The need for boosters depends on what a country’s COVID outbreak looks like and which vaccines are in use. (Gauteng provincial government, Twitter)

Please note: Fully vaccinated people over the age of 18 can get a booster dose from 23 February 2022. Instead of a six month gap, people can now get a booster vaccine 2 months after their first Johnson & Johnson jab or 3 months after their second Pfizer shot. The health department now also allows a “mix and match” approach to boosters, which means people can choose Pfizer or Johnson & Johnson regardless of which one they got previously. Teenagers are not eligible for a booster.

  • South Africans over the age of 18 who received both doses of the Pfizer COVID vaccine can get a third booster dose of the jab in early 2022.
  • People of 12 and older can also get an extra Pfizer dose if they have an extremely weak immune system, 28 days after receiving their second shot. This is technically not a booster, but forms part of the primary vaccination schedule of such people because the normal number of doses don’t work well enough for them.
  • South Africa’s medical regulator has not yet received an application or data for a “mix-and-match” approach to boosters. Technically, the health department can make a policy decision on “mixing and matching” without the regulator’s approval, but in this case, the department has asked the regulator to make a recommendation that they will then follow. Until such a recommendation, people can only receive a Pfizer booster if that is the vaccine they originally received.
  • Johnson & Johnson (J&J) has also applied with the regulator for booster approval. If approved, the health department says Pfizer and J&J boosters will be rolled out simultaneously in January.

All South African adults who were vaccinated with Pfizer’s COVID jab can get a third dose — the health department says the roll-out will most likely start in January and will be phased in, starting with people of 60 and older

The extra shot was approved by the South African Health Products Regulatory Authority (Sahpra) on 8 December for everyone over 18 who got their second dose at least six months ago.

South Africa, however, will still not be allowing a mix-and-match approach to booster shots. This means that you can only get an extra dose of the vaccine that was used for your primary schedule. Technically, the health department can make a policy decision about mixing and matching without Sahpra’s approval, but Sahpra says in this case, the health department has asked them to study data and make a recommendation.

In the case of Pfizer, booster doses are given six months after the second dose, but additional doses are administered 28 days after a second shot. People with weak immune systems who have been jabbed with Johnson & Johnson (J&J) can also get an additional dose 28 days after their first J&J shot.

Booster doses of J&J’s jab have been available since 8 November to the half a million healthcare workers who were vaccinated through the country’s Sisonke implementation trial.

These doses are being provided through a new leg of the study, which will end on 17 December.

The Sisonke study ran from February to May and immunised 496 900 healthcare workers with J&J’s COVID jab. The programme used leftover stock from J&J’s international vaccine trials and ran at a time when South Africa had no other jabs available. The local study’s goal was to provide protection to South Africa’s frontline workers.

Sahpra on 29 October approved a submission by Sisonke’s researchers, according to Sahpra’s chief executive officer Boitumelo Semete-Makokotlela. The regulator’s task was to review the data and to decide whether it is safe and potentially effective for the trial’s participants to get another shot up to eight months after their first jab.

What is a booster shot?

Each COVID vaccine comes with its own recommended dose.

For example, the J&J jab requires only one dose which means, at this stage, that you are considered fully vaccinated after just one shot. Meanwhile, those who get the Pfizer vaccine are only considered completely immunised after getting two jabs.

But, some countries such as the United States and Israel, have decided to give an extra shot to some of those who are already fully vaccinated. These extra doses are called “booster” shots, as they are additional jabs given to people already fully immunised.

For now, boosters are mostly given to specific groups of people. Extra shots are especially important for people who have weakened immune systems, such as people who have undergone a bone marrow transplant or who are 60 years or older.  

People who have had organ transplants use medication that suppresses their immune systems to prevent their bodies from rejecting the organs and older people’s immune systems respond less effectively to foreign invaders in their bodies than those of younger people

Such individuals may therefore not be able to build up enough protection after receiving the standard number of vaccine doses.

