Booster bandits and booster jabs

10 Comments

 

With the world clearly divided between those vaccinated against COVID-19 and those who are not, ethicists, public health specialists and politicians have become more preoccupied by the prospect of booster shots. 

The rush to promote boosters in certain countries has not impressed the World Health Organization’s director-general Tedros Adhanom Ghebreyesus. By 9 August, a meagre 12.6 million of the globe’s 4.46 billion COVID-19 vaccine doses were administered in low-income countries. High-income and upper-income states had received 3.65 billion. The WHO had every reason to be concerned.

In an address that month, Ghebreyesus spoke of the plight of Harriet Nayiga, a Ugandan midwife who ‘was one of many health workers in Africa and around the world who was still waiting for her turn to be vaccinated.’ While Uganda had been initially spared the ravages of COVID-19, a surge commencing in May saw variants move through a mostly unvaccinated population. He had received an email from a disconcerted Nayiga. ‘I got my first shot and am yet to receive the second.’

It disturbed the director-general that rich countries were galloping in their rush to acquire booster doses even as ‘hundreds of millions of people’ were still waiting for their first jab. While he understood that ‘all governments’ would seek to protect their people from the Delta variant, ‘we cannot accept countries that have already used most of the global supply of vaccines using even more of it, while the world’s most vulnerable people remain unprotected.’  In his view, a moratorium on boosters should be put in place until the end of September ‘to enable at least 10 per cent of the population of every country to be vaccinated.’

Three reasons for resorting to such shots are advanced by Dr. Katherine O’Brien. The person may not have responded adequately to the first two doses. The second is that immunity wanes over time, meaning that a dose might well arrest that deterioration. Third, the performance of the vaccines might prove inadequate against new variants of the virus. The fact that the vaccines were ‘holding up really well to protect you against severe disease, against hospitalization and against death’ suggested that a third shot was unnecessary.

On 1 September, the European Centre for Diseases Prevention and Control observed that fully vaccinated individuals did not need a top-up shot, nor would it be advisable. ‘Special consideration should be given to the current global shortage of global COVID-19 vaccines, which could be worsened by the administration of booster COVID-19 vaccine doses.’

 

'The battle against COVID-19 has shown that global vaccine solidarity comes a distant second to the partial approaches of high-income states and booster bandits who see vaccinations in terms of clouded self-interest rather than epidemiological soundness.'

 

Another factor is also significant. Unvaccinated reservoirs of people leave the chance wide open to viral replication, creating the prospect for new, more transmissible strains. These may actually blunt or be resistant to vaccine-induced immunity.  An editorial at The Lancet suggests that extensive global vaccination is preferable to avoid a ‘perverse social experiment’, where low income countries would face the ravages of a virus unchecked, leaving high-income countries to re-engineer vaccines to counter new variants.

Despite such warnings, a number of countries have decided to push ahead on the road of self-interest. Israel became the first country in the booster rush, making a third jab available to people 60 and older in late July. Next month, it expanded the eligible pool to anyone 12 and older.  European countries – Hungary, France, Germany, Belgium, and Ireland have begun to, or are in the process of affording additional doses. 

The Biden administration has been adamant that all Americans should receive a booster shot eight months after their second one. White House spokesperson Jen Psaki called it a ‘false choice’ to suggest that the US would have to decide between booster shots for Americans and donating more vaccines to low-income states. ‘We can,’ she asserted confidently, ‘do both.’

But even within the US, the issue is a contentious one. In September, advisors to the US Food and Drugs Administration voted to recommend COVID-19 vaccine booster shots for Americans 65 years and older, and those at high risk of severe illness.  The panel further recommended that various groups of people facing the occupational hazard of viral exposure – health care workers, for instance – also receive the third dose. 

But Rochelle Walensky, director of the Centers for Disease Control and Prevention decided to overrule the panel on the issue of giving booster shots to frontline workers. Her decision was helped by a 6-to-9 vote by the Advisory Committee on Immunization Practices of the CDC, which declined to recommend boosters for people 18 and older at risk of contracting COVID-19 because of where they work or live. Some members argued emphatically for permitting the jabs; others insisted that data on the utility of a third shot remained inconclusive.  This was, concluded Walensky, a case of ‘very clear scientific equipoise.’ In other words, the question remained open to debate.

Despite this public health wrangle, many fully vaccinated Americans had already boasted about receiving their third doses earlier in the year.  Describing them as ‘booster bandits’, Rachel Gutman of The Atlantic claimed they had ‘considered the risks to their body and their conscience and concluded, Hey, it couldn’t hurt.’  The CDC was not even sure how many of these bandits were raiding supply, though an estimate of over 1 million Americans who had received a third shot even prior to the recommendations for immunocompromised peoples was suggested.

The issue in Australia is also problematic. The Nobel Laureate Peter Doherty suggests that old approach: if you have the resources and means close at hand, use them. The institute that also bears his name has noted some research showing that booster shots have the effect of not only restoring immune responses against COVID-19 but enhancing them. 

