On Monday, amid reports that the highly infectious Delta variant is causing surges in new Covid-19 infections in states with low vaccination rates and countries with vaccine shortages, Pfizer announced plans to seek emergency authorization as early as next month for booster shots that would complement its existing two-dose regimen and ideally, protect against emergent and future variants of SARS-CoV-2.
Almost immediately the drug company’s statement was met with fierce criticism from the World Health Organization (WHO) and equivocation from US health officials. WHO director-general Tedros Adhanom Ghebreyesus said at a press conference that such ventures reflect a conscious choice “not to protect those in need”—referring to countries where the vast majority of the population has yet to receive even one shot—while the CDC and FDA also questioned the timing of the proposal, claiming the evidence that might justify the urgency is lacking.
The real issue, however, isn’t whether we should develop boosters or not, but who and what is to blame for the lack of progress in worldwide vaccination efforts. The WHO posits that pharmaceutical giants like Pfizer and wealthy nations like the United States have taken more than their fair share of available resources, creating conditions of scarcity for populations who need them most. However, Tedros’ argument only deflects attention from the glaring reality that low-income countries are in dire need not of more vaccine donations, but more vaccine manufacturing capacity—a root cause that delaying the production of booster shots won’t fix.
There is no denying that the disparity in vaccinations between high- and low-income countries is vast. Just six countries, the US and UK among them, have in their possession about 70 percent of the nearly three and a half billion vaccine doses administered to date, while low-income countries have less than one percent. COVAX (COVID-19 Vaccines Global Access), an initiative co-led by the WHO, Coalition for Epidemic Preparedness Innovations (CEPI), and Gavi, has to some extent helped the haves redistribute their excess doses to the have-nots. But the entire continent of Africa still has less than ten manufacturers to its name that are capable of producing Covid-19 vaccines, while most Asian countries—with the major exception of China—have underinvested in vaccine manufacturing capacity as well.
Some attempts to bolster domestic production are underway. According to Ngozi Okonjo-Iweala, Director-General of the World Trade Organization, Africa is set to join forces with the European Union and erect vaccine manufacturing hubs in Senegal, South Africa, Rwanda, and possibly Nigeria. The Institut Pasteur has committed to running the Senagalese manufacturing plant based in Dakar, which will produce an estimated 25 million monthly doses by late 2022. Meanwhile Thailand has begun clinical trials for its own mRNA vaccine, at the same time that Moderna, another mRNA vaccine maker, is considering the possibility of setting up shop in Asian countries like Japan.
Inevitably it will take time for these plans to come into fruition. But in the meantime, castigating wealthy nations and pharmaceutical companies for moving forward with booster shots seems misplaced. Further protection in the face of increasingly contagious variants, especially for high-risk populations like older and/or immunocompromised adults, is not a matter of greed or frivolity. For these individuals, just like those who remain unvaccinated, a booster shot could mean the difference between life and death. And so long as the Covid-19 virus, SARS-CoV-2, continues to evolve in ways that promote not just transmissibility but immune evasion, they’re not the only ones who will remain vulnerable. If adults aren’t sufficiently protected, children 12 and under—who don’t yet have their own vaccine—will also be at higher risk of contracting infection and developing severe disease.
The general consensus, shared by WHO and US senior officials both, appears to be that until hospitalizations and deaths are on the rise among the vaccinated, it is safe to assume that current vaccines offer adequate protection from disease. But nothing feels safe about the present state of the pandemic in the United States, where vaccination rates are stalling, restrictions loosening, and highly infectious variants circulating in several states.
In no small part due to inadequate testing and tracing capabilities, epidemiological data on the direct impact of the Delta variant on immunizations is so far scarce, with the exception of case studies like one recently published (and awaiting peer review) on medRxiv about an outdoor, fully vaccinated wedding in Texas that led to six breakthrough infections and one death. Virological research on the variants, however, has established that the SARS-CoV-2 genome encodes several mechanisms that allow it to antagonize, suppress, and evade our immune defenses. Since the surest way for one variant to eclipse its competitors is through increased fitness, we can expect this capacity to only grow in succeeding versions of the virus, as studies that played out such scenarios in the laboratory already suggest.
In addition to the latent vulnerability of high-risk groups and children, the emergent condition known as long Covid promises to be a major stressor on already overburdened health systems. Though usually not so grave as to require hospitalization, long Covid afflicts thousands with debilitating symptoms long after the virus should have cleared. Nearly 40 percent of people who recover from Covid-19 in the UK still have symptoms twelve weeks after the fact. That the US would want to protect its population from these risks isn’t just expected, but justified.
Booster shots and global vaccination efforts more broadly cannot and should not be mutually exclusive. But the duty of the leadership of any country is to protect its people. To truly achieve vaccine equity and end the Covid-19 pandemic once and for all, governments everywhere should honor this commitment. Otherwise the opposing sides of the two-track pandemic are doomed to become ever more divergent.