The pandemic problems that boosters won’t solve

The US booster program is about to get underway, after the CDC backed additional shots for a large swath of the American public.

The agency now recommends that people aged 65 years and older, adults in long-term care, and those over 50 with underlying medical conditions get a third Pfizer-BioNTech shot. (Those whose first shot was Johnson & Johnson or Moderna will have to wait a little longer.) Frontline workers or those with a higher risk of infection will also get the chance to get a booster, categories added when the CDC's director, Rochelle Walensky, overruled her committee.

But the decision has been contentious, not least because the vaccines are still doing a great job at protecting people from serious illness and hospitalization. Many experts believe that the priority should be getting more people vaccinated in the US, and sending much-needed doses to low-income countries where a little more than 2% of the population has been vaccinated.

Earlier this month, the World Health Organization called for a moratorium on boosters until at least 10% of every country has been vaccinated. But several rich countries, including the UK, France, Israel, and now the US, are plowing ahead with a booster program regardless.

The fraught debate around access to boosters raises some complex ethical questions for public health officials, politicians, and bioethicists. Is it justifiable for citizens of richer countries to get a third dose when so much of the world is awaiting its first? And how do agencies like the CDC decide who should get them?

So we decided to speak with Anita Ho, an associate professor in bioethics and health services research at the University of British Columbia and the University of California, San Francisco. Ho has spoken with us before about the US vaccine rollout and inequality. We asked her how the picture has changed at this point in the pandemic.

The interview has been edited for length and clarity.

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What are some ethical considerations of offering booster doses to just some Americans? I'm particularly curious about the idea of offering them to people in high-risk jobs.

In some ways, the ethical considerations are similar to late last year when the vaccines first became available. If there is a limited supply and more people need it, you want to promote the greatest good without sacrificing equity, and start with those who would be at the highest risk of getting very sick if they don't get the booster dose soon.

But fully vaccinated healthy people in high-risk" jobs, meaning that they have more chances of being exposed to the virus, aren't necessarily at higher risk of getting sick even if they catch the virus. That's the whole point of getting vaccinated-so you won't get very sick even if you are exposed to the virus.

But high-risk" job is a fluid definition. There is now a federal requirement for health-care workers to get vaccinated, and more schools are requiring staff and eligible students to get vaccinated. So here is the irony: if you are already fully vaccinated, you are in a high-risk" job mostly because your colleagues or others who come through your doors aren't or can't be vaccinated. Get them vaccinated, and you won't be in a high-risk job anymore!

So it's tricky for the CDC. The ACIP (Advisory Committee on Immunization Practices) didn't think healthy people, regardless of where they work, need the booster dose yet to protect themselves. The protection from the vaccines against severe illnesses and hospitalization has remained high across age groups. And even though a booster dose may further increase antibody levels, it's not clear whether that is needed to protect against severe covid-19, and whether that would decrease viral transmission.

We know that some people still haven't had access to an initial course of vaccination. Does it make sense to offer boosters when we haven't even thoroughly vaccinated everyone who wants a shot in the US?

The booster doses won't do much if we still have big pockets of unvaccinated people. These people should be our urgent focus. It takes resources to have community outreach to get to bring the vaccines to those who can't take time off work, or live in more rural or low-resource neighborhoods where they don't have access to the news or reliable scientific information.

There is already a shortage of nurses, pharmacists, and community health workers right now. Would we have the resources to plan booster doses and still reach the unvaccinated?

Can you tell us how the ethical picture has shifted since the last time we spoke in January? Does the Biden administration's pledge to donate half a billion more vaccines change the calculus?

It's disheartening that more than 18 months after the pandemic was declared, we still have not reached what I call relational solidarity: for the global community to work together to promote the common good, to make sure nobody is left behind. Donation is better than nothing, but poorer countries are left at the mercy of rich countries. Many of these 500 million Pfizer doses won't arrive until later next year. If it is urgent for Americans who have better health-care access to get vaccinated as soon as possible, or even get the booster dose, how would later next year be considered acceptable? This means that many people in poorer countries won't be getting their first shot until more than 18 months after the US gave out its first doses.

The disparity we create and allow is simply appalling. And the Pfizer vaccine requires special refrigeration, so the poorest countries that don't have the storage and handling capacity may still not benefit. To solve the supply-chain issues, we need to build capacity and have manufacturing plants for different vaccines spread across the globe. Pharmaceutical companies should partner with drug companies in the global south to do that. This can also help to make sure that the shots can be adapted for local variants faster.

A lot of your research has focused on public trust. What's a top takeaway for authorities right now?

The pandemic has unfortunately been politicized in the US. Conflicting messages from different officials have made things worse. I think a top takeaway is that authorities need to have a united front in fighting this pandemic, maintain consistent messages, be transparent in their reasoning, and work with community partners that local people trust to help promote public health messages.

Public health interventions such as mask or vaccination policies can minimize viral spread but also impose inconveniences and financial hardship on people, especially for more disadvantaged populations. In order to build trust, so that people would get on board and stay on board with public health goals, authorities need to show that they are competent in guiding us through this pandemic, understand the pain people are going through, and would minimize any hardship various interventions may cause.

This story is part of the Pandemic Technology Project, supported by the Rockefeller Foundation.