Ask the Pharmacist

Q) There are many people worldwide whom have yet to have even their first dose of the COVID vaccine. What are the pros and cons of us administering booster shots when we could be donating vaccines to less affluent countries?

A) As we mentioned at the end of last week’s article, the argument on either side of this debate is an interesting cocktail of scientific data and ethical points. To be honest, as we wait and see how our federal and provincial governments wish to proceed on booster doses, we have gone back and forth on this issue.

We are also not the only country that is confronting this debate. Israel has already gone ahead with administering third shots to all their citizens over the age of 60 as of July the 30th. A little over a week later they dropped the eligible age for a booster to 40 and also included pregnant women, teachers and health care workers who were below that age. The United States has also already announced plans to offer booster shots to all Americans starting this fall. Many other developed countries such as France, Germany and even Hungary (which has administered booster doses to more than 187,000 so far) have also announced booster campaigns of one stripe or another.

So what should Canada do? Well, one thing we know for certain is that the World Health Organization (WHO) would prefer us to hold off for now and allow the surplus vaccines to flow to less well off countries to start and/or continue their primary vaccinations. The WHO is requesting a two month moratorium on administering COVID-19 booster vaccines as a means of reducing vaccine inequality as many countries are sitting on growing stockpiles of vaccines (all of which will expire in due course) while many countries have been able to vaccinate only a small fraction of their population.

Of the 4.8 billion vaccine doses delivered to date globally, 75% have gone to only 10 countries while vaccine coverage in Africa is less than 2%. Not surprisingly, the number of confirmed COVID-19 cases in Africa reached 7.72 million this week. This number is likely much higher as the number of “confirmed” cases represents only a fraction of the actual number of cases given the challenges of testing that most African nations face and their casualty numbers climb correspondingly. This raises the ethical question of when are we going to start putting a value on all life while we simultaneously watch vaccines go to waste in pharmacy fridges across the nation as hundreds of thousands die elsewhere needlessly.

There is also a question of self-interest when it comes to vaccinating the third world. Variant versions of the vaccine continue to come into existence among the unvaccinated and these have continually been shown to be more contagious than their predecessors. The large worry is that at some point there will be a mutation to the virus that results in a version that is resistant to all of our current vaccines. This is not a certainty, but it is far from impossibility either.

Just this week another new variant in South Africa has been identified. Given our permeable borders and global travel, it is inevitable that new variants that occur elsewhere in the world will eventually impact us just like previous versions of the virus has done. There are also many wondering how necessary a booster dose really is.

There is no question that the level of protection that the various COVID vaccines provide wanes over time, as is the case with every other vaccine we have ever developed. Initial protection from 2 doses of the Pfizer vaccine was 88% one month after the second dose but had decreased to 74% after 5 to 6 months. With the AstraZeneca vaccine, the numbers went from 77% to 67% after 4 to 5 months. These numbers are all lower than those originally published by their manufacturers which most likely reflects the increased contagiousness of the Delta variant.

There is concern that if those numbers continue on that trend, a reasonable worst case scenario could see protection fall below 50% by winter for healthcare workers and the elderly who were vaccinated first according to analysis by the ZOE COVID study. However these are just numbers. The question that we need to answer is what does this mean in terms of health implications?

Experts such as Dr. Peter English believe there is “a world of difference between efficacy against, on the one hand, any infection (which is what the study is pointing towards), and on the other hand, illness severe enough to require hospitalization, critical care, or to cause death”. There is in fact no strong evidence to date that immunity to severe disease wanes over time in the general population whereas we know for a fact (well at least most of us do) that an absence of vaccinations does lead to poor outcomes. The argument for vaccine boosters is also a science/ ethical one as well.

The cold reality is that we are not all one big happy world. Our Darwinian evolution has produced a species that has survived largely because of our inherited ability to take care of ourselves, more or less, and we have already seen other countries such as India and China deny us supplies when we needed them most.

It is perhaps a government’s most fundamental responsibility to preserve the health of its population and whether vaccine booster doses are absolutely necessary in the general population is far from a known, there is no debate that a booster dose will not hurt and probably help, at least a little. There is also the question of whether a country that has as much debt as we currently have and talking about fixing long-term care, providing Pharmacare, dealing with the opioid, indigenous and affordable housing crises is really in a position to donate hundreds of millions of dollars worth of vaccines to other countries whose ability to execute a proper vaccination campaign is definitely in doubt.

These are hard decisions with real world ramifications. What isn’t a hard choice is to support what Ontario (to date the only province to have taken this position) has decided to do when it comes to booster doses as we discussed in last week’s article. Without rehashing all of the details, Ontario has committed to providing booster doses to our immunocompromised. This equates to about 3% of our population and includes people such as transplant recipients, patients with cancer and other diseases that impair the immune system. People with compromised immune systems are 10 times as likely as the rest of us to die from the disease and there is additional evidence that they are more likely to transmit the virus to family and healthcare workers than those with fully functioning immune systems.

Viruses work by stimulating the immune system to produce antibodies but as many as 80% of the immunocompromised produce no detectable antibody response with the standard 2 doses of a coronavirus vaccine. For those who do produce a response, antibody levels can be more than 100 times lower than in the general population. The implications of this has already been felt in Israel and in the States where almost half of all hospitalized COVID-19 “breakthrough” cases (i.e. cases in people who have received both shots) occurred in the immunocompromised. What’s more, recent studies have shown that for many immunocompromised people, a third dose of the vaccine seems to dramatically improve their antibody response to such a significant degree that supporters of this policy say that it is less a booster dose than an attempt to provide an adequate level of primary immunization. It appears that Ontario at least has found the right balance between taking care of those close to home without neglecting the rest of the world’s population. For more information about this or any other health related questions contact your pharmacist.