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Brian Lehrer: It's the Brian Lehrer Show on WNYC. Good morning, again, everyone. The CDC and the FDA both say if you are fully vaccinated against COVID-19, you do not need a booster shot at this time to be protected from disease. They say that's true even for the new variants turning up in the United States, Delta especially right now. Despite that, the pharmaceutical company Pfizer announced it would be seeking authorization for a third shot of its vaccine. The company said it was developing a new vaccine specifically targeting the Delta variant.

In Israel, a highly vaccinated country, pretty much all with the Pfizer vaccine, they are now giving third shot Pfizer boosters to select vulnerable people. Booster shots, will we need them, and when will we need them if we do? Who will need them more than others, and should richer countries even be talking about administering extra doses when so many people around the world are yet to receive even a single shot?

With me now to talk about all this is Dr. Celine Gounder, Professor of Medicine and Infectious Diseases at the NYU School of Medicine in Bellevue Hospital, a member earlier this year of the Biden, Harris transition, COVID-19 advisory board, and now founder and CEO of Just Human Productions, a nonprofit multimedia organization, host and producer of the podcast, American Diagnosis. Dr. Gounder, thanks for your time today. Welcome back to WNYC.

Dr. Celine Gounder: Thanks, Brian. It's great to be here.

Brian Lehrer: When we talk about a booster, first of all, what exactly are we talking about, and is it different in content from the original vaccine?

Dr. Celine Gounder: I think the word booster is really not the right terminology here. I think what we're talking about is refining the COVID vaccine dosing regimen. I think a good analogy here is when your doctor prescribes you a medication for high blood pressure, and then maybe they have you come back three months later, recheck your blood pressure, and increase the dose.

It doesn't mean that that medication doesn't work, it means that we're trying to find the right dose for you. I think similarly, with COVID, we're still trying to optimize our dosing regimens. The problem with the word booster is it implies that this is going to be a yearly shot. I think it's going to far more likely be something like the hepatitis B vaccine series where you get three doses, and then you're done, and I think COVID may turn out to be quite similar.

Brian Lehrer: Interesting. The Delta variant breakthrough infections that have been in the news, vaccinated people getting COVID, not much, but enough to make people not feel as much as before, and I think this has changed, Dr. Gounder, for a lot of people just in the last few weeks where vaccinated people used to feel like, "This is over for us, the pandemic is over for us." Now not so much. Would a booster help with that?

Dr. Celine Gounder: There's this concept of breakthrough infections, and I think it's helpful to break that down further. Are you getting infected, are you getting symptoms, are you getting disease, and are you ending up in the hospital? Is this breakthrough infection or breakthrough disease? People who have been vaccinated, some are getting breakthrough infections where maybe they have no symptoms, maybe they have very mild symptoms, but these people are not ending up in the hospital and ultimately, we vaccinate to prevent severe disease, hospitalization, and death and the vaccines remain highly effective with respect to that kind of protection, even in the face of the Delta variant.

Brian Lehrer: Listeners, your booster vaccine questions. Dr. Gounder doesn't even like that word, so we take that into account, but that's what most people call them. Your booster shot questions for Dr. Celine Gounder at 646-435-7280, 646-435-7280, or tweet a question @Brian Lehrer. What reason is Pfizer giving for asking the FDA to authorize a third shot? What data are they looking at?

Dr. Celine Gounder: That data has yet to be made publicly available. They did brief the White House COVID response team with that data about a week ago. The team felt like that data was not enough to justify recommending additional doses at this time, so I think we're still waiting to get more information.

Based on the data we have now that's available in the public domain so what's been published or released, at least as a preprint and it's still undergoing peer review. What we've seen is that there are certain groups of people who probably would benefit from an additional dose of vaccine. That includes people who have immunosuppression, and it's not everybody who has immunosuppression, it's a very specific group of people.

For example, people who have had a solid organ transplant, like a heart transplant or a kidney transplant, and people who have autoimmune disease or cancer where they're getting highly immunosuppressive drugs and these are very specific drugs, most people are actually not on those who have those conditions. Those people would certainly benefit from an extra dose of vaccine. In the case of Pfizer or Moderna, that would mean a third dose. In the case of Johnson & Johnson, it would mean a second dose of vaccine.

The other group of people who would probably benefit from an extra dose of vaccine is people who got the J&J vaccine and that's because we're realizing as good as the J&J vaccine is, and it's so good that we thought one dose would be enough. With the Delta variant, it may not be enough and we may need an extra dose because of the Delta variant for those folks.

