J&J-vaxxed, mRNA-boosted, and pondering a third shot

Reviewed by Emily Henderson, B.Sc.Mar 1 2022

Yes, we are all exhausted by the covid pandemic. Flummoxed by the constantly shifting science and guidelines. Worried about a succession of scary new variants, each with its own name, like hurricanes.

But a sizable minority — nearly 17 million U.S. residents, including me — has its own special quandary. Our initial vaccine was Johnson & Johnson, which was just one shot, and that has many of us confused. Are we fully vaccinated, even with a booster, or should we get a third shot to catch up with the 92 million vaccinees who got two doses of Pfizer or Moderna early on and have since been boosted? Since J&J has largely disappeared from the public eye, actionable information is in scarce supply — not to mention that the guidance is constantly shifting, for everybody.

On April 4, 2021, I dutifully traveled across Los Angeles to line up for my J&J shot at a mass vaccination site. Like many of my J&J brethren, I was following the advice of public health officials to take the first available vaccine.

At the time, J&J was kind of a cool newcomer among covid-19 vaccines. The protection it provided against illness, though apparently less than that afforded by the so-called messenger RNA (mRNA) vaccines from Pfizer and Moderna, seemed sufficient to ward off serious illness.

And while those vaccines required two shots, J&J was billed as "one and done" — a big advantage for people with needle phobia and for transient populations, including farmworkers, people living in homelessness, and inmates in county jails. Its easy storage requirements, compared with the deep freeze needed to handle the Pfizer and Moderna vaccines, also made it a good choice for remote rural populations.

But just days after I got my shot, the reputation of J&J entered what would prove to be a disastrous tailspin, with news of the vaccine's link to a rare but potentially deadly blood clotting disorder. That prompted federal health officials to hit the pause button on it, only to clear it 10 days later and then reverse course in December by recommending the Moderna and Pfizer vaccines over J&J's, mainly because of studies that intensified the blood clot concern.

In the interim, J&J was plagued by production snafus and concerns about its vaccine's efficacy. Research showed a disproportionate share of breakthrough infections among J&J vaccinees during a covid surge on Cape Cod last summer. State data from California covering most of 2021 paints a similar picture, not only for infections but also for hospitalizations and deaths.

With J&J seemingly destined to be a benchwarmer among covid vaccines in the U.S., it often has been left out of public discourse and guidance on covid.

"Very little J&J vaccine is currently being used, which is part of the reason that people don't talk about it very much anymore," says Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center in Nashville, Tennessee.

When the Biden administration first recommended boosters in August, it initially excluded J&J vaccinees, citing a lag in the data.

No wonder the citizens of J&J Nation have been feeling a bit like neglected stepchildren.

"I wish I had chosen something that more people had received so I could get more information," says Leah Justman, a 39-year-old resident of Los Angeles, who preferred the J&J shot last April because she was breastfeeding her newborn baby at the time, was nervous about the new mRNA technology, and thought J&J was "more similar to getting a regular vaccine."

Now, she says, she feels as if there's a bit of a stigma attached to being a J&Jer: "When I go to restaurants or show that I'm vaccinated, people are like, 'Oh my God, you got J&J.' It's almost like a joke, where people think, 'Thank God I didn't get it.'"

In December, Justman got the half-dose Moderna booster recommended by the Centers for Disease Control and Prevention. That leaves her behind the curve compared with Moderna and Pfizer recipients who received two full doses initially and a booster later on. She worries about how long she will be protected and what her next move should be.

There appears to be a growing consensus in scientific circles that one shot of J&J was never enough and that it could account for the lower efficacy compared with the mRNA vaccines.

"A lot of us believe it should have been a two-dose vaccine all along," says Bradley Pollock, associate dean for public health sciences at the UC Davis School of Medicine. In coming months, he says, "it is entirely possible that they're going to say a three-dose schedule is full vaccination."

That got me thinking about whether I am fully vaccinated. Factoring in the half-dose Moderna booster I received in late October, I'm still behind those who've had three Pfizer or Moderna shots.

I've spoken to several J&J vaccinees who, thinking similar thoughts, sought a second booster even though the current federal guideline for J&J vaccinees calls for just one mRNA booster, two months or more after the initial vaccination.

I recently went online to book an appointment for a second Moderna booster. On my first try, I got a message from the pharmacy saying I wasn't eligible. A second pharmacy allowed me to book a slot, but I canceled at the last minute after receiving dissuasive emails (albeit mild ones) from two of my expert sources.

"It's not as quantitative as you're making it out to be," wrote Dr. George Rutherford, a professor of epidemiology at UCSF. The J&J and mRNA vaccines work differently, he said, "so it's not like one J&J plus one Moderna equals 1.5 Pfizer doses. I don't think it will make you sick, but I'd just sit tight. Omicron is going away."

New research suggests that as few as two covid shots could be enough to protect most people from serious illness and death for many months, or even years.

If you are among the nearly 17 million J&J people and have had a booster, consider standing pat like I finally did. But if you haven't had a booster yet, do so ASAP. It seems clear, or at least as clear as anything can be where covid is concerned, that if you are vaccinated and boosted, your risk of developing severe illness is very low.

New federal guidance allows for a second booster if your immune system is compromised by, for example, cancer treatment, HIV, or an organ transplant. If you're not immunocompromised but are worried about weak protection, you can try to persuade a pharmacist or the staffers at a vaccination site to give you another shot. It won't be easy, but it's possible. Or talk to your doctor, who may be willing to prescribe one.

Now that I've spent most of this column pointing out the problems with the J&J vaccine, it's only fair that I say a few positive things about it.

First, even though it appears to be less effective than the Pfizer and Moderna shots, the J&J vaccine still provides a high degree of protection against serious illness and is vastly preferable to no vaccine. J&J, which is cheaper than the mRNA vaccines and easier to transport, also has a critical role to play in low-income countries with large rural populations and poor transportation infrastructure.

Even in the United States, where use of the J&J shot has declined sharply, it's helpful to have the vaccine in stock. It's a good alternative for those who are anxious about the mRNA shots and would otherwise not get vaccinated.

And it's always possible that demand for it could return. The mRNA vaccines carry a risk of heart inflammation for young men, a side effect that appears to be short term in most cases. But if future studies show it can lead to permanent damage or even death, "that would make the J&J vaccine potentially at least as attractive, if not more attractive," says Dr. Walter Orenstein, a professor of epidemiology at Emory University in Atlanta.

The vaccines are still new, many clinical trials have yet to yield unambiguous results, and every new variant throws doubt on data collected when a different strain was dominant.

"It may turn out to be true that three doses or two doses and a variant-focused booster are going to turn out to be best. We don't know yet," says Dr. Gregory Poland, director and founder of the Mayo Clinic's Vaccine Research Group in Rochester, Minnesota. "And the way things have been going, we will barely be getting the answers to those questions, and more time will have passed, and a new variant will arrive."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.