While federal regulators continue to limit who can receive a coronavirus booster shot, a growing number of governors from both political parties and other officials are circumventing that guidance to offer boosters to anyone 18 or older in hopes of staving off a spike in cases over the holidays.

California made the first move to expand access when public health officials quietly sent a letter to local health jurisdictions and vaccine providers on Nov. 9, instructing them to trust patients to decide whether a booster is appropriate.

“Do not turn a patient away who is requesting a booster” if the person is 18 or older and has waited the required period after their first vaccine series, the letter said.

Within days, officials in Colorado, New Mexico, Arkansas, West Virginia and New York City endorsed boosters for all adults – and more states and jurisdictions are expected to follow.

“If you’re in doubt and you meet the waiting period, just get a booster. Choose the side of greater protection,” said New Jersey’s Democratic Gov. Phil Murphy, who hinted at a news conference Monday that his state might also make boosters more widely available in the coming days. “With the holidays coming up, we need as many people boosted as possible. It’s that simple.”

The state-level expansion of booster eligibility comes as top-level Biden administration officials are pushing federal regulators to open access to all adults in the United States. Doing so would belatedly fulfill President Biden’s summer promise to make the shots available to most Americans by September.

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Makers of the vaccines are also pressing regulators to open access, as Pfizer and its partner BioNTech last week requested the Food and Drug Administration grant an emergency use authorization to allow all adults to receive its booster dose. The FDA is expected to grant that request this week. The Centers for Disease Control and Prevention’s outside vaccine advisory panel is meeting Friday to discuss expanding booster eligibility for the Pfizer product, CDC spokesman Jason McDonald said Tuesday. CDC Director Rochelle Walensky would need to sign off on a final booster recommendation.

Several panel members say a “boosters for all” recommendation would simplify confusing guidance for clinicians. But they worry an overly broad push for boosters could undermine efforts to convince the unvaccinated to become vaccinated.

The CDC recommends booster shots for people who received Moderna or Pfizer to those 65 years and older, adults 18 and older who are at a heightened risk of serious infection because of underlying conditions, and adults 18 and older with an increased risk of exposure at work or in institutions like long-term care facilities. Those who received the Pfizer-BioNTech or Moderna vaccines must wait six months after receiving their second dose. Any adult over the age of 18 who received a single-dose Johnson & Johnson vaccine more than two months ago is eligible for a booster under the CDC recommendations.

CDC spokesman Scott Pauley reiterated Tuesday that providers are supposed to follow these recommendations. But in practice, local health officials, clinicians and consumers are getting boosters by self-attesting. The guidelines have left many Americans unsure if they qualify to get a shot.

“This was already a confusing and murky area, and the line between who is and is not ‘eligible’ for a booster is not clear,” said Jennifer Kates, a senior vice president at the Kaiser Family Foundation. “Most fit at least one of the federal indications for a booster, and in practice, many were already getting them. At this point, states are leading on this and the train has left the station.”

One federal official who favors boosters for all adults worries that these state and local efforts are getting ahead of federal policy and could undermine the credibility of the FDA and the CDC. But another Biden administration official said the state and local actions were understandable given the uptick in cases in parts of the country. The officials spoke on the condition of anonymity because they were not authorized to discuss the issue.

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S. Vincent Rajkumar, an oncologist at the Mayo Clinic, warned against second-guessing state and local officials.

“They are desperate,” he said. “People know what is happening in their area, and we need to allow them to make judgment calls” based on covid cases in their regions and the availability of hospital beds. “They are in the best position to make that decision.”

Others say a focus on universal boosters is misguided, no matter where it is coming from.

“Our fate this holiday and in early 2022 does not hinge upon boosters,” said Jeremy Faust, an emergency medicine physician at Brigham and Women’s Hospital, in a recent tweet. “It hinges upon the unvaccinated.”

He and others have said the booster push could undermine faith in the vaccines by suggesting that the initial shots are not effective and hurt efforts to increase vaccination rates.

Still, with or without federal approval, states are acting to more widely distribute boosters.

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The conflicting state-level and federal policies put pharmacies in a tricky spot. Even as some states encourage all adults to get booster shots, large national pharmacy chains like CVS and Walmart say they have to abide by the federal rules.

“We understand that some states may expand the criteria for COVID-19 boosters, but our participation in the Federal Pharmacy Program requires us to follow recommendations from the CDC,” Joe Goode, a spokesman for CVS Health, said in an email. “In line with that guidance, we are relying on self-attestation from patients with regards to their qualifying conditions as outlined in the agency’s recommendation and guidance.”

Two days after California quietly told providers to open access to boosters, Colorado Gov. Jared Polis, D, signed an executive order that allowed boosters for anyone who is 18 and older. Polis cited increasing case numbers, waning hospital capacity and overextended health-care workers.

“I’ve been very frustrated with the convoluted messaging out of the CDC and the FDA,” Polis said on CBS’s “Face the Nation” on Sunday. “Everybody should get the booster after six months. The data is incredibly clear that it increases your personal protection level.”

On Nov. 12, New Mexico Gov. Michelle Lujan Grisham, D, issued a similar executive order. Officials in New York City, West Virginia and Arkansas said Monday they encouraged boosters for all adults.

“I think it will eliminate some confusion and it will also encourage everyone across the board that meets this criteria to go get the booster shot,” Arkansas Gov. Asa Hutchinson, R, said at a news conference Monday. “That’s the best protection from the virus and from serious health consequences.”

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West Virginia Gov. Jim Justice, R, said wider access to boosters may help protect vulnerable people in the state, which has the lowest overall vaccination rate in the country. “I absolutely believe if you’re 18 years of age, you can get your booster shot,” he said Monday.

To maneuver around the federal rules, many states zeroed in on this part of the FDA’s emergency use authorizations for booster shots: Those who are at increased risk due to “institutional” exposure qualify for a shot. Officials in Colorado and other jurisdictions have argued that an entire geographic region qualifies as an “institution” and justified expanding boosters because high case rates put every resident at increased risk.

“We decided the state, as an institution, has a higher exposure for people in that institution,” Eric France, chief medical officer for the Colorado Department of Public Health and Environment, said in an interview last week. France said he did consult with the CDC to explain his reasoning before implementing the policy.

Officials in New Mexico similarly declared the entire state a “high-risk setting.”

“Case counts are significant, spread rates are far too high and the delta variant is far more transmissible than previous variants,” Department of Health Acting Secretary David Scrase said in a statement. “In addition, our hospitals are well beyond capacity, and several have declared Crisis Standards of Care. Those factors absolutely make New Mexico a high-risk setting.”

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