Brian Lehrer: What are they doing in Israel? Who are they giving the third Pfizer shot to? I've seen conflicting news reports on this. Some say it's just that particular small group of immunocompromised people that I think you were just referring to. I've seen one other report that said it's also older people, but I don't know above what age. Have you seen what they're doing in Israel?

Dr. Celine Gounder: Yes, the emphasis is by and large, on immunocompromised people and Israel was not the first to do this. France actually started doing this a couple of months ago of giving extra doses to people who had some of these severely immunosuppressive conditions, elderly people, especially people over the age of 80, we do see a less robust immune response to vaccination in that age group, but that age group also has, by and large, gotten either Pfizer or Moderna. They were among the very first who were vaccinated and at least at this time, I wouldn't recommend a change in terms of how we're managing that group in this country.

Brian Lehrer: Really, because a 93-year-old asked me the other day, that 93 year old said, "I got the shot." It was either Pfizer or Moderna, I don't remember. When it first came out in January, it's July, it's six months, Pfizer is saying six months, and this person is 93 years old, should they be considering a booster shot right now.

Dr. Celine Gounder: Looking at how durable the immune response is, it's actually quite durable, even in elderly persons. There are a number of different aspects of the immune system that we look at. One is antibodies but antibodies don't stick around forever. If antibodies stuck around forever, for every infectious disease you ever got, for every vaccine you ever got, your blood would turn to sludge from all of those antibodies in your blood.

The immune system has a way of dealing with that where it has a memory and is ready to kick into action and produce antibodies again when you're rechallenged, when you are reinfected with an infectious disease. What we also need to look at are those memory cell responses, what we call B cells, and those memory responses are actually quite long-lived and so six months really seems much too short an interval to be considering additional doses.

Brian Lehrer: Joan in North Haledon in New Jersey, you're on WNYC with Dr. Celine Gounder. Hi, Joan.

Joan: Hi, Brian. I'm on the fence and I can't get off of it.

Brian Lehrer: Which fence are you on?

Joan: I haven't gotten any vaccine. Two-thirds of my family are opposed to it based on that mRNA thing. I'm 74. I'm a cancer survivor. I'm a heart attack survivor. I don't know if I'm [unintelligible 00:09:12], but I teach and my job may now make me get it or get tested every day. I'm trying to decide which one would be best because I think I should probably go for it because the TV commercials are driving me nuts.

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Brian Lehrer: They're working.

Joan: As everybody, right?

Brian Lehrer: Dr. Gounder, can you offer Joan some advice?

Dr. Celine Gounder: Yes, Joan, that's a really great question and a lot of people hear mRNA and that makes them nervous. They think, "Oh mRNA, that sounds like DNA. That means it's going to change my DNA" That is completely wrong. It will not change your DNA and that is simply because the mRNA does not get anywhere near your DNA. It's not able to enter the cell nucleus.

Every cell has this jelly-like substance called cytoplasm, which is actually most of your cell. Then it has this small cell nucleus, which is where your DNA is hidden away, protected and the mRNA never makes it into that cell nucleus. It is biologically impossible for mRNA to change your DNA. mRNA also does not travel all over your body, it really just sticks in those muscle cells in your arm, where they inject it. Just in those specific muscle cells, the mRNA gets taken up to help produce the protein to which your immune system has a response, but it will not change your DNA.

Brian Lehrer: I think she's asking, go ahead, Joan.

Joan: Which one would work for me? I don't believe I want that one shot one. Just because of different reasons, I might maybe stupid thinking, but it's like everything in one shot. What am I going to be sick after that? I know looking Moderna or Pfizer.

Dr. Celine Gounder: They're equivalent. Whichever one, really they're equally good, so whichever one you're able to get. In my own family, half of us have gotten Pfizer, half of us had gotten Moderna, one person got Johnson & Johnson, but Pfizer, and Moderna, it's really equivalent.

Brian Lehrer: Joan, thank you. I hope this was helpful and good luck with all of it.

Joan: Thank you and thank you for taking my call.

Brian Lehrer: Certainly, call us again. Dr. Gounder, this touches on the misinformation that's out there about what mRNA does, it's relationship, it's not a relationship to DNA and so much. This was one of the prime topics on one of the new shows I was watching this morning, that Facebook is allowing all of this misinformation to get out there unchecked. It's running faster than the scientific information that's being put out by reputable sources. Have you been thinking about the misinformation problem regarding the vaccines and how to deal with it?

