Promoting Covid-19 vaccine boosters before equitable access for all is unethical

Louis Reynolds is a paediatrician, now retired from his job as an intensive care specialist at the Red Cross Children’s Hospital and the University of Cape Town.

Pharmaceutical companies are putting pressure on EU countries and the US to authorise booster vaccinations against Covid-19 for people who are already fully vaccinated. These marketing campaigns go against the World Health Organisation (WHO) call to halt boosters in favour of the unvaccinated. Several countries, including the UK, France, Germany, Sweden, Israel, the UAE and the US will soon make boosters available to segments of their populations.

The pharmaceutical companies insist that boosters are necessary because vaccination immunity wanes over time, leading to a risk of reinfection. This may be true to some extent, but in a world of unnecessarily extreme vaccine scarcity and inequity, where most people have not yet had their first dose, the push to give boosters to already immunised people raises important moral and ethical questions.

A recent opinion piece in the Journal of the American Medical Association takes a critical look at this matter. The authors argue that, in the context of limited global supply, it is unethical to provide booster vaccinations while the existing vaccine schedules provide effective protection against variants. 

Here is a summary of the key points they make.

Current vaccine regimens work well. Research shows that the vaccine regimens in use are more than 85% effective in protecting us against hospitalisation, severe disease and death caused by Covid-19 disease. The vaccines tested include Johnson & Johnson, Pfizer-BioNtech and Astra-Zeneca. They protect against all the dangerous variants, including Delta.

The scale of global vaccine inequality is stark.

So far, more than 4.72 billion vaccine doses — 61 doses for every 100 people — have been administered worldwide. Of all these shots, 83% have been administered in high- and upper-middle-income countries. Only 0.3% of doses have been given in low-income countries. Among continents, Africa has the slowest vaccination rate. Some African countries have not even started mass vaccination campaigns.

Vaccine inequity exists between and within countries. 

In South Africa, for example, you are between two and three times more likely to be vaccinated if you have private medical insurance than if you don’t. In Western Cape, coverage of people over 60 varies from a low of 34% in Mitchells Plain to more than 90% in Overstrand, reflecting, in part, unequal access and uptake across suburbs of differing socioeconomic status.

Large-scale booster vaccination campaigns, therefore, increase inequality in access. Putting vaccines into the arms of already fully vaccinated people in wealthy countries and insured populations uses up vaccines that could have gone to poorer countries and populations. This robs unvaccinated people in poorer countries of their first dose. 

Low vaccination rates mean that more people will get very sick and die unnecessarily. Already overstressed health services will collapse. Currently (mid-August 2021), six of the 10 countries with the highest death rates per capita from Covid-19 (Tunisia, Georgia, Botswana, Eswatini, Namibia and South Africa) have less than 10% of their populations fully vaccinated. Vaccine inequality also predisposes to the emergence of more viral variants, especially in places with the lowest access to vaccination. 

The Journal of the American Medical Association argues that, in the context of limited global supply, it is unethical to provide booster vaccinations while the existing vaccine schedules provide effective protection against variants. (Photo: Gallo Images / Papi Morake)