How long do COVID vaccines protect you? 

Waning immunity is not a new concept — it also may not be a reason to panic.

Childhood vaccines, such as jabs used for protection against measles and mumps, have shown a yearly drop of between 3 and 10% in the amount of antibodies that people produce against those diseases after vaccination. 

In the case of COVID, vaccines protect people against getting very sick with the disease, but we don’t yet know how long that protection lasts and the strength of the protection remains unclear. 

For the Pfizer vaccine, there’s some data that shows people are protected against symptomatic COVID for about six months after having received two shots, but scientists don’t yet know for certain whether the fact that people produce fewer antibodies against SARS-CoV-2 (the virus which causes COVID-19) six months after they had been fully immunised with certain jabs, translates into weaker protection against the virus.

Here’s why researchers don’t yet have an answer for this.

Your immune system consists of complex defence systems and some of these responses become weaker as time moves on after vaccination. Each part of your system is responsible for a different type of attack on foreign invaders such as viruses or bacteria. 

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Your immune system produces two types of cells to get rid of germs, attack them and to kill off infected cells. They are called B cells and T cells.

B cells make antibodies which fight against the invading germ. T cells, on the other hand, fight and remove cells which have already been infected by the invading germ. When you’re exposed to SARS-CoV-2, your body has to fight off the virus using these internal defence systems.

Your immune system’s ability to “remember” germs it’s come across in the past is an important part of why vaccines are so successful.

Back in May, a group of Australian researchers published a paper in Nature Medicine predicting that after eight months the protection provided by COVID vaccines against infection would drop — but they would still be protected from severe disease.

That’s because of memory cells, which can be T or B cells, but we’re only looking at B memory cells in this article. 

Memory B cells make antibodies when they come across a familiar foe. Although the number of antibodies people produce may decrease from about six months after vaccination, memory cells usually stick around for longer. 

An October paper in Science found that memory B cells triggered by mRNA vaccines increased six months after people had been fully immunised. This protection also held strong for the Alpha, Beta and Delta variants of the virus. The mRNA COVID jabs on the market are Pfizer and Moderna’s shots (South Africa uses Pfizer).

The increase of memory cells over time in those who have been vaccinated seems to mirror similar findings in people who were naturally infected with SARS-CoV-2 and recovered from COVID. In a February study in Science, their antibodies had begun dropping eight months after infection, but memory B cells increased.

So even though people may be losing some antibodies a few months after vaccination, it doesn’t necessarily mean that the jabs aren’t doing their job.

In summary: Your immune system has many different prongs through which to protect you and antibodies are only one part of that. The long-lasting presence of memory B cells and the continued protection vaccines grant against severe disease means that boosters may not be entirely warranted just yet.

How does a country decide if they need boosters?

The need for boosters depends on what a country’s COVID outbreak looks like and which vaccines are in use.

The World Health Organisation (WHO) says there are three things nations should look at when considering booster shots.

The first is waning immunity.

The second factor the WHO says countries should look at when they decide if they need boosters pertains to how long vaccines protect people against specifically mild forms of COVID infection — in other words, the likelihood of getting infected with SARS-CoV-2. Most of the research that looks at protection against mild COVID has, so far, been conducted in unvaccinated people.

What scientists now need to find out is how well vaccinated people are protected against mild COVID disease and if that protection changes over time.  

But statistics about breakthrough infections are promising. Breakthrough infections are infections which occur in vaccinated people, so it’s when people get infected with SARS-CoV-2 despite having received a COVID jab. 

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Data from England shows one Pfizer jab offers 36% protection against mild infection from the Delta variant and two shots reduce your chances of infection by 88%.

The Delta variant is the form of the virus which is currently dominant in South Africa.

Real life data from the US government’s Centres for Disease Control (CDC) reveals that fully vaccinated people are five times less likely to get infected with the Delta SARS-CoV-2 variant than those who are unvaccinated. 

