Controversy has erupted over the policy of booster-dose vaccination against Covid-19, already adopted by some countries and proposed by others. Israel started it for persons over 60 years who were vaccinated more than five months earlier. France and Germany are determined to go ahead with booster doses.
The UAE has given the green light. Cambodia wishes to protect frontline workers with booster doses, who had earlier received Chinese vaccines. The UK and Switzerland have announced plans for vaccine boosters. Public health experts in the US are divided on the issue, while government spokespersons say they await the recommendation of the FDA. Alarmed by these developments, WHO director general Tedros Adhanom Ghebreyesus has implored high-income countries to defer such a practice, at least till the end of September.
Countries wishing to administer the third shot (or a second shot, in the case of the Jenssen vaccine), not heeding WHO’s plea, say they wish to protect vulnerable persons such as the immunosuppressed and the elderly. They argue that the spread of the Delta variant has altered the situation, as it has shown reduced response to immunity from several vaccines. This is different from the very high levels of efficacy demonstrated by those vaccines against the ancestral wild virus or the Alpha variant. While healthy persons still generate sufficient immunity to counter the Delta variant, after two doses of those vaccines, persons who are unable to generate a strong enough immune response may still be vulnerable to severe disease if infected. Hence the rationale offered for a third dose.
Pfizer CEO Albert Bourla set off the controversy when he declared that the Delta variant evoked an immune response that wanes in about 10 months, thus requiring a third shot. Moderna’s Stephane Bancel chimed in, citing ‘variant’ worries. When critics demanded proof, unpublished data from Israel were cited as evidence of vaccine-induced immunity being short-lived against Delta. However, there is, as yet, no evidence that booster doses substantially reduce reinfections, compared to the conventional two doses. Public health advocates say that the companies are motivated by the prospect of more profits, trying to create a continuing market opportunity for their vaccines.
The decision of rich countries to administer booster doses to fully-vaccinated persons, when there is a huge global inequality in vaccination rates, appears an abandonment of global solidarity. More than 80% of the vaccines administered are in high income and upper middle income countries. While UK has vaccinated 65% of its population, less than 2% of Africa has been vaccinated. In high income countries, 101 vaccine doses have been administered so far for 100 people, compared to 1.5 per 100 persons in low income countries.
WHO’s position—that countries which have already vaccinated in high numbers, should avoid third dose boosters and supply surplus vaccines to countries that have much lower rates of vaccination—is ethically correct. Even from a public health perspective, low vaccination rates in low-income countries not only make them highly vulnerable to high rates of severe disease and death, but also make the likelihood of new variants emerging from those populations very high. Should that happen, even the high-income countries will become very vulnerable of those highly infectious variants. They will then have to go for even more booster shots. The only winners will be the virus and the vaccine companies.
WHO does say that special categories of persons who have low immune response, such as immunocompromised persons, may be given booster doses even before September. It is the widespread demand for boosters in rich countries which will become a problem. It is very likely that many who do not fall into the category of vulnerable persons will demand vaccines because they are alarmed by the public discussion on waning immunity and feel endangered. That will reduce vaccine supplies to other countries where many vulnerable people are still waiting for their first shot.
In the US, White House spokesperson Jen Psaki dismissed WHO’s position as presenting a false choice. She said that US has enough doses to administer booster doses and also supply to other countries. One health expert, Leana Wen, said that the US has a large stock of vaccines so close to expiry date that they cannot be sent to other countries and the only option is to use them in the US as boosters. While offering a credible explanation, this disclosure raises questions on why such a large stockpile was created in the first place and how wastage is resulting from vaccine resistance generated by toxic American politics, while the rest of the world craves the shots.’
With international travel now being linked to ‘vaccine passports’, there is a danger of wide disparities in vaccination rates creating two worlds that cannot meet in the near future. Will we see a V-20, of the vaccine aristocracy among nations, holding conclaves which the rest of the world cannot attend? International students and business travellers will find it difficult to travel between these two worlds. The trickle down effect will not work to close the gaps in global vaccination, just as it failed to bridge economic inequities within countries.
High-income countries are exhibiting vaccine nationalism in use of vaccine stocks and patent protection. By doing so, they will put themselves in peril. They must learn to share vaccines, speedily and liberally, out of ennobling altruism and enlightened self-interest.
The author, a cardiologist and epidemiologist, is president, Public Health Foundation of India (PHFI)
Views expressed personal