This is certainly not the view of the authors of a piece in The Lancet, who see such an endorsement, notably in the general population, as premature. ‘If unnecessary boosting causes significant adverse reactions,’ they warn, ‘there could be implications for vaccine acceptance that go beyond COVID-19 vaccines.’

For the moment, the Australian Technical Advisory Group on Immunisation (ATAGI) is focusing on prioritising the uptake of first and second doses, though it foresees ‘a relatively small cohort of individuals, such as those with severely immunocompromising conditions’ who will likely need a third dose. The Therapeutic Goods Administration (TGA) has yet to receive a registration application for additional doses of COVID-19 vaccines. 

The pessimists will claim that such applications are merely a matter of time. The battle against COVID-19 has shown that global vaccine solidarity comes a distant second to the partial approaches of high-income states and booster bandits who see vaccinations in terms of clouded self-interest rather than epidemiological soundness. Those with supplies will continue to apply and administer; those without doses will continue to feel the crippling inequality that characterises their condition, preparing the ground for the next strain, and possibly, then next pandemic.

 

 

Binoy KampmarkDr Binoy Kampmark is a former Commonwealth Scholar who lectures at RMIT University, Melbourne. Email: bkampmark@gmail.com

Main image: Repeated vials with covid-19 vaccine on the blue background. (Yulia Reznikov / Getty Images)

Topic tags: Binoy Kampmark, COVID-19, booster shots, vaccine equity

 

 

submit a comment

Existing comments

It was sad to hear today that production of the Astra-Zeneca vaccine is to end in Australia when the current contract ends. At a time when our Pacific and Asian neighbours are struggling to immunise their populations it is surely incumbent on Australia to keep on producing vaccines and distributing them to those in need until all are given the opportunity to join the anti-COVID campaign.


Joe | 15 October 2021  

Thanks Binoy, a good risk audit article which identifies some major factors potentially leading to further catastrophic outcomes: viral replication and new strains. The statistics are becoming a blur of incomprehensible numbers and we've already effectively burned out meaningful words to alert of any potential further crisis. After "redline" we just remain in the red; there isn't any more. There is a possible solution to redirecting the supply to 3rd world countries: coordinated global legal challenges. Many governments moved quickly to indemnify the vaccine manufacturers and (importantly) medical practitioners to allow the speedy delivery of the then untrialled jabs against law suits by individuals or class action. A successful coordinated challenge to repeal the indemnity and allow damages claims might slow down the practitioners and manufacturers enthusiasm to supply in countries where they were exposed. Then you'd find a period where supply and storage of short term expiry products suddenly became very affordable in the 3rd world. Step in the "humanitarian good will angle" and voila... governments and manufacturers only too willing to oblige; vote winner. The indemnity has served Australia and other G countries well; there comes a time to let the lawyers have a slice of the cake (pandemic). Just sayin'...


ray | 15 October 2021  

Its good to be alerted to the ethics of 'Third-Shot boostering', Binoy. I'm grateful too that Ray sees a way ahead for more equitable 'shot-sharing' with our poorer neighbours. I like your consciousness-raising as well as Ray's thoughtful solution-brokering optimism. I hope and pray that it works.


Michael Furtado | 16 October 2021  

Gordon Brown, Helen Clark et al. have been lobbying US and other governments to help share the Covid vaccine IP intellectual property to allow vaccination programs in the developing world.

If this did happen, then India and China would be key in production and logistics, both have much expertise and high capacity in generic pharma related contract manufacturing.

It simply takes political and commercial foresight, duty of care and will.


Andrew J. Smith | 16 October 2021  

‘global vaccine solidarity comes a distant second to the partial approaches of high-income states and booster bandits who see vaccinations in terms of clouded self-interest rather than epidemiological soundness.’ This is the clouded kernel of the article, clouded because it contains a sneer that the rich are selfish. If there were no scarcity, there would be no ‘solidarity’. There is no competition between rich and poor countries for oxygen, for which booster in-breaths after the first post-natal one are an unavoidable necessity. Perhaps the scarcity should be attended to by some extra-muscular industrial production. ‘Partial’ is because the science is ‘equipoised’ about epidemiological soundness, some medical authorities choosing to go with one poise (Israel, US). Perhaps, the future, where it is easy to be wise in retrospect, may show that the relaxed poise about epidemiological soundness has turned out to be the public health policy equivalent of administering hydroxychloroquine and that Israel and the US were correct. Rather than sneer, the article should pose the simple moral question: assuming boosters are necessary, is it an intrinsic or prudential evil not to do the St. Paul thing (give preference to the poor to get their two shots before we get our boosters)? If it is an intrinsic evil, the poor should get their shots first. If it isn’t, the answer could go either way but perhaps the airline policy applies: put on your oxygen mask first before masking your child. The have your cake and eat it sneer here is: we don’t know what the true scientific answer is but let’s say that Israel (a tiny nation in a militarily existential situation) and the US (military guarantor of world peace and subject daily to a deluge of unvaccinated uninvited guests on its southern border) are selfish rather than prudent.


