As wealthy nations weigh offering COVID-19 booster shots to their residents without clear evidence they are beneficial, global health advocates have implored them to focus instead on alleviating vaccine shortages in less prosperous countries where dangerous new variants could emerge if the virus continues to spread out of control.
Health officials across the United States are reporting an uptick in patients seeking an additional dose of COVID-19 vaccines, including some who are apparently willing to lie about their vaccination status to get it. An Associated Press analysis found at least 900 instances of people receiving third doses without Food and Drug Administration approval.
“People are cheating," Dr. Ali Mokdad, chief strategy officer for the Population Health Initiative at the University of Washington, told KOMO. "People are saying, ‘I have not received a single dose and I want to get it.’”
Last week, San Francisco officials announced people who received the single-dose Johnson & Johnson vaccine would be eligible for a supplemental dose of the Pfizer or Moderna vaccines, although they stressed they were not promoting or recommending that. The White House said the city’s policy was “not reflective of current public health guidance.”
Interest in booster shots has risen in recent weeks as the highly contagious delta variant spreads rapidly across the country, filling hospitals and driving some cities to reimpose mask mandates. New data suggests people who are vaccinated might be able to transmit the virus easily once infected, but the shots continue to protect against severe symptoms or death.
Although Pfizer and Moderna have warned they expect booster shots will be needed within a year of the initial two-dose regimen of their vaccines, the FDA and the Centers for Disease Control and Prevention have challenged those claims. It is not yet clear when or if the protection afforded by the initial shots begins to fade, and the vaccines have been highly effective against the known variants.
President Joe Biden’s administration has sought more data before determining if boosters are required, but it has also purchased far more than enough doses of vaccines to give extra shots to all Americans if it is deemed necessary. Other countries are moving faster to offer additional doses in hopes of bolstering immunity against the delta variant.
Israel has begun administering booster shots to the immunocompromised, and it will soon provide a third dose for the elderly, as well. An Israeli hospital study released Tuesday indicated organ transplant recipients were twice as likely to develop antibodies after a third dose compared to the second dose, with no major side effects reported.
Officials in Britain recently announced booster shots would be available to 32 million people who are older or are vulnerable for health reasons starting in September. Germany and France have taken similar steps to provide additional doses to populations at high risk.
Amid the uncertainty about booster shots, federal and state health officials in the U.S. have also stepped up efforts to change the minds of the 30% of Americans who are eligible to get vaccinated but have chosen not to do so. At the same time, the Biden administration remains committed to advancing global vaccine equity, and the White House insists the debate over prioritizing vaccination at home or abroad is a “false choice.”
“We can do both,” White House press secretary Jen Psaki said.
Whether the U.S. and its wealthy allies can do both quickly and effectively enough to stem the spread of the virus and the development of variants is an open question, though. The delta variant was first identified in India, where less than 10% of the population is fully vaccinated, and other mutations of the virus have originated in less-developed countries.
According to The New York Times, only 5.7 vaccine doses have been administered per 100 people in Africa, compared to 87 doses per 100 people in North America. Of the nearly 4.5 billion doses that have been administered worldwide, 0.3% have gone to people in low-income countries.
The White House acknowledges those numbers need to improve, and the U.S. has done more than every other country combined to deliver vaccines to countries that cannot afford to buy their supplies. As the U.S. grapples with its latest COVID-19 surge, those efforts have only made a small dent in vaccination and infection rates in other countries where the virus is thriving.
"You can't build a wall high enough to keep us safe from COVID in other countries," President Biden said last week.
So far, the U.S. has shipped out more than 110 million doses of vaccines to dozens of countries. By the end of August, the Biden administration aims to begin distributing part of a 500-million-dose order it purchased from Pfizer for donation to about 100 lower-income countries.
The need is still dire in much of the world, though, and critics say wealthy nations are making shortsighted decisions under the influence of powerful pharmaceutical companies that stand to profit from selling them booster doses. They argue getting first doses into the arms of more people around the world would slow the spread of the virus more than an extra shot for those who already have some protection.
