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.
Dr 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)