In Singapore, being ‘fully vaccinated’ will mean getting a booster as Omicron forces countries to strengthen vaccine rollouts

“We need to treat COVID-19 primary vaccination as a three-dose regime. And our policies need to be geared toward that,” Ong Ye Kung, Singapore’s health minister, said at a press conference.

Ong said that Singapore will introduce a “validity period” for what it means to be fully vaccinated, meaning that citizens will lose their fully vaccinated status after a set amount of time. Ong explained that Singapore’s government has not come to a conclusion on how long that validity period may last, but he pointed to a recent U.K. study that found the effectiveness of twoPfizer-BioNTech doses wanes to 50% against Omicron within three months of getting the second dose. After a booster dose, the study found, the vaccine’s efficacy shoots back up to 75%.

“We all need to take our boosters. Because with waning protection, full vaccination status cannot last perpetually,” Ong said.

Singapore’s plan to change its definition of fully vaccinated comes two months after Israel changed its own definition to mandate a minimum of three doses for Pfizer shots. Now, amid the emergence of the Omicron variant of COVID-19, which appears better able to evade vaccines than previous strains, more countries may be set to adopt a booster standard for what it means to be fully vaccinated.

Singapore’s rules

Singapore has one of the world’s highest vaccination rates, with 87% of its population fully vaccinated and 31% of Singaporeans jabbed with a booster dose. The city-state currently considers people who received two shots of the Pfizer-BioNTech, or three shots of vaccines from Chinese makers Sinovac and Sinopharm, as fully vaccinated. The U.S., for comparison, has fully vaccinated 60.9% of its population with one shot of Johnson & Johnson’s vaccines or two shots of vaccine from either Moderna or Pfizer, while 16.4% of people have received booster shots.

After a slow start to its campaign, Singapore deployed a series of carrot-and-stick incentives to improve its vaccination rate.

At the beginning of April, Singapore had fully vaccinated just 8% of its population, compared to 20% in the U.S., but the campaign picked up over the summer as a COVID-19 wave hit the city and the government expanded distribution efforts. From April to July, Singapore nearly doubled its daily vaccination rate to provide 70,000 doses a day to city residents.

In July, Singapore also introduced differentiated rules for vaccinated and unvaccinated people, and the city-state now bars unvaccinated people from entering shopping malls, gyms, and other retail stores. The unvaccinated are allowed to dine in restaurants but only if they take a COVID-19 test beforehand. Vaccinated residents, meanwhile, can move through the city, eat at restaurants, go to the gym, and attend events relatively freely while using a health app to prove their vaccination status. But they still face some curbs, such as limiting social gatherings to five people in a group. Museums and concert venues are limited to holding 50% capacity too.

Since Dec. 8, Singapore has also made unvaccinated patients pay for medical expenses related to COVID-19 infections. Singapore, which has a privately run health care system in which patients usually pay out-of-pocket for medical bills, previously granted free health care services to all COVID-19 patients.

“We have to send this important signal, to urge everyone to get vaccinated if you are eligible,” Ong said in November about the billing policy.

Singapore has not yet announced a start date for when it will begin mandating a booster dose to be considered fully vaccinated.

Changing definition

In October, Israel became the first country in the world to restrict its definition of “fully vaccinated” to only cover those with booster shots. Like Singapore, Israel allows vaccinated citizens more privileges than the unvaccinated, such as the freedom to enter museums, restaurants and hotels or host private gatherings without presenting a negative COVID-19 test.

At the time, Israel was amid an early campaign to roll out booster shots even as the World Health Organization called for a moratorium on boosters in September amid concerns that wealthier countries could take doses away from poorer countries where vaccination rates lag.

But in recent weeks, and amid the rise of Omicron, more countries appear eager to make “fully vaccinated” mean getting a booster shot—that means a total of three jabs for the Pfizer-BioNTech, AstraZeneca, or Moderna vaccines, or a total of two shots for the Johnson & Johnson vaccine.

In the U.S., top infectious disease expert Dr. Anthony Fauci said last week that “it’s going to be a matter of when, not if” the definition of being fully vaccinated changes to include boosters. But he explained that the U.S. did not have plans to change the definition within the next week.

Starting Wednesday in France, people over the age of 65 will be required to get booster shots to still be considered fully vaccinated and enjoy privileges like using the country’s so-called vaccine passport to access restaurants, cafés, and other public venues without being tested. The same booster rule will apply to all adults starting on Jan. 15.

The European Union, meanwhile, is considering a proposal that would require non-European travelers that received their first jabs over nine months prior to arriving to show proof of a booster shot to enter Europe. But even as discussions pick up on mandating boosters, the WHO believes that for now, booster campaigns should target only vulnerable groups as low-income nations still struggle to get their first round of doses.

“In the context of ongoing global supply constraints, broad-based administration of booster doses risks exacerbating inequities in vaccine access,” Alejandro Cravioto, chair of the WHO’s expert group on immunization, said in a press briefing last week. “We believe [the unvaccinated] should be vaccinated instead of giving further doses to those that have already received [a full primary course].”