Dr. Celine Gounder: Sure. I've been among many people who have been agitating about this very issue for months now, even before the current administration came into office. During the transition period, we had meetings with Facebook and Twitter and all of the social media platforms to raise this issue.

Back in the spring, I testified before Congress about this very issue, is back in April or so that I told them, "Look, there's this disinformation dozen that the Center For Countering Digital Hate had already highlighted several months ago, which are 12 people who are on Facebook, who are responsible for 65% of the disinformation on Facebook and are allowed to continue putting that disinformation out there. They have not been deplatformed."

That's very low hanging fruit to remove those people from Facebook. If you can get rid of 65% of the disinformation out there just by that simple intervention, you could have a huge impact. There's a wide range of people who are among that disinformation dozen. Everyone from John F. Kennedy Jr, to people who peddle naturopathic alternative medicines and denigrate vaccines to create themselves a market for their pseudo drugs. Unfortunately, Facebook has not listened to these appeals and now the White House is also getting increasingly involved in that conversation as well.

Brian Lehrer: Three of our callers have the same question. I'm going to let Kate in Brooklyn ask it and I think it represents some thinking and a question that a lot of people out there have right now. Kate, you're on WNYC with Dr. Celine Gounder. Hi there?

Kate: Hi, Brian and Dr. Gounder. Thank you guys so much for having this segment. I was just speaking with my siblings about this last night. My father is in his 60s and he did the Johnson & Johnson vaccine. We were just discussing if he should be doing a booster of maybe the Pfizer or the Moderna, should he be doing the two shots, just one or what would be your recommendation for him with this new Delta variant?

Dr. Celine Gounder: The data on this points to probably needing another shot. Again, the Johnson & Johnson vaccine is an excellent vaccine. It's so good that we thought one dose would probably be enough and it's only with the emergence of the Delta variant that we're really starting to question that. The CDC has not come out formally with guidance on that. I anticipate they will in the next month or two, so it really depends on how you're feeling about this and whether you want to wait for that guidance.

I think that the data that we have now looking at both vaccine effectiveness, as well as levels of both antibody response, as well as other branches of the immune system The data would indicate, you probably would benefit from an extra dose of vaccine if you got J&J to begin with.

The other thing, I would just point out is mixing and matching vaccines actually seems to be a very good strategy. When we see people who get J&J followed by either Pfizer or Moderna, they have very robust immune responses, perhaps even better than two of Pfizer or two of Mordena. I think you're going to see more mixing and matching of vaccines in the future.

Brian Lehrer: What about the other way around? I know that the question usually gets asked if you have the J&J since there's some doubt now about that. Although, I don't think the data is conclusive, but there's some doubt about whether it's as protective against the Delta variant as the Pfizer and the Mordena. That's the way people are usually asking the question, "If I had the J&J, should I get one of the others as well?"

What about the other way around? What if you had the Pfizer or Moderna vaccines and you're thinking, since the J&J is the one that's a different mechanism, maybe I'll get a broader spectrum of protection if I go and get that one too?

Dr. Celine Gounder: It's a good question. We don't have as much data on that particular sequence. I'd be a little bit more cautious about doing it in that order, simply because we don't have as much data on that. Secondly, the supply of Johnson & Johnson is just nowhere near the supply we have of Pfizer and Mordena. Unfortunately Johnson & Johnson has had some issues with their manufacturing plants. There's one in particular in Maryland called Bio Emergent, that has had some problems where they had to shut down manufacturing for a while. For supply reasons as well, I think it's more difficult to do it in that order.

Brian Lehrer: One of my producers told me they know, at least a few people who've gone rogue and gotten a third shot. They just walked into a local drug store and lied and said they had not received any shot at all or had just received the first shot. Ethical arguments aside, is that a dangerous thing to do?

Dr. Celine Gounder: What I think is unfortunate about that and why I really hope the CDC and the FDA come out with some advice on this soon, is we really need to be gathering that data. We really should be getting information on who's getting vaccines? Is that leading to issues with more side effects down the line in a year or two? How are people going to be able to demonstrate that they got what vaccine when? I think it's really important to be able to gather that data and in the absence of official guidance, it's very difficult to do that.

