COVID-19 booster shots are highly controversial from a global perspective. Similar to other industrialized nations, 75% of the people in United States have taken at least one dose, 63% are fully vaccinated, and 25% have received the booster.
Yet, more than 30 countries worldwide have less than 10% of their population vaccinated. Many of these nations had problems with refrigeration storage and shortages of syringes before the pandemic began.
Central Africa is a vaccine desert. Consider these examples: The Democratic Republic of Congo — a nation of 90 million people — has 0.4% of its population with at least one shot and 0.2% fully vaccinated. Nigeria does a little better with 6.2% with one shot and 2.5% fully immunized.
President Biden announced recently that the Federal Emergency Management Agency (FEMA) will stand up vaccination clinics all across the country specifically to give booster shots to those who have been completed the standard two-shot regimen. The third-shot booster dramatically increases the immune response for the Pfizer and Moderna vaccines.
Meanwhile, Israel is deploying a fourth shot — or second booster — because of signs of waning immunity in its third dose. The nation’s pandemic response team ruled that medical workers and anyone older than 60 years of age could receive a fourth shot of the Pfizer coronavirus vaccine.2 The shot will be available four months after receiving the third dose.
Now the Centers for Disease Control and Prevention (CDC) has called for boosters for all eligible to be vaccinated. Certainly, this raises ethical questions and it could undermine the pandemic response because highly mutated variants will continue to arise in unvaccinated patients.3
“I was a holdout on boosters,” said Joshua Barocas, MD, an infectious disease physician at the University of Colorado Anschutz Medical Campus, at a recent briefing by the Infectious Diseases Society of America (IDSA). “I agreed, and I still agree, with the World Health Organization (WHO) that vaccine equity is one of the most important things worldwide that we need to do. That said, I have been boosted. I was boosted because I want to protect my community and I want to protect myself so that I can remain in my workforce. Boosters have been shown to do just that.”
‘Do What You Can, with What You’ve Got’
Karam Ahmad, MPH, a policy analyst at the Colorado Health Institute in Denver, wrestled with this problem as well after reviewing the global inequities in vaccine coverage.
“These glaring disparities raise a question: Are those who are getting boosters while so many have not had access to even an initial dose doing the right thing?” Ahmad wrote in an essay.4
Even wanting to do the right thing carries considerable logistical challenges, as Coloradans cannot simply increase the global supply of vaccines by sending their booster doses abroad, he noted. They could defer for ethical reasons, but at this point, he recommended against it.
“A saying made famous by Theodore Roosevelt comes to mind: ‘Do what you can, with what you’ve got, where you are.’” Ahmad wrote. “‘What can be done now is getting people vaccinated and boosted, being good stewards of resources, and pressuring political leaders for more support for global vaccine efforts.”
Indeed, leaders of rich nations must follow through to help the world’s population, about half of which is completely unvaccinated for COVID-19, UNICEF USA reports.
“Just 6% of Africans are fully vaccinated,” UNICEF says.5 “Africa cannot wait. More COVID-19 vaccine doses are needed immediately.”
High-income nations have pledged to donate more than a billion COVID-19 vaccine doses by the end of 2021, and hundreds of millions more in 2022. As of Nov. 29, 2021, the United States has shipped 271,407,320 doses to countries around the world, the majority through the COVAX dose-sharing mechanism.
Aiming for fair and equitable vaccine coalitions distribution in every country, COVAX is co-led by such organizations as the WHO and the Coalition for Epidemic Preparedness, with UNICEF as a key delivery partner.
WHO: Boosters Will Prolong Pandemic
One of the more outspoken critics of booster programs is WHO Director General Tedros Adhanom Ghebreyesus, PhD.
“Blanket booster programs are likely to prolong the pandemic, rather than ending it, by diverting supply to countries that already have high levels of vaccination coverage, giving the virus more opportunity to spread and mutate,” he said in a Dec. 22, 2021 address.6 “It’s important to remember that the vast majority of hospitalizations and deaths are in unvaccinated people, not unboosted people.”
About 3.5 million people died of SARS-CoV-2 in 2021, exceeding the deaths caused by human immunodeficiency virus (HIV), malaria, and tuberculosis combined in 2020, he said. Globally, the pandemic virus is killing about 50,000 people per week.
“It’s frankly difficult to understand how, a year since the first vaccines were administered, three in four health workers in Africa remain unvaccinated,” Tedros said. “While some countries are now rolling out blanket booster programs, only half of WHO’s Member States have been able to reach the target of vaccinating 40% of their populations by the end of the year because of distortions in global supply.”
The prevailing theory about the origins of the highly mutated Omicron variant is that it arose over months and months in an unvaccinated patient with uncontrolled HIV in South Africa.
“Remember worldwide, most people don’t have access to the vaccine,” Jeanne Marrazzo, MD, MPH, said at the IDSA briefing. “These populations are a perfect place for variants to emerge.”
People left untreated with HIV eventually are about as immunocompromised as you can be and still be alive. With no countering immunity, an infecting SARS-CoV-2 virus may remain in a state of mutation indefinitely in an untreated HIV patient. Thus, the world’s failure globally to extinguish the HIV pandemic — to leave it burning among the impoverished and untreated — now compounds the risk of another pandemic of a highly mutable virus. Some may now better understand why Monica Gandhi, MD, an HIV specialist at the University of California, San Francisco, gave such a harsh assessment about the progress against acquired immunodeficiency syndrome last year on the 40th anniversary of the discovery of the disease.
“There are 38 million people living with HIV worldwide and only 26 million of them have access to antiviral therapy,” Gandhi tells Hospital Infection Control & Prevention (HIC). “Knowing that in the world we have 12 million people who don’t have HIV therapy — that we have had since 1996 — I call that a massive failure.”
Asked to revisit her thoughts for this issue of HIC, Gandhi says, “Leaving so many people untreated for HIV is a complete tragedy and is reminiscent of what is happening with COVID-19. The Delta variant was first reported in a country (India) with a 4% vaccination rate; the Omicron variant was first reported from a country (South Africa) with a 25% vaccination rate. With global vaccine equity standing at just 9.5% of individuals in low-income countries having received one dose, many preventable deaths since January 2021 have occurred worldwide and we are setting ourselves up for the emergence of further variants.”
- Holder J. Tracking coronavirus vaccinations around the world. The New York Times. Published Jan. 17, 2022. https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html
- Tercatin R. Why did Israel’s COVID-19 team recommend a 4th vaccine? A member explains. The Jerusalem Post. Updated Dec. 23, 2021. https://www.jpost.com/health-and-wellness/coronavirus/article-689485
- Centers for Disease Control and Prevention. Stay up to date with your vaccines. Updated Jan. 16, 2022. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html#:~:text=CDC%20recommends%20that%20people%20remain,shot%20and%20a%20booster%20shot
- Ahmad K. Is it ethical to get a COVID booster when other countries lack vaccines? Colorado Health Institute. Published Nov. 18, 2021. https://www.coloradohealthinstitute.org/blog/it-ethical-get-covid-booster-when-other-countries-lack-vaccines
- UNICEF USA. As omicron spreads, Africa needs COVID-19 Vaccines. COVAX is the key. Published Nov. 29, 2021. https://www.unicefusa.org/stories/omicron-spreads-africa-needs-covid-19-vaccines-covax-key/38920
- World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19. Published Dec. 22, 2021. https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---22-december-2021
