SEATTLE — Filled with action figures, stickers and cartoons, Seattle Children's COVID-19 vaccine clinic has kept busy for months, accommodating hundreds of immunization appointments per week. But staffers have noticed a glaring hole in their schedule recently: Fewer and fewer people are returning for booster shots.
"Boosters have really been ramping down," said Children's nurse manager Emmeline Ong. "It's been a while since we've gotten a lot of those appointments."
When boosters became available in Washington in September 2021, little was known about what new SARS-CoV-2 variants could emerge. Infection levels were on the decline after an explosion of summer delta cases, and the omicron variant hadn't yet taken hold in the state.
At the time, the additional doses were celebrated by public health officials and doctors as an extra, but optional, layer of protection for older adults and those who are immunocompromised.
Nearly a year later, as the coronavirus has continued to evolve and develop new, more contagious subvariants, many experts are changing their tone around boosters — now thinking of them as an absolute necessity for protection against severe disease and death.
Still, rates of booster shots are lagging across all age groups in Washington, but particularly among kids and teenagers, potentially setting the state up for another brutal round of COVID in upcoming months.
"For some reason, there's some complacency around vaccine boosters," said Dr. Seth Cohen, medical director of infection prevention at UW Medical Center. "I'm personally very concerned about what the fall may have in store for us, and what effect decreased booster rates might have in the fall and winter."
On a recent weekday at Seattle Children's, the hospital's vaccine clinic was filled with families, but Shawna Millette and her two kids were one of the only ones in for a booster appointment.
For Millette, a preschool teacher in Mountlake Terrace, the decision to get her children boosted was easy. Her family is traveling by plane soon, and she also wanted 9-year-old Sienna and 6-year-old Easton to be boosted in time for the new school year.
"The booster is not fun," said Millette, who was incapacitated by the virus in February 2020 and missed 16 days of work, unable to walk or eat much. "But it doesn't matter. ... We just want to do our part to keep everyone safe," she said after Sienna and Easton received their shots, with minimal tears.
Washington state trends
In Washington, about 57.7% of people eligible for a booster have received at least one additional dose — meaning more than 40% of the state's eligible population has not, said Michele Roberts, the state's assistant secretary for prevention and health who's been leading COVID vaccine distribution efforts.
Booster rates are higher among older adults, she said. But among 18- to 34-year-olds, 69.7% have completed their primary series, while only 43.3% have also received a booster shot. And while the majority of those 12 to 34 years old have received two doses of COVID vaccine, fewer than half of them have received a booster.
Parents of younger children also seem to be more cautious around boosters and vaccines in general, Roberts said, adding that many want to "wait and see" how rollout goes.
"Children, regardless of age, are also at risk of severe disease from COVID," said Dr. Ruth McDonald, chief medical operations officer at Seattle Children's. "Of course those with underlying conditions are at higher risk, but we've seen that approximately a third — or 1 in 3 — of children hospitalized for COVID disease do not have any underlying risk factors."
Roberts' team has also continued to track booster disparities among racial and ethnic groups, with Asian and white populations reporting the highest rates at 65% and 62.2%, while Native Hawaiian/Pacific Islander and Hispanic populations have reported about 40% to 45%.
"There's just not equal access," Roberts said, pointing to people's challenging work schedules, limited child care and ability to take time off for post-shot symptoms.
Because the state has pulled back on its mass vaccination sites due to "incredibly low" demand, she said, her team has recently relied more heavily on other more direct initiatives, like the Care-a-Van, a mobile COVID vaccination clinic that travels from county to county, prioritizing communities of color and those with less access to health care.
To date, the mobile clinic has doled out nearly 20,000 doses, including about 300 last weekend at community clinics from Ocean Park to Walla Walla. This week, the van is scheduled to visit at least 15 sites in the Tri-Cities, Walla Walla, Auburn, Maple Falls, Bellingham and Seattle.
