'Everything Has Changed': You're Going to Need a COVID-19 Booster

John Whyte, MD, MPH; Eric J. Topol, MD


February 01, 2021

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  • The one-shot Johnson & Johnson COVID-19 vaccine is reported to have 66% efficacy, but the information from the company is "muddled" and the data have not been released yet.

  • The Johnson & Johnson vaccine is not as effective against the South African variant. The company reported 72% vaccine efficacy in the United States but only 57% in South Africa.

  • The Moderna and Pfizer vaccines probably would not show 95% efficacy against the South African variant either.

  • Individuals will eventually need to get booster shots directed toward the new strains. But people should not wait for boosters; get the vaccine as soon as you can because some protection is better than none.

  • The United Kingdom's more contagious B.1.1.7 strain is likely to become the dominant strain in the United States, unless vaccine distribution speeds up and people adhere more strictly to mask-wearing and social distancing.

This transcript has been edited for clarity.

John Whyte, MD, MPH: Welcome, everyone. You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Have you heard the news about the vaccine from Johnson & Johnson? How effective is it, really? And if it's less effective than the current vaccines, how do you make the choice whether or not to get it?

To provide insights, I've asked Dr Eric Topol. You all know him from previous Medscape episodes. Dr Topol, thanks for joining me.

Eric J. Topol, MD: Great to be with you, John.

Whyte: I've seen a range of headlines today. One says the J&J vaccine is 72% effective. One says it's 60% effective. One says it's 80% effective. They're all parsing the data, whether we're talking about moderate to severe disease or we're talking about hospitalizations. I'm returning to you to help us understand: How effective is it? What do listeners need to know?

Topol: It's a really good question because the company didn't do a good job in making it clear about the data. We do know that there was a drop-off between the United States and South Africa. So it was in the 70s (72%) and down to 57% in South Africa. We also have been seeing all these things about suppression of severe infection: 85%, 100%. Well, there are no data; they don't give us any data. So, right now we can say — with the one shot, which is out of the deep freeze — there is a vaccine that works, which is good.

What we really don't know is how it stands up against the mRNA vaccines, which were very clear on 95% efficacy, right? It was communicated clearly. This is muddled. So it's tricky; it's hard for us, and I hope that in the days ahead we're going to get more clarification because it's so confusing. The bottom line is 66% by the criteria that we usually use. But that accounts for South Africa where there's now resistance to the new variant.

Whyte: You've been educating us about the variants, first the United Kingdom and now South Africa. I've got to be honest when I'm hearing that there's a shortfall of efficacy in South Africa where there is a variant. How concerned do we need to be?

Topol: We have to be concerned because it has this immune escape property.

Whyte: Explain that to people.

Topol: This variant is known as South African; B. is the real name. In the test tube experiments, it didn't bind to the antibodies as it should. But we had hope that when we get a vaccine, we make such large quantities of antibodies that we will override that. As it turns out, it doesn't. It drops down. Novavax also reported on South Africa (4400 people). Just like with Johnson & Johnson, there was a big drop-off. For Novavax, it went from almost 90% to 49% in South Africa. Here in the US, it went from 72% to 57%. These are big drops.

We do know that variant is in the US — it was found in South Carolina [at the end of January], two community transmission cases. It means there's more here. Now, there's one good thing about this variant. Not much, but it may not be a superspreader like the one from the UK. So maybe we're not going to be in such a bad position to cope with it. But it's going to provide a vaccine resistance to some extent. The vaccine still works; it just doesn't work as well. We're going to have to do some tweaking of the vaccines coming up.

Whyte: Well, here's what people are thinking: There's a shortage of supply, and we do know that [the manufacturers] still have to apply for emergency use authorization. But let's be realistic — the likelihood that it'll be authorized is very high. They may have a few million doses next month, 30 million roughly by April. Perhaps 300 million by the end of March? Those are all best-case scenarios in terms of manufacturing and problems that may happen. People are thinking, If I can get a vaccine that's 70% or 60% effective (somewhere in that range, and it's only one shot) versus 94%-95% effective, do I take that? Or am I putting myself at risk later on?

