In January — long before the first jabs of COVID-19 vaccine were even available to most Americans — scientists working under Dr. Anthony Fauci at the National Institute of Allergy and Infectious Diseases were already thinking about potential booster shots.
A month later, they organized an international group of epidemiologists, virologists and biostatisticians to track and sequence COVID variants. They called the elite group SAVE, or SARS-Cov-2 Variant Testing Pipeline. And by the end of March, the scientists at NIAID were experimenting with monkeys and reviewing early data from humans showing that booster shots provided a rapid increase in protective antibodies — even against dangerous variants.
Fauci, whose team has closely tracked research from Israel, the United Kingdom and elsewhere, said in an exclusive interview with KHN on Wednesday that "there's very little doubt that the boosters will be beneficial." But, he emphasized, the official process, which includes reviews by scientists at the Food and Drug Administration and the Centers for Disease Control and Prevention, needs to take place first.
"If they say, 'We don't think there's enough data to do a booster,' then so be it," Fauci said. "I think that would be a mistake, to be honest with you."
The support for an extra dose of COVID vaccine clearly emerged, at least in part, from an NIH research dynamo, built by Fauci, that for months has been getting intricate real-time data about COVID variants and how they respond to vaccine-produced immunity. The FDA and CDC were seeing much of the same data, but as regulatory agencies, they were more cautious. The FDA, in particular, won't rule on a product until the company making it submits extensive data. And its officials are gimlet-eyed reviewers of such studies.
On boosters, Americans have heard conflicting messages from various parts of the U.S. government. Yet, Fauci said, "there is less disagreement and conflicts than seem to get out into the tweetosphere." He ticked off a number of prominent scientists in the field — including Surgeon General Vivek Murthy, acting FDA Commissioner Janet Woodcock and COVID vaccine inventor Barney Graham — who were on board with his position. All but Graham are members of the White House COVID task force.
Another task force member, CDC Director Rochelle Walensky, said her agency was tracking vaccine effectiveness and "we're starting to see some waning in terms of infections that foreshadows what we may be seeing soon in regard to hospitalizations and severe disease." As to when so-called boosters should start, she told PBS NewsHour on Tuesday, "I'm not going to get ahead of the FDA's process."
Differences in the scientific community are likely to be voiced Friday when the FDA's vaccine advisory board meets to review Pfizer-BioNTech's request for approval of a third shot. Indeed, even the FDA's official briefing paper before the meeting expressed skepticism. "Overall," agency officials noted, "data indicate that currently US-licensed or authorized COVID-19 vaccines still afford protection against severe COVID-19 disease and death." The agency also stated that it's unclear whether an additional shot might increase the risk of myocarditis, which has been reported, particularly in young men, following the second Pfizer and Moderna shots.
Part of the disagreement arose because President Joe Biden had announced that Americans could get a booster as soon as Sept. 20, a date Fauci and colleagues had suggested to him as practical and optimal in one of their frequent meetings just days before — though he cautioned that boosters would need CDC and FDA approval.
Now it appears that that decision and the timing rest with the FDA, which is the normal procedure for new uses of vaccines or drugs. And Fauci said he respects that process — but he thinks it should come as quickly as possible. "If you're doing it because you want to prevent people from getting sick, then the sooner you do it, the better," Fauci said.
Researchers at the NIH typically focus on early-stage drug development, asking how a virus infects and testing ways to treat the infection. The job of reviewing and approving a drug or vaccine for public use is "just not how the NIH was set up. NIH does relatively little research on actual products," said Diana Zuckerman, a former senior adviser to Hillary Clinton and president of the nonprofit National Center for Health Research in Washington, D.C.
"It's no secret that FDA doesn't have the disease experts in the way that the NIH does," Zuckerman said. "And it's no secret that the NIH doesn't have the experts in analyzing industry data."
'Data in Spades'
Yet no other infectious disease expert in any branch of the U.S. government has Fauci's influence. And while other scientific leaders support boosters, many scientists believe Fauci and his colleagues at the NIAID — some of the world's leaders in immunology and vaccinology, men and women in daily contact with their foreign peers and their research findings — are leading the charge.
Fauci was hard-pressed to give exact dates for when his thinking turned on the need for boosters. The past 18 months are a blur, he said. But "there's very little doubt that the boosters will be beneficial. The Israelis already have that data in spades. They boost, they get an increase by tenfold in the protection against infection and severe disease."
In July, Israel, which started vaccinating its population early and used only the Pfizer-BioNTech vaccine, began reporting severe breakthrough cases in previously vaccinated elderly people. Israel's Ministry of Health announced boosters July 29. Fauci noted that Israel and — to a lesser extent — the U.K. were about a month and a half ahead of the U.S. at every stage of dealing with COVID.
And once Israel had boosted its population, the Israeli scientists showed their NIH counterparts, hospitalizations of previously vaccinated people, which had been rising, dropped dramatically. Emerging evidence suggests boosters make people far less likely to transmit the virus to others, an important added benefit.