"Many communities have rightfully had lack of trust in the health care system," said Dr. Mark Del Beccaro, assistant deputy chief for COVID testing and immunization programs with Public Health — Seattle & King County. "So please talk to your trusted health care adviser or community leaders about what is going to be best for you."
Booster timing
One of the most common questions patients have about boosters, according to Cohen at UW Medical Center, is whether they should hold off on getting one to see what updated versions might be available in the fall.
Generally, his response is simple: Get your booster as soon as possible.
For those 50 and older, those with compromised immune systems and people who are often around others or are planning to travel soon, boosters are "really a no-brainer," he said. There might be some situations where it makes sense to hold off until the federal government approves an omicron-specific booster, he said, like if someone is at low-risk of developing severe disease or isn't often in crowded, group settings, but he wouldn't generally recommend waiting.
"Particularly with BA.5, being up-to-date with vaccines is more important than ever," he said. "Two doses does not cut it with omicron."
At the end of July, the U.S. Food and Drug Administration announced it was no longer considering authorizing a second booster for adults under 50 this summer, as some Biden administration officials and outside experts had previously suggested, The Associated Press reported.
Instead, the Food and Drug Administration is focusing on revamped vaccines for the fall that will target the more recent viral subvariants, marking a significant change. To date, all COVID immunizations in the U.S. have been based on the original version of the virus that began spreading across the country in early 2020.
The change comes in response to the rapid spread of BA.4 and BA.5, the two omicron subvariants that are more contagious than their predecessors and have pushed new daily cases in the U.S. above 125,000 and hospitalizations to 6,300. Those are the highest levels since February, though deaths have remained low, at about 360 per day.
While the White House has also emphasized that getting a fourth dose now won't impact a person's ability to get omicron-targeted shots once they're made available, how long it's been since their last dose will play a role in how soon they're eligible, according to the AP.
Details about the upcoming vaccine, however, are limited, Roberts said.
"We don't have info on timing, how many doses will be available and when they'll come," she said. "We also don't know the clinical recommendations yet [from the FDA and CDC]."
Because so much is still unknown, Roberts said it makes more sense for those eligible to get a booster dose now, before another potential fall or winter surge could hit the region.
"The more we can do now to prevent any of us needing hospital care, the better we're going to be able to do and maintain that capacity when there is an emergency and when people really need it," she said. "Yes, we're all going to be glad to get an omicron-specific booster, but any booster is going to help you right now against severe health outcomes."
County efforts
Significant differences in booster rates also exist depending on the county.
In Jefferson County — responsible for one of the highest booster rates in the state — public health teams have worked furiously to keep community vaccination efforts up, even when local infection levels dipped or plateaued.
Dr. Allison Berry, health officer in both Jefferson and Clallam counties, attributed part of the high demand to the county's demographics. In Jefferson County, 39% of people are 65 and older — compared to about 13.8% in King County — and were "interested right upfront" in boosters, Berry said.
When the omicron variant started to send more and more people to the hospital in January, Jefferson County was largely spared due, in part, to its high vaccination rates, Berry added.
As of last week, Jefferson County's booster rates were higher than the state's average in every age group, and more than 10% higher among those 65 and older. About 9.3 people per 100,000 are hospitalized for COVID there, compared to about 19.6 per 100,000 in Adams County and 22.9 per 100,000 in Pacific County — areas with some of the lowest booster rates in the state.
Jefferson County also maintained mass vaccination sites for boosters until February, much longer than in other parts of the state. The county brought on new hires to specifically handle COVID communications and consistently participated in regular Q&As on the county's local radio station, Berry said.
"We've wondered if we should scale our efforts back, but every time we do the weekly radio shows, we find people really listen," Berry said. "Schools and classrooms even listen in on Monday mornings."
Populations in her county also tend to be more politically liberal and vaccine confident, another huge factor in driving demand for boosters, she said.
"We just refuse to ever give up," she said. "In many communities, the booster has felt like an extra. It's really not."
Now, she has a simple clarification for her most of her patients: "If you're under 65, being up-to-date with COVID vaccines means three doses. If you're over 65, it's four."
