Booster Confusion

https://www.nytimes.com/2021/10/15/briefing/johnson-and-johnson-booster-fda.html

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For the 15 million Americans who have received the Johnson & Johnson Covid vaccine, the confusing messages from the federal government just keep coming.

An F.D.A. advisory panel is scheduled to vote today on whether J. & J. recipients should receive a booster shot. But the panel is not likely to vote on what seems to be the most relevant question: Should the booster shot come from one of the other vaccines — Pfizer’s or Moderna’s, which are known as mRNA vaccines — rather than a follow-up J. & J. shot?

The scientific evidence increasingly suggests that the answer is yes (as I explain below). Still, the F.D.A. panel seems likely to duck the question and rule only on whether J. & J. recipients should receive a J. & J. booster.

It is the latest example of a recurring Covid problem. Again and again, government officials have chosen to follow pre-existing bureaucratic procedures even when doing so has led to widespread public confusion and counterproductive behavior.

Officials often defend this approach by saying they merely “follow the science,” but that’s not quite accurate. When there is a conflict between scientific evidence and bureaucratic protocols, science often takes a back seat. Consider:

At the start of the pandemic, health officials around the country were desperate to conduct Covid-19 tests, but the C.D.C. sometimes kept those officials from developing their own tests — even as the C.D.C.’s own initial test was a failure.

Around the same time, federal officials discouraged the public from wearing masks, saying there was not enough evidence to support them — despite masks’ longtime effectiveness in Asia and inside hospitals.

For much of this year, the F.D.A. refused to grant full authorization to any Covid vaccine — even as its top leaders were saying the shots were safe and effective and urging Americans to get vaccinated.

The F.D.A. has been slow to approve rapid Covid tests, which helps explain why Britain, France and Germany are awash in the tests — but your local drugstore may not have any.

The repeated slowness of U.S. officials stems from a worthy goal. They want to consider the scientific evidence carefully before making decisions. They want to avoid confusing the public or, even worse, promoting less than optimal medical treatments.

Yet in their insistence on following procedures that were not written with a global pandemic in mind, officials have often ended up doing precisely what they sought to avoid. They have perplexed the public and encouraged medically dubious behavior.

During a public-health crisis, officials are most effective when they are “first, right and credible,” as the sociologist and Times Opinion columnist Zeynep Tufekci has written. They are least effective when they offer “mixed messaging, delays and confusion.”

Last month, this newsletter published a guide to whether J. & J. recipients should follow the mix-and-match approach of getting a booster shot with the Pfizer or Moderna vaccine. We concluded that the available scientific evidence argued for the mix-and-match approach, but that there was still uncertainty. We wrote that we understood why many people would not want to do so until the government encouraged it.

This week, the data in favor of the mix-and-match approach became even stronger.

The National Institutes of Health, which is part of the federal government, released a study comparing the antibody levels in J. & J. recipients who had received a J. & J. booster with those who had received an mRNA booster. With both of the mRNA shots — Moderna’s and Pfizer’s — the antibody levels were higher. The study did not involve enough people or a long enough time frame to be definitive, but many experts believe it’s significant.

It also follows other evidence in favor of a mix-and-match approach. In other countries, a similar approach appears to be successful. Partly as a result, an unknown number of U.S. doctors and scientists who received the J. & J. vaccine have already taken it upon themselves to get a follow-up shot from Pfizer or Moderna. And the city of San Francisco already offers mix-and-match booster shots. “At the end of the day, folks having the Johnson & Johnson should probably get an mRNA booster,” Scott Hensley, an immunologist at the University of Pennsylvania, told The Times.

Absent a late addition to its agenda, however, the F.D.A. panel will only discuss the mix-and-match issue today but take no action on it. If you’re a J. & J. recipient looking for clarity from your government, you’re on your own.

Bureaucratic sluggishness and confusion are not new problems. At several points in U.S. history, the federal government has taken steps to address them.

In 1947, Congress created the National Security Council to help the president make sense of competing advice from military leaders, diplomats and others. In the 1990s, Bill Clinton created a similar council to coordinate economic policy. And some individual officials — like Ben Bernanke, the former Federal Reserve chairman — previously managed to avoid the problem that has bedeviled the F.D.A. and C.D.C.: These officials refused to let inertia block common-sense policies during a crisis. Bernanke’s memoir, as I’ve noted before, is titled “The Courage to Act.”

During the pandemic, many Americans have come to think of Dr. Anthony Fauci as playing a similar role. He occasionally has (especially when Donald Trump was flouting medical evidence). But Fauci is an N.I.H. official who lacks the power to coordinate federal policy. It isn’t his job to clarify the government’s competing public-health messages. He has not done so on some big issues, including rapid tests and J. & J. boosters.

Nobody has. As a result, federal policy has sometimes fallen behind the scientific evidence, leaving many Americans to feel confused and frustrated — and the country’s Covid response to be less effective than it could have been.