Lastly, the WHO says, governments must consider the ethics of supplying booster jabs to their populations when much of the developed world is still waiting for jabs to complete round one of their roll-outs.

“Offering booster doses to a large proportion of a population when many have not yet received even a first dose undermines the principle of national and global equity,” the WHO warns.

South Africa has bought enough doses to immunise 40-million people and has fully vaccinated 19.5% of its population so far. 

What is happening with COVID in countries that are rolling out boosters? 

In July, Israel became the first country to introduce COVID boosters for those over 60. Less than a month later, the extra shots were available to anyone over 30. When the country started to roll out boosters, 62% of the population had been fully vaccinated, yet there was a surge of COVID cases. 

Scientists were concerned that the rise in infections was because of the highly infectious Delta variant circulating in the country and the fact that the protection offered by vaccines was possibly waning

An August preprint study from Israel showed that immunity had begun dropping in vaccinated people six months after they had been fully immunised.

More Israel data was published in the New England Journal of Medicine (NEJM) in October, showing that six months after a second Pfizer vaccine jab, the immune system’s antibody response substantially decreased, especially among trial participants who were men, people older than 65 and those with weakened immune systems.

They also found that antibody levels were stronger in people who had previously recovered from COVID and then gotten two Pfizer shots compared to those who had never been naturally infected and only been vaccinated. This, researchers argue, could possibly indicate the benefit of people receiving a third booster shot.

What do we know about boosters?

In October, data from this booster roll-out was published in the NEJM. Israel’s approach to giving third doses of Pfizer’s vaccine helped lower the chances of people getting infected with SARS-CoV-2 and developing severe illness.

The NEJM paper shows that 12 days after receiving the third shot, people over 60 were almost 20 times less likely to develop severe COVID than those who had gotten the standard two-dose vaccine. Study participants who received boosters had been fully vaccinated at least five months prior.

Following Israel’s lead, several countries began rolling out booster programmes.

In September, the US Food and Drug Administration (FDA) approved a third Pfizer shot for everyone aged 65 and older, as well as for those who may be younger but at high risk for severe disease.

In October, the FDA also cleared Moderna and J&J COVID vaccines to be used as booster shots. (The Moderna vaccine is not part of South Africa’s vaccine roll-out.) 

Moreover, the US regulator approved the “mix and match” use of vaccines. That means people who received Pfizer’s two-dose vaccine initially would be able to get a J&J or half a dose of Moderna vaccine for their third dose.  

Those who got J&J’s one-dose vaccine can likewise be given one Pfizer shot as their third dose. 

Third doses should be administered at least two months after a person has been fully vaccinated with one dose of J&J, or six months after two doses of Pfizer, the statement reads. 

This decision followed data from a preprint study which showed that people who started off with a J&J shot were better off with a Pfizer or Moderna jab as their booster. 

For people who had Pfizer or Moderna in the first round of vaccinations, it didn’t make much of a difference whether they got a J&J, Pfizer or Moderna booster – they all worked equally well. 

South Africa’s health minister, Joe Paahla, said in October that the health department will offer Pfizer jabs as second doses to people from South Africa who had received a first jab of the Moderna or AstraZeneca vaccines in a different country. 

[Update: 2021/10/29 13:40 This article was updated to reflect that South Africa’s medicines regulator approved an updated study protocol submitted by Sisonke researchers. Health workers vaccinated as part of the study will now be eligible for a booster dose of the J&J vaccine from 8 November.]

Please note: On 23 February 2022 fully vaccinated people over the age of 18 can get a booster dose. People can now get a booster vaccine 2 months after their first Johnson & Johnson jab or 3 months after their second Pfizer shot. The health department now allows a “mix and match” approach to boosters, which means people can choose Pfizer of J&J regardless of their previous shots. Teenagers are not eligible for a booster.

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Aisha Abdool Karim was a senior health reporter at Bhekisisa from 2020 to 2022.

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Joan van Dyk is Bhekisisa's acting news editor.