roy chen yee | 17 October 2021  
Show Responses

Dear Roy, for one who cannot see the habitual pain and insult he causes to others in these columns, this newfound adroitness on your part to reveal and classify the author's intention (which, until now, I had regarded as perfectly befitting St Paul's advice in Galatians 2:10). As a descendant of Messianic Sephardi Jewish converts to Catholicism who sympathises with the plight of the Palestinians I wonder about how many of those on the West Bank might regard your own remarks here as partisan and, in the way you take issue with Binoy, equally sneering. Thanks.


Michael Furtado | 18 October 2021  

Michael, I can interpret roy's comment as generally valid and suitably critical of the article in respect to reasonings and a tone of cynicism. It may be confronting (painful) to deal with roy's direct "plain speakin'" but it's kinda like a splash of disinfectant on a wound, possibly necessary to endure a bit of pain for an outcome, perceived clarity. In a similar roy-like observation, poverty might not have money in their pocket but they've got the numbers to influence the debate in a humanitarian consideration. If we consider the epidemic purely on statistics the common sense approach is protect the majority and limit replication and unknown strains. Previous to now, the vaccine production was too small quantity to be effective so the Israel application was justifiable if not "fair" by a government in application. Consider the global leadering countries who failed in containment; the question was "how can this happen to us?"; their own expectations were higher, as were others. Government has an imperative to its own people; as their exposure reduces or products become unnecessary, locally (e.g.:A-Z) things change but not necessarily properly. I'm with Joe; why stop manufacturing AZ in Australia which is cheaper and less storage-critical when we could export...unless our license is restricted to domestic consumption?


ray | 18 October 2021  


Here you are again, reacting but not responding. The science is ‘equipoised’. That means that there is a 50% chance that we need boosters. The question then, based on the story of the woman who donated two small coins to the Temple, is whether you must give out of your need when you cannot give out of your plenty. If he doesn’t know whether boosters are needed, what criteria should the writer of this article judge someone’s decision to withhold vaccines to be used as boosters? And can he make the criteria explicit for several reasons: humans are rational beings; rational beings make decisions according to principle because that is how like cases are identified as being alike; it is the opposite to rationality to make decisions by whim and emotion. If you cannot find a transparent resort to principle, you are looking at a subterranean appeal to emotion. If you don’t like ‘sneer’, try ‘dog whistle’.


roy chen yee | 20 October 2021  

‘As a descendant of Messianic Sephardi Jewish converts to Catholicism’ One can’t add to Scripture but perhaps you can add to Tradition, or to para-tradition from which Tradition can benefit, a published account of why some Sephardi Jews came under the thrall of the Great Commandment and, for that matter, why some pious Punjabis came under the thrall of the same.


roy chen yee | 20 October 2021  

If I'd understood your last remark, Roy, I'd owe you a laugh. Half marks though for valiance.


Michael Furtado | 22 October 2021  


‘If I'd understood your last remark’: ‘Great Commandment’ should have read ‘Great Commission’ and there is evangelism value in knowing why one side of the family chose to go beyond the Old Testament and the other chose to renounce Guru Nanak.


roy chen yee | 23 October 2021  

Well, Binoy, you've cracked at least the trifecta on this one, with Ray, Michael F and Roy agreeing that we should distribute, or facilitate, the distribution of anti-Covid vaccines more equitably to our poorer neighbours in this world. Andrew J Smith offers some very sensible, practical advice on this one. I agree but am not sure what positive steps, if any, will come from Canberra here. Certainly the poor and often greviously misgoverned Pacific Island nations need our help.


Edward Fido | 19 October 2021  
Show Responses

Protest. Edward, I didn't agree we should, I just made observations on the global statistical risks, reasonable actions and technicalities then suggested how it might be achieved. A basic human right is medical care and similarly an ability to be comphensated for malpractice or negilgence; valued very differently internationally. I'd be hesitant to decide what's appropriate for boosters until there was an established control on migration, testing and frequency of boosters. Not much use giving 100% of the world only 15% protection nor legislating reduced prophylactic protection to nations exposed to immigrants or (more particularly) tourism-oriented border protection policies. Humanitarian imperatives must be supported by people movement restrictions; even double-dose vaccinated can be carriers. The law change might create a shift to vaccine availability and cost but needs the gambit of controls (PPE, barriers, administrative, engineering and elimination) to be wise. Binoy's heart is in the right place, the numbers tell us that; the timing needs to be right to match availability without excessive reduction of immunity elsewhere. Not quite the trifecta but if there was a triella on the race it was paid; but no third dividend.


ray | 21 October 2021  

x

Subscribe for more stories like this.

Free sign-up