Brian Lehrer: Kylie and Northern Virginia, you're on WNYC with Dr. Celine Gounder. Hi Kylie?

Kylie: Hi Brian. Hi, Dr. Gounder. This is a very hard conversation. I am in what I'm calling a split household. My husband is not vaccinated, I am vaccinated and I actually had a reaction from the second Moderna shot. I'm actually going through physical therapy right now for a Bell's palsy, which fed my husband's skepticism about the vaccine because I myself had a reaction. Then when this conversation about the booster came up, it further feeding his skepticism.

I don't have so much of a question, I don't know what to do about that, but I just have a comment that I wish that Pfizer, there were some ways to reel them back in. Because the optics of a pharmaceutical company saying what the CDC is not saying, the optics are really bad here and given how much public trust, for skeptical people, I think this is a big challenge. I just wanted to hear Dr. Gounder's reactions to that point because the optics are pretty bad, that a pharmaceutical company is saying, "We might need a booster," when the CDC is saying, "Maybe not, or you don't."

Dr. Celine Gounder: I 100% agree with you. I think that this conversation needs to be led by scientists at the CDC and at the FDA that we should be looking to them for advice on this, not to the pharmaceutical companies. They do have a conflict of interest, even if what they're saying is right, there is a conflict of interest there. I think so much of vaccine confidence is about trust and people who don't feel like they can trust the messenger are going to feel more nervous about getting vaccinated. I think, we really need to have trusted, agencies providing that information.

Brian Lehrer: Kylie, thank you for that story. It's troubling, but also very revealing. How much would Pfizer stand to gain monetarily from a booster shot authorization and how much do you think they are acting out of conflict of interest against science in the interest of their bottom line profits?

Dr. Celine Gounder: I don't want to try to get into the mind of Albert Bourla the head of Pfizer, or other folks at Pfizer, but they certainly see that mRNA vaccines, not just for COVID, but broadly are going to be a highly lucrative market. mRNA vaccines, you're going to see used against other infectious diseases in the near future, but also against cancer, which is an even far more lucrative market. I know for sure that they view this as a source of tremendous profit for the company, whether that is truly driving their statements about additional doses of COVID vaccine, I really can't say.

Brian Lehrer: Regina and Westchester, you're on WNYC with Dr. Celine Gounder. Hi Regina?

Regina: Thank you. My daughter has an autoimmune disease. She received Pfizer shots in January. She recently took an antibody test and learned that she has no antibodies. Now, should she have the booster, Pfizer again, which is readily available, I think. How soon will it show up that she has antibodies? How long will it take for her body to respond?

Dr. Celine Gounder: This is a bit of a complicated question because one, it depends on what kind of autoimmune disease she has and what kind of medication she's on for that. Is that something you're willing to share here?

Regina: She has liver disease. I'm not sure of the medication, but she's had it for many, many years, autoimmune liver disease.

Dr. Celine Gounder: Okay. It really depends on which medication she's on. Some of the medications we use to treat these conditions, you can pause the medication for a month or so, vaccinate in the interim and then restart the medication. In some cases that's plenty. In other cases you may want to give an additional dose. That's really something that probably needs to be discussed in detail with her, doctor and then probably bringing in an infectious disease specialists or immunologist into the mix there.

Brian Lehrer: Regina, I hope that's helpful. Is the antibody test the only measure of whether the vaccine is protecting you? That's what the caller cited, but I've been told on the show by other experts that you can't just judge by these commercially available antibody tests, that you can go to a lab and take, because it could be T-cells that are protecting you or something else.

Dr. Celine Gounder: Yes. This is why the FDA has recommended against routine antibody testing after vaccination. There are many different kinds of antibody tests. Some of them look for an entirely different antibody from the one that you would generate to the vaccine, that you would only generate if you got infected. Of course, if you got vaccinated, but not infected, you're going to show up negative on those antibody tests and so that doesn't really tell you anything.

Some of these antibody tests are less sensitive than others so may be what we call a false negative. We really don't recommend routinely using, antibody tests. I think those only should be used in consultation with an immunologist or an infectious disease specialist who knows exactly which test to order, how to interpret it and that even then should be reserved for people who are at risk of not responding to the vaccine. That's really highly immunosuppressed persons.

Brian Lehrer: Here's a vaccinated Delta variant breakthrough case caller. Louie in west New York, you're on WNYC. Hi Louie.