To be sure, members of the White House COVID response team — including Fauci and former FDA Commissioner David Kessler — had begun preparing a timeline for boosters months earlier. Kessler, speaking to Congress in May, said that it was unclear then whether the boosters would be needed but that the U.S. had the money to purchase them and ensure they were free.
Fauci explained that "practically speaking, the earliest we could do it would be the third week in September. Hence the date of the week of September the 20th was chosen." The hope was that would give regulators enough time. The FDA's advisory board meeting Friday is set to be followed next week by a gathering of the CDC's immunization advisory committee, which offers recommendations for vaccine use that can lead to legal mandates.
Tuesday, Dr. Sharon Alroy-Preis, Israel's head of public health services, told a Hebrew-language webinar that her country's booster launch came at a critical time. She provided supporting data that Israeli scientists are bringing to the FDA meeting Friday.
Some U.S. scientists have discussed limiting the boosters mostly to those over 60, Alroy-Preis noted, but "if you don't keep it under control, it's like a pot on the flame. If you don't start lowering the flames of the pandemic, you can't control it."
Scientists tracking the coronavirus are swimming in data. Hundreds of COVID studies are published or released onto pre-publication servers every day. Scientists also share their findings on group email lists and in Zoom meetings every week — and on Twitter and in news interviews.
Kessler, chief science officer of the White House COVID response team, said the case for boosters is "rooted in NIH science" but includes data from Israel, the Mayo Clinic, the pharmaceutical companies and elsewhere.
As Fauci put it: "Every 15 minutes, a pre-print server comes out with something I don't know."
The SAVE group, active since February, was organized by NIH officials who in normal times track influenza epidemics. The 60 to 70 scientists are mostly from U.S. agencies such as the NIH, CDC, FDA and Biomedical Advanced Research and Development Authority, but also from other countries, including Israel and the Netherlands.
"This is very much the basic scientists who are in the weeds trying to figure things out," said Dr. Daniel Douek, chief of the human immunology section within NIAID. Douek said the larger SAVE group meets every Friday but several subgroups meet several times a week, focusing on different aspects of the virus, such as early detection of viral variants and testing suspicious variants for their ability to evade vaccine-induced immunity and sicken vaccinated mice and monkeys.
The sharing of data and information is free-flowing, Douek said. SAVE is "an amazing thing."
Matthew Frieman, a participant and associate professor of microbiology at the University of Maryland School of Medicine, said the data makes it clear that the time for boosters is approaching. Biden's booster announcement "may have gotten ahead of the game, but the trajectory is pointing toward the need for boosters," Frieman said. "The level of antibody you need to protect against delta is higher because it replicates faster."
While SAVE is an elite group, it's not the only forum for discussing late-breaking data, said Natalie Dean, a biostatistician at the Rollins School of Public Health at Emory University. "We all saw the same data out of Israel," she said. Dean, like many other scientists, found that data unconvincing.
Monday, an international group of scientists led by Dr. Philip Krause, deputy chief of the FDA's vaccine regulation office, and including his boss, Dr. Marion Gruber, published an essay in The Lancet that questioned the need for widespread booster shots at this time.
Krause and Gruber had announced their retirements from the FDA on Aug. 30 — at least partly in response to the booster announcement, according to four scientists who know them. Gruber, who will remain at the agency until later this fall, is listed as a participant in Friday's meeting.
The Lancet paper argues that vaccine-based protection against severe COVID is still strong, while evidence is lacking that booster shots will be safe and effective. University of Florida biostatistician Ira Longini, a co-author on the Lancet paper, said it would be "immoral" to begin widespread boosters before the rest of the world was better vaccinated. As the disease continues its global spread, he noted, it is likely to develop deadlier and more vaccine-evasive mutants.
Longini was also skeptical of an August study, which Israeli scientists are to present to the FDA on Friday, that NIH officials had touted as strong evidence in support of boosters. On an Aug. 24 call with Israeli officials, Fauci urged them to publish that data, and a version appeared in the New England Journal of Medicine on Wednesday.
That study found that people receiving a third dose of the Pfizer-BioNTech vaccine were 11 times more likely to be protected from COVID infection than those who had gotten only two doses. But the study observed people for less than two weeks after their booster vaccinations kicked in. Biostatisticians felt it had irregularities that raised questions about its worth.
"I don't want to say the study isn't correct, but it hasn't been reviewed and there are possible biases," said Longini, who helped design the 2015 trial that resulted in a successful Ebola vaccine and now works on global COVID vaccine trials.
Fauci emphasized that no single study or piece of data led Biden or the members of the White House COVID response team to conclude that boosting was necessary. The compilation of evidence of waning immunity combined with reams of research was a factor. Now the crucial decisions are in the hands of the regulators, awaiting the FDA and CDC's judgment on how the nation should proceed.
"It isn't as if," Fauci said, "one day we're sitting in the Oval Office saying, 'You know, Mr. President, I think we need to boost.' And he says, 'Tony, go ahead and do it.' You can't do it that way. You've got to go through the process."
Journalist Nathan Guttman contributed to this report. This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California healthcare Foundation.