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End College Booster Mandates
Outdated and overcautious policies are doing more harm than good.
By Leslie Bienen DVM MA, Allison Krug MPH, and Shveta Raju MD, MBA
In April, a Stanford doctoral student from Portugal almost lost his visa over his lack of a Covid-19 booster. Failure to comply with Stanford University’s booster mandate for all students, even those studying virtually, results in an “enrollment hold,” meaning they cannot register for classes and thus risk losing their student visas and housing. The student, Diogo Braganca, finally received a religious exemption soon after taking his story to the media. Braganca had recently recovered from a mild Omicron infection, which has been shown to boost vaccine-induced antibodies. Not only did his recent infection mean he did not need a third shot—his belief that the potential harms are likely to outweigh the potential benefits was grounded in reality. As of June 7, however, Stanford still requires students to be boosted or undergo twice-weekly asymptomatic testing.
Hundreds of other universities continue to enforce booster policies that were crafted in the fall of 2021, when vaccination was more protective against breakthrough infections and we had fewer data on the risks of vaccination in certain groups.
The truth is, booster mandates on university campuses are an example of the failure of public health officials and college administrators to follow the data and acknowledge both natural immunity and the potential harms of overtreatment. It is time to recognize that mandates requiring healthy students who are vaccinated or have natural immunity to get boosted is bad policy and bad medicine.
A primary reason that booster mandates don’t pass a risk-benefit analysis is that initial vaccination and natural immunity both provide durable protection against severe illness. One study found that prior infection provided 88% protection against severe disease from Omicron with about one year of follow-up. Meanwhile, the CDC has estimated that the chance of hospitalization due to Covid for unboosted but fully vaccinated young adults ages 18 to 29 is about 1 in 8,700. A Canadian study showed that the true risk of hospitalization in younger age groups during Omicron was possibly half this high—closer to 1 in 17,000. And while a booster on top of the primary two-dose series does provide short-term protection against symptomatic infection with Omicron, that protection wanes quickly, within weeks to a couple of months.
Another important consideration is missing from policies mandating boosters for young people: adverse events after boosters are more common than infection-related hospitalizations. Multiple studies, including new data analyses by the CDC, have shown that the mRNA coronavirus vaccines pose a small but nonzero risk of post-vaccination myocarditis, a type of heart inflammation, especially among males. A recent study placed the risk of a likely booster-related cardiac injury at 1 in 6,800 young men, which aligned with data from Israel placing the chance of myocarditis at 1 in 7,000 to 9,000. The upshot is that once young adults are vaccinated or recovered from Covid, their risk of hospitalization from infection drops so low that nearly any harm that boosters cause—even if it is extremely small—weighs the scales against forcing a booster.
Perhaps these data are what persuaded Cornell University to drop its booster mandate, though their website says they still “strongly encourage” it. This change is a major step in the right direction, and all colleges and universities that are still requiring booster doses should follow suit. But Cornell’s decision is an outlier—more than 300 colleges continue to mandate boosters, and some are even considering requiring a fourth dose.
Ironically, the infections these colleges are trying so hard to prevent may be an important part of building future immunity. Until a nasal vaccine becomes available, breakthrough infections will be inevitable because current vaccines do not generate antibodies that line the upper airways, where the virus first enters the body. In the meantime, breakthrough infections, unlike vaccines, do provide this type of immunity, known as mucosal immunity. In many cases, a booster will just be delaying superior protection that comes from infection.
Repeated boosting with outdated antigens may actually be counterproductive in other ways, too. In a recent conversation, Pawel Kalinski, a Buffalo-based immunologist, explained that, contrary to the idea that more vaccinating will lead to better immunity, the opposite may be true. “By injecting an older version of SARS-CoV-2 antigen into a recently recovered person, we risk shifting T and B cell resources to a target that is less relevant than the newly mutated virus the body just battled.” This argument adds fuel to the idea that, particularly for young people who have recently had Omicron, requiring boosting may be leaving them worse off.
Mandatory boosting in order to prevent infection is, in many cases, just delaying the inevitable, and preventing the form of immunity that comes from infection. Initial vaccination, meanwhile, may be less effective against Omicron than against prior variants, but it does greatly reduce the potential of serious illness. This is why universities should accept a history of Covid-19 or primary series vaccination as a requirement to be on campus, as is done for measles and chickenpox, and let go of requiring boosters.
If evidence emerges that boosters substantially limit transmission or provide significant and long-lasting protection against serious illness to young healthy people, or if variant-specific vaccines become widely available, then an updated calculation of risks and benefits is warranted. But, as of now, such vaccines are still in development. If university administrators are willing to follow the data, they should abandon punitive booster policies that are likely doing more harm than good.
Leslie Bienen is a faculty member at the OHSU-Portland State School of Public Health.
Allison Krug is an epidemiologist in Virginia Beach, Virginia.
Shveta Raju is a primary care internal medicine physician.