Louie: Hi. How are you? I got my second dose of the Pfizer vaccine on April 1st. I took a trip recently to Florida and contracted COVID on the 26th. I had full symptoms for three weeks. I just tested negative two days ago, even though I had tested positive just 10 days before that and they had discouraged me from getting retested because they said they assumed that I would come back positive.

Now I'm in a quandary because I am HIV positive asymptomatic for over 35 years now. I'm wondering, would the booster help me. Obviously the vaccine kept me from getting very sick even even though I developed all the symptoms except shortness of breath. When and if would a booster be prudent in my case and are my HIV medications autoimmune suppressing my system at the moment?

Dr. Celine Gounder: Let's break that down piece by piece. We do know people who have HIV, especially if they have aids are at higher risk for severe disease from COVID. If you are on HIV medications, and you are what we call virally suppressed. Your virus in your blood is undetectable, your risk of severe COVID is extremely low relative to somebody who has AIDS. Your HIV medications are going to help you in this situation, keep your immune system strong.

Now, if you did not end up with shortness of breath, which is a defining characteristic of severe COVID, if you did not end up in the hospital, if you did not die, the vaccine worked. That's what we are really trying to protect against. Now, it sounds like you did have some symptoms that were, at the very least bothersome. I'm very sorry that happened. Unfortunately, that does happen to some degree.

What I would say with respect to needing an additional dose of vaccine, you got two doses of Pfizer. Now you've had natural infection. You're essentially what I would call super immune to COVID now, because that infection functioned as a booster in and of itself. I really wouldn't counsel getting an additional dose of vaccine in your case.

Brian Lehrer: I hope that's helpful, Louie. Thank you very much. To wrap this up, since you were on the Biden, Harris COVID advisory transition team, a policy question we've been dealing mostly with medical questions. Two quick policy questions. One is, we see that in France president Macron has now ordered that everybody have to show proof of vaccination, or I guess a negative COVID test if they're going into public spaces. I think that's going to apply to all restaurants and just all public spaces if they're going indoors.

In New York, we have a teeny tiny version of that, Mayor de Blasio ordering that healthcare workers in the public hospital system now to get vaccinated or show proof of a negative COVID test on a weekly basis. You're an advisor to the incoming president. Should anything like that be done on a national level in this country, in your opinion, and assuming that's politically impossible anyway, what should be done at the local level?

Dr. Celine Gounder: Yes, I think at a national level, that's just a non-starter. That's why the White House really has not pursued that kind of approach. I think at a local level, I am actually, have been speaking to some of the local public officials about what this might look like here in the New York city area. I think one, there's a lot of concerns about civil liberties, privacy, that do get in the way of this. You need to have a system that's really easy and fast if you're going to be trying to verify people's vaccination status or testing status.

If you can imagine going to your local restaurant and the waitress needs to be checking everybody, and you don't have an easy app to do that, and then they have to enforce it, all of these small businesses are going to have to hire additional staff to do this, and then deal with irate customers who for whatever reason maybe don't have the credential to show or are positive on a test or haven't gotten vaccinated. That's a big burden on small businesses in particular.

I think unless there's an easy way to do this. I think that's also going to be somewhat of a non-starter. I think what you're going to see are perhaps requirements, like they have for health and hospitals extend to other first-line workers, other workplaces, where employers can be verifying their employees. I think it's going to be very difficult to do that for the general public.

Brian Lehrer: Last question, we have 30 seconds left. How much should we even be talking about administering extra doses or boosters when so many people around the world are yet to receive even a single shot?

Dr. Celine Gounder: Excellent question. If you look at what drives the emergence and variants, it is allowing the virus to spread when it spreads it mutates. It's no surprise that some of these most dangerous variants emerged in countries where the virus was being allowed to spread like wildfire, countries like Brazil, like the UK, like India. Our best protection against variants is to get the rest of the world vaccinated.

Brian Lehrer: Dr. Celine Gounder, Professor of Medicine and Infectious Diseases at the NYU school of medicine in Bellevue hospital. She was a member earlier this year and after the November election of the Biden, Harris transition COVID-19 advisory board, and now founder and CEO of Just human Productions, a nonprofit multimedia organization and she's host and producer of the podcast, American Diagnosis. Dr. Gounder, thank you so much for everything today.

Dr. Celine Gounder: My pleasure.

Brian Lehrer: Brian Lehrer on WNYC. More to come.

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