“Wealthy governments shouldn’t be prioritizing giving third doses when much of the developing world hasn’t even yet had the chance to get their first COVID-19 shots...,” said Kate Elder, a senior vaccine policy adviser at Doctors Without Borders, last month. “Rich governments need to urgently redistribute those doses to the rest of the world. The longer billions of people remain unvaccinated, the more variants will develop that threaten all of us.”
In theory, at least, supply is no longer the issue. Manufacturers are projected to produce 14 billion doses of vaccines by the end of next year, far more than the 11 billion the World Health Organization estimates would be needed to fully inoculate 70% of the world’s population, but achieving that goal would require a drastic shift in priorities for rich countries that have been more concerned with immediate protection for their residents.
“Obviously, it’s great if there are more donations, but it’s more about your place in the queue to receive your vaccine delivery,” said Amanda Glassman, executive vice president of the Center for Global Development, noting rich countries monopolized access to early batches of vaccines and have placed holds on additional doses they might never need.
The World Health Organization, backed by its Strategic Advisory Group of Experts on Immunization, reiterated concerns Tuesday that introducing booster shots at a time of global supply shortages could exacerbate inequities. A review of the available data determined there is “limited and inconclusive” evidence that boosters are needed for most people.
“Offering booster doses to a large proportion of a population when many have not yet received even a first dose undermines the principle of national and global equity,” the WHO said in an interim statement. “Prioritizing booster doses over speed and breadth in the initial dose coverage may also damage the prospects for global mitigation of the pandemic, with severe implications for the health, social and economic well-being of people globally.”
In a separate statement, the WHO cautioned against reducing the size of doses to stretch the vaccine supply. It concluded there had been insufficient research on whether smaller doses would be effective, and it encouraged additional studies on the matter.
The WHO has been sounding alarms for months that the rush to vaccinate wealthy countries while less than 1% of the population of some lower-income nations is immunized could create a “two-track recovery.” The effects of that dynamic could spread beyond public health, as slower vaccination rates are also likely to correlate to a more sluggish economic recovery that places vulnerable and marginalized people at greater risk.
“Vaccine inequity is the world’s biggest obstacle to ending this pandemic and recovering from COVID-19,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said recently. “Economically, epidemiologically, and morally, it is in all countries' best interest to use the latest available data to make lifesaving vaccines available to all.”
Tedros has called for a moratorium on booster shots through the end of September with the aim of helping every country vaccinate at least 10% of its population. However, the WHO does not oppose administering extra shots to the immunocompromised, who might need more than two doses to develop any immunity.
Convincing richer countries to give up some of their vaccine supplies is only part of the solution, though. Covax—the WHO-backed initiative coordinating most vaccine donations—has encountered administrative, financial, and logistical challenges that have left many donated doses unused, and it is not clear it will have the funding and resources necessary to distribute the hundreds of millions of additional doses expected to arrive this fall and winter.
“The next issue is delivery of vaccines, and that’s not a small issue,” Glassman said. “We know that from our experience in the United States.”
An open letter to the White House signed by Glassman and other global public health experts last week urged the Biden administration to develop an aggressive plan to fight “a global war against a virus that doesn’t respect borders.” They warned the rampant spread of COVID-19 in other parts of the world could lead to vaccine-resistant strains developing and undermining the protection wealthier nations have built up for themselves.
“We are facing the very real possibility that low- and lower-middle-income countries will be stuck at low vaccine coverage levels through 2022 and beyond, an outcome that will be deadly,” the letter stated. “The deep divide between vaccine haves and have-nots is a challenge to our conscience and a major threat to our economic recovery and national security.”
The experts’ recommendations included hosting a Global Vaccination Summit, launching an emergency plan for global COVID-19 relief, increasing U.S. and allied vaccine donations to up to 2 billion doses by the end of 2021, and accelerating production, distribution, and administration of vaccines around the world. They also called for strengthening global health systems to prepare for future pandemics.
“We should do it sooner rather than later due to the threat of variants,” Glassman said.