With global vaccine inequity still remaining a significant problem in many parts of the world, Epidemic Ethics hosted a webinar which discussed the ethical issues surrounding the provision of COVID-19 vaccination boosters.
To watch the webinar COVID-19 Vaccine Boosters: when & why? click here
Chair:
- Professor Michael Parker, Professor of Bioethics, Director of Wellcome Centre for Ethics and Humanities , University of Oxford
Panel:
- Dr Ayoade Olatunbosun-Alakija, Co-Chair of the Africa Union Africa Vaccine Delivery Alliance for COVID-19, Abuja, Nigeria
- Dr Kate O’Brien, Director, Department of Immunization, Vaccines and Biologics, World Health Organization, Geneva, Switzerland
- Professor Sir Andrew Pollard, Professor of Paediatric Infection and Immunity. Director of the Oxford Vaccine Group, University of Oxford
Key questions:
- What are the ethical arguments for and against providing booster doses of COVID-19 vaccines?
- Should countries refrain from booster shots until we have global vaccination coverage?
- WHO has called for a moratorium on boosters until the end of 2021. Can any exemptions to this moratorium be justified, such as for specific, high-risk populations?
Professor Pollard began his presentation with a general overview of the impact of COVID-19 on health and the value of vaccines in this context. He noted that many months ago, there were enough vaccination doses to prevent the majority of deaths which occurred in the latter half of 2021. These deaths haven't been averted because doses are concentrated in a relatively small number of countries. In June 2021, G7 countries made several pledges to make more vaccines available, particularly for low and middle-income countries (LMICs), however the timescale wasn’t clear. Since then, another one million people have died, and it’s estimated another 600,000 people will die by the end of December 2021. Consequently the vaccination boosters remains ethically controversial. Professor Pollard argued as a global community, we have failed to provide worldwide vaccination coverage. He argued that because COVID-19 vaccines deliver 80-100% protection from fatal disease, it would be better if countries with high vaccine coverage, donate boosters to regions of the world without vaccines. However, as vaccine decisions are taken at a national level, the small gains provided by boosters, are at the expense of equitable global distribution. This leads to the key question of what this means for future pandemics. If we accept the idea of moral failure, how would we do things differently in the future?
Dr Alakija argued that vaccine supply, rather than ethics, was driving decision-making about boosters. She noted that, while pledges are being made by global leaders, there doesn’t appear to be a tangible plan of action or timescale for vaccine delivery. This is particularly evident in LMICs where there have only been a trickle of vaccinations taking place. In the context of LMICs, as well as deaths being under-reported it is important to take into account the excess deaths which have occurred due to hospitals being overwhelmed. The question of whether vaccination boosters should be used, can only be framed and discussed as an ethical issue by those in a position of privilege. The question we currently face in regard to the usage of vaccination boosters is a rather choice between individualism and collectivism. The former characterised by hoarding and wastage, the latter by collective efforts towards redistribution. In this context the benefits of collective efforts extend way into the future, and should outweigh any national political agenda of the moment. Dr Alakija concluded that we need to move away from what is essentially an anti-science nationalistic view which prioritises the self over others to a more collectivist approach which recognises our common bonds.
Dr O’Brien, began her presentation by highlighting the fact that one fifth of the world’s population has not yet achieved the benchmark of 10% vaccination coverage. Therefore, the use of vaccination boosters is both an ethical and an epidemiological issue. The purpose of COVID-19 vaccines is to protect individuals against the severe end of the disease spectrum. While immunity wanes over time, the current products are doing remarkably well in protecting against severe disease. We need 200 million doses of COVID-19 vaccines for every country to achieve even 10% coverage. At present there are currently over 30 countries delivering booster doses, with several more initiating rollouts. So far the booster doses delivered equate to 20million doses, which is only 10% of the supply needed to reach the goal of 10% coverage in every country. There were enough doses administered worldwide by the 19th May have immunised 10% of the world’s population if they had been distributed equitably. On the 29th September, the amount of doses delivered worldwide would have equated to 40% coverage, and by February 2022, would reach 70%. Equitable distribution is therefore a good decision both ethically, and epidemiologically. There’s almost no scenario where booster doses in countries with high vaccine coverage can outperform a primary dose in low-coverage country. From an ethics, economic, social and health perspective the justification for booster doses is poor, and does not align with the world’s aim of ending the pandemic.
Questions and Answers
The panel also addressed several questions from the audience, including:
Is global vaccine inequity caused by regulatory problems?
The panel noted that regulatory problems were not the cause of global vaccine inequities and that the seven COVID-19 vaccines in circulation have been authorised around the world at record speed. Reasons for global vaccine inequity arguably include individualism, nationalism and greed. In many cases opaque manufacturing contracts, and manufacturers not meeting their contractual obligations, result in short supply. The focus moving forward should, therefore be on deployment to the countries which need it most, and addressing the infrastructure issues remaining in some countries.
What does this mean for us as individuals who are offered boosters?
The responsibility for booster policy is at the governmental level and WHO recommends individuals follow the policies of their government. The emerging data which suggests some immunocompromised individuals may benefit from boosters but there is very little evidence that they provide any additional benefit to otherwise healthy adults. Returning to the problem of global vaccine inequity, doses which are near expiration cannot logistically be redeployed, and more attention needs to be paid to scheduling, to ensure doses are used effectively.
Should surplus vaccines, including boosters be redeployed, or should manufacturing capacity be built up in low and middle income countries?
This was not necessarily a binary question, both approaches may be important. However many vaccines now arriving in many LMICs are near expiration, which means they often can’t be used. The narrative which then emerges is that Africa doesn’t know how to coordinate or manage vaccination drives. It could be argued that building up vaccine manufacturing capacity now would be questionable, because will take longer to do this, than it would for the supply problems to correct themselves. A contrasting view is that this argument was put forward by manufacturers six to nine months ago, and that capacity-building should begin immediately as LMICs remain vulnerable today because of their lack of manufacturing capacity.
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