Topol: First of all, take a vaccine — any vaccine. That's better than getting COVID, right? For sure. But second, do you want to get the one that's very high efficacy or the one that is still kind of murky at this point? Maybe it's actually pretty close, but as we reviewed it, the data are all over the place. If there really is a gradient in efficacy, then that's going to make it tricky. You're going to say, "I want the 95% one; I don't want the 66% one or the 70% one."

Whyte: Do you predict that people will have a choice? Or will they just have to get what's in their county? Remember, it's the government buying it and distributing it to the states and counties.

Topol: Well, I don't know because it's been chaotic these early weeks (since mid-December) when it got started. We haven't gotten into a groove yet for getting the shots in arms. The point is that we have Novavax, which is almost 90% effective — pretty good against the strain that we've lived with for a year.

Whyte: They're going to have manufacturing issues, aren't they? They're not going to be readily available.

Topol: Yeah. Hopefully we've got the whole world of pharma to help them — all these other companies (Novartis, Sanofi, GSK, and Merck) that can make vaccines. If we all cooperate, we can get into high production faster. Also, when we get that final data on the J&J vaccine, maybe it's going to look better than the 66% or what it was in the US.

Whyte: Does it ever look better after a press release? Let's be honest.

Topol: I don't know. I can only react to what I've seen, and it's all over the place.

Whyte: But let's presume that it's around 70%, if we use it as a comparator to the mRNA vaccines. Is it unethical to give it to populations in the US? Say we're looking at rural communities and we won't have to worry as much about these super-cold temperatures. Or we're looking at underserved communities, so then we can bring it to them. Is there anything wrong with that to say, "Well, you know what, 70% is better than nothing." But guess what? You could still be exposing yourself to virus and have a false sense of security. Is there equity in that setting, or is it about getting whatever is out there? If you can get it now, take whatever.

Topol: Well, two things on that, John. You're raising a critical issue. Number one, everything has changed. We're all going to need another shot, so just get started. Get a vaccine. It almost doesn't matter, because remember those 95%—

Whyte: Why do you say "everything has changed"?

Topol: Remember the mRNA vaccines (Moderna and Pfizer) and the 95% efficacy. If you tested them in South Africa, they wouldn't be 95% anymore.

Whyte: Do we know? They haven't really said what they were. They just said there's a decrease but still enough for protection.

Topol: Yeah. Well, they haven't been tested. The companies didn't do those trials in South Africa when it became the 90% strain there. The problem here is that we have now seen this hyper-evolution of new strains, trouble strains, and we're all going to need not just one or two shots but actually another booster that's directed toward the new strains, right? So, you just need to get started.

Whyte: But people don't want to wait either. And some people are saying, "Well, if you're going to have to make a booster and fix it, I'll just wait and do it all then."

Topol: You're going to get a lot of protection from the shots that we have today. And that's a good place to be — to get protection. Maybe it's not 100%. If we get better in our country, maybe we'll get suppression of the South African variant or the Brazil P1 variant. Wouldn't that be nice?

We can probably live with B.1.1.7. It isn't as vaccine-resistant even though it spreads badly. Unless we gear up now with better masks and better mitigation, B.1.1.7's destiny is that it's going to become dominant. It has a slight drop-down in efficacy too, but the problem is whatever we've seen in the pandemic until now, it could be much worse. So that's why we have to gear up. I got my two doses. I am sure you did as well. We're going to have to get extra help from vaccination as we go forward, whether it's later this year, next year, or at some point.

Whyte: If people are offered 70%, do they take it?

Topol: Oh, absolutely. I'd take 50%. Better than zero, right?

Whyte: You can't mix it later. You can't be like, "I'm going to do 70% adenovirus and then do an mRNA virus later." We can't do that.

Topol: Oh, you can. What you—

Whyte: Well, we don't know that.

Topol: I think the bigger worry than what you're bringing up is using adenovirus repetitively. That's tricky. But doing a protein and mRNA, you could do that.

Whyte: Well, we still have to double-check that, Dr Topol.

Topol: We're going to get data on that.

Whyte: I'm going to follow up with you on that. You've been very helpful in explaining everything. I want everyone to follow Dr Topol on Twitter and Instagram. He's terrific. We did an Instagram Live together, which was one of our most popular ones in answering your questions. And we'll check in with you very soon. Thank you, Dr Topol.

Topol: Thank you, Dr Whyte.

Whyte: If you have questions for us, send them my way at drjohn@webmd.net. Thanks for watching.

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