.S. has secured more than 1 billion COVID vaccine doses through direct purchase and contracting agreements, or more than triple the number of shots as the entire population of the United States.

When will I be able to get a COVID vaccine booster dose?

Experts from the FDA and CDC, prominent health officials, and COVID vaccine makers themselves all seem to agree that while most people don’t need a COVID booster “at this time,” pretty much everyone will eventually. That shouldn’t come as a shock—many vaccines require updating as pathogens evolve or your body’s immune response weakens, though some (such as seasonal influenza) need far more regular boosters than others.

But it’s hard to gauge exactly when one individual will be officially eligible for a third dose of Pfizer’s or Moderna’s shots, or a dose of something to supplement the Johnson & Johnson vaccine, in the coming weeks and months. The FDA’s pace for opening up eligibility may pick up as a growing number of institutions such as the National Institutes of Health (NIH) and its partners conduct studies into COVID boosters, including new early-stage studies examining whether the mix-and-match approach is more effective than others with the Pfizer, Moderna, and J&J vaccines.

“Although the vaccines currently authorized by the U.S. Food and Drug Administration offer strong protection against COVID-19, we need to prepare for the possibility of needing booster shots to counter waning immunity and to keep pace with an evolving virus,” said Anthony Fauci, director of the NIH’s National Institute of Allergy and Infectious Diseases (NIAID), in a statement announcing the Phase I/II trial in June. “The results of this trial are intended to inform public health policy decisions on the potential use of mixed vaccine schedules should booster doses be indicated.”

Initial data from those trials is expected sometime in September. And that data could give the FDA and CDC sufficient scientific assurances to speed things up on the eligibility front. After all, all Americans age 16 and older were cleared to get their initial COVID vaccine doses by April 19, just four months after Pfizer’s jab won the first FDA emergency authorization for a small subgroup of the population. Assuming a similar timeline, that could mean wide-ranging use of boosters by late fall or early winter, which meshes with what companies like Moderna envision as an appropriate time frame for getting more people more doses.

That may still prove cold comfort to those approaching the pandemic with a greater sense of urgency due to the Delta variant and concerns over long-lasting immunity. And it doesn’t solve the underlying systemic and verification gaps that can turn the hunt for a second or third dose into a free-for-all.

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