While the FDA and CDC have yet to weigh in on fall Covid boosters, experts in infectious disease and public health are already discussing who should get them, and who may not need to.

High-risk groups get a resounding “yes” — but when it comes to younger, Healthy adults, the answer is less clear.

There’s wide agreement that older adults will receive a hearty recommendation to receive the booster, which targets the XBB.1.5 strain, said William Schaffner, MD, of Vanderbilt University Medical Center in Nashville, Tennessee and a spokesperson for the Infectious Diseases Society of America (IDSA).

The same goes for people younger than 65 who have chronic conditions, are immunocompromised, or who are pregnant, he said.

“Now for adults who are otherwise healthy and younger than 65, and young adults, adolescents, and children, that’s all going to be debated,” Schaffner noted, anticipating how discussions at CDC’s Advisory Committee on Immunization Practices (ACIP) will go when the group meets on September 12. “Whether they receive a routine recommendation or one for shared clinical decision making … I think there will be some brisk discussion about that.”

Aaron Glatt, MD, of Mount Sinai South Nassau in Oceanside, New York, who is also a spokesperson for IDSA, said that people “who have been vaccinated, who are healthy, who are younger, are probably not the first people who should be getting in line to get another COVID booster, especially if they’ve had one.”

In addition, someone who’s recently had COVID probably doesn’t need a booster, he added.

Glatt was a strong advocate for shared decision making when it comes to COVID boosters. He gave the example of a 62-year-old who was boosted 6 months ago and is in good health. “I think for that group, there’s more leeway to say, let’s individualize the decision.”

Georges Benjamin, MD, executive director of the American Public Health Association, said unlike last year, when CDC recommended bivalent BA.4/5 boosters for all people ages 5 and up (and later expanded the recommendation further), he expects CDC to take a risk-based approach to its recommendations.

“The good news is that you’ve had the full primary series of the vaccine and a bivalent booster, or you were vaccinated and infected, you have substantial protection against getting very sick and dying,” Benjamin told MedPage Today. “But the older you are, the greater your risk of getting very sick and dying.”

Paul Offit, MD, of Children’s Hospital of Philadelphia, said the goal of the vaccine has always been to prevent serious illness, and on that basis, the highest-risk groups who should be candidates for vaccination include the elderly, especially people over 75; people with multiple chronic conditions; pregnant people; and the immune compromised.

“These four groups will get the most benefit,” Offit said. “We’re just not going to prevent mild disease for a short-incubation-period mucosal infection for any reasonable amount of time.”

Neither Schaffner, Glatt, nor Offit thought children should be strongly recommended to get a COVID booster. Schaffner noted that in young children, Omicron has been less likely to cause severe disease. In addition, he said, doctors are seeing less multisystem inflammatory syndrome in children (MIS-C) due to COVID.

“Virtually every child has been exposed to COVID through infection or vaccination or both, so the population immunity, children included, is pretty high,” Schaffner said. “I wouldn’t be surprised if some of the recommendations for these younger healthy populations are in the shared clinical decision-making category.”

“Why does a healthy 12-year-old with three doses of vaccine need another dose?” Offit said. “There would have to be protection against severe disease and I just don’t see that evidence.”

Glatt noted that “an immunocompromised, very sick child is a different story.” But if the child is healthy, “you’d really have to show me [good data] that there’s a reason to [boost].”

Even the U.K. is focusing its booster recommendations on older and more vulnerable people. Its Joint Committee on Vaccination and Immunisation (JCVI) recommended offering vaccines to those at high risk of serious disease, including adults ages 65 and up, people with chronic conditions, and people who work in care homes for older adults.

Indeed, that recommendation makes sense from a population health perspective that asks who would benefit most from this intervention, said Bob Wachter, MD, of the University of California San Francisco.

But he believes even young people can get an incremental benefit from fall boosters. Wachter, whose wife has long COVID and who himself experienced a trip to the hospital because of COVID — not from respiratory distress, but from a related fall — said he would recommend a booster to his 30-year-old children because the benefits outweigh the minimal risks.

Even though people in this age group have a low baseline risk of hospitalization from the disease, a booster would reduce that risk even further, he said. It might also help lower their risk of long COVID, he added.

“I start from the baseline that this is a very safe intervention, and there is potential benefit in almost everybody, including relatively young and healthy people,” Wachter said. “But to the question of who’s most likely to benefit, clearly those are the people at higher risk of bad outcomes.”

He added that this year’s fall booster will probably not be very popular, “because not a lot of people got it when the risk was higher and the public attention on COVID was greater.”

“It’s pretty clear that the national consciousness is over it,” he said. “If you’re a healthy 40-year-old, you’re not making a crazy choice not to get boosted.”