US boosters or vaccinate the world?

The Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) this week shared recommendations for COVID-19 vaccine booster shots, which — alongside mandates to boost vaccination rates — will help get the pandemic back under control as the second COVID-19 winter looms. 

These recommendations — and the underlying evidence of vaccine effectiveness and durability — are good news more or less across the board, despite the concerns of those who oppose boosters so long as global vaccination rates remain low.

The FDA and CDC drew on evidence showing that the vaccines are working incredibly well in most people, and also that, at this point, a minority of Americans will benefit from third shots of Moderna and Pfizer to shore up lower immunity and prevent severe infections amongst the most vulnerable. Newer evidence means that Americans who got the Johnson & Johnson’s vaccine, rolled out as a single dose, will likely be asked to get a second shot to improve its efficacy to similar levels as the other two mRNA shots.

These recommendations make sense. Some have argued that the U.S. should wait on booster shots until less-vaccinated countries have had a chance to catch up, including the World Health Organization (WHO) Director General Tedros Adhanom Ghebreyesus and a distinguished group of epidemiologists from both the U.S. and the WHO writing in the medical journal The Lancet. Their argument is well-intentioned, but risks throwing away shots that can only be used to help curb the pandemic in the United States.

There are difficult choices ahead over where and how to allocate vaccine doses in the months to come, but we can choose to both protect vulnerable Americans and pursue global vaccination as quickly as possible. 

Evidence from Israel and the United Kingdom, both of which have started giving boosters, indicate that efficacy of the current two dose regimen of the Pfizer and Moderna vaccines appears to wane significantly in the elderly and that third shots improve the immunity of both the elderly and medically vulnerable. The Johnson & Johnson vaccine, in contrast, appears not to wane, but a second shot boosts its efficacy significantly.

The FDA panel also recommended boosters for those whose work puts them at special risk — teachers, doctors and first responders. This recommendation could sound like special dispensation or “danger pay.” It’s true that a teacher or doctor spending their days in close quarters with large numbers of people is more likely to be exposed to infection than most Americans, but the FDA panel concluded that the vast majority will recover even if they have symptoms. It is at least as urgent to vaccinate teachers, doctors and first responders because they work with the most vulnerable — children and those whose health is compromised. Rare breakthrough infections in these professions present much greater risk of leading to severe illness or death in others than for other Americans. 

Researchers will continue to study the value of boosters for healthy Americans, but it appears that fully vaccinated, otherwise healthy adults continue to be well protected against severe disease by two shots. For most people who get vaccinated, the vaccines are working. The challenge — as global health advocates remind us — is that too many people in the world still lack access to these incredible vaccines.

With 80 million doses already distributed around the country, we have the shots on hand to meet immediate needs due to both mandates and boosters while simultaneously mobilizing as many new doses as possible to boost global vaccination rates. Doses already distributed in the U.S. must be used as soon as possible. After vaccination rates in the U.S. flatlined this summer 12 million doses expired, squandering our best weapon in the pandemic.

The doses already distributed in the U.S. cannot be shared internationally because of expiration dates and quality assurance. There simply is no mechanism for safely and effectively gathering up millions of doses from U.S. clinics and pharmacies and repackaging them for export. Even if it were possible, countries would be appropriately wary of doses with such an uncertain chain of custody. Many of the booster shots — the recommendations apply to approximately 70 million people — can come from these distributed doses.

Global vaccination is both a moral imperative and an urgent public health need, and until we achieve sufficient levels of vaccination around the world, we will continue to see immeasurable, preventable suffering as well as the emergence of new variants that threaten to evade our vaccines.

Meeting the global demand for vaccines will require both billions of doses and ensuring that new doses go where they are needed as they are produced. While about 44 percent of people around the globe have received at least one dose, in Africa only 6 percent have been vaccinated. With India set to resume exporting vaccines and global vaccine production set to accelerate rapidly over the next few months, we should direct new vaccines to meet global needs as quickly as possible.

Here, America can and must do more. President Biden, hosting a global vaccine summit, called for “all hands-on deck.” To turn these words into action, we must use the power of the U.S. government, including the Defense Production Act and other tools, to increase manufacturing through accelerated technology transfer and partnerships with manufacturers around the world. Now that America can meet its own vaccine needs, including new recommendations on boosters, we should ask manufacturers to give priority to other contracts, swapping delivery dates so that countries in Africa and elsewhere can receive the doses they have contracted for as soon as possible. And the U.S. must continue to share surplus vaccines from its own purchases with COVAX and other global partners such as the Africa CDC.

Ashish K. Jha, MD, MPH is a physician, health policy researcher and dean of the Brown University School of Public Health. Previously, he was the K.T. Li Professor of Global Health at the Harvard T.H. Chan School of Public Health and Director of the Harvard Global Health Institute. Follow him on Twitter: @ashishkjha