WorldThird dose exacerbates global inequality in access to coronavirus vaccines

Third dose exacerbates global inequality in access to coronavirus vaccines

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Humanity has faced few global challenges in recent decades like the coronavirus pandemic. The response to the crisis 20 months and 4.5 million deaths later, however, does not show a more cohesive and solidary world, but guided by national interests and in which inequalities between countries are consolidated. It happened in the first wave, when borders were closed to not share basic products. It happened again with the first vaccines, monopolized by rich countries. And now, with the debate over the need for the third dose open, those with higher incomes are preparing to use several hundred million vaccines that the World Health Organization (WHO) is asking to be sent to countries that have not yet been able to protect their most vulnerable groups. Less than 2% of the population in poor countries is protected, according to this body.

“We lacked a global vision to face the pandemic”, laments Africa González, a professor at the Center for Biomedical Research (Cinbio) at the University of Vigo. “If we did, the focus of the debate now would be how to increase vaccination coverage around the world and not give the third dose just in some countries. The risk is that variants will emerge that render all current vaccines useless, “adds the expert. Quique Bassat, epidemiologist and ICREA researcher at the ISGlobal institute, defends a similar position: “We are repeating mistakes. Israel and the United States [que anunciaram a terceira punção para toda a população adulta] they will follow their path, but the key will be whether all countries will follow them or limit themselves to the groups for which it was believed necessary ” .

Among the large European countries, France and Germany announced that they will apply an armor punch from September to the most vulnerable population – in the first case with very loose criteria – and to those over 65 years of age. Spain, for the time being, awaits the position taken by the European Medicines Agency (EMA). This week, the Brazilian Ministry of Health announced that it will apply, also from September, the booster dose in people over 70 years and in immunosuppressed patients. On Thursday, Pfizer, a vaccine planned to include this boost in Brazil, announced a partnership with Eurofarma to produce its vaccine in Brazilian territory, with a view to supplying immunizations to Latin America.

The WHO, on the other hand, is asking rich countries for a moratorium to postpone the third injection. “The evidence on the benefits of booster doses is inconclusive. We also face a moral problem when there is a large proportion of the world’s population unvaccinated. Rich countries cannot use these doses so that others can get rid of them. We are all in the same boat and treating only a part of the population will not help to get out of the pandemic”, defended this Wednesday the director general of WHO, Tedros Adhanom Ghebreyesus.

Science and the pharmaceutical industry, with huge public support — up to 10 billion euros, according to Doctors Without Borders (MSF) — have achieved unprecedented success, developing a dozen vaccines in a year and a half. Furthermore, and despite initial problems, global production capacity has grown. On a planet with 7.8 billion people, between 10 billion and 14 billion injections were needed this year. Industry forecasts are that in December it will exceed 12 billion.

Achievements that, however, still do not guarantee that the vaccine reaches all those who need it on time. According to Our World in Data, coverage shows big differences between countries. While several of the richest, including Spain, reach 70% of the population with the full standard, many of the poorest remain below 1%. The world average resulting from these great disparities is one in four protected inhabitants of the globe.

The Covax system, led by the WHO and which aims to guarantee vaccines for at least 20% of the population of countries participating in the program, was the key for the rich countries to guarantee their doses as quickly as possible — after all, they are the ones who advance the money and where the big pharmaceutical companies are—and for the vaccine to reach the rest of the planet later. But the initiative is not working at the pace expected and now, when it was possible to see an increase in the available vials, the third dose threatens to reduce them. Covax should have already received 640 million vaccines (2 billion for the whole year), but only 160 million have arrived.

Irene Bernal, head of access to medicines at the independent organization Salud por Derecho, says: “Covax did not receive the funds it needed and was not considered a priority player in the procurement of vaccines. Governments relegated it and preferred to accumulate doses. The basic problem is that it is a program that depends on the political will of rich countries and pharmaceutical companies”, he explains.

Vaccine retail

The result is a planet transformed into a veritable vaccine bazaar. In some cases, doses are resold. That’s what Poland did to Australia, with a million doses of Pfizer. In others, they are donated. This is what the United States, Canada and the European Union are doing, which have acquired several times the amount they needed. Spain has pledged to send through Covax more than six million doses to Latin American countries.

This situation, in which less developed countries are relegated to access to vaccines, has fueled the debate on patents. The World Trade Organization (WTO) will resume in its general council in October the initiative of India and South Africa, with the support of more than 100 countries (including the United States), to release licenses. The objective is not just to increase production, but to make it in less developed countries so that they are self-sufficient.

Irene Bernal believes that “the third dose could cause a new bottleneck in vaccine production that needs to be tackled on several fronts.” “Patents are just a first step that must be accompanied by the transfer of knowledge by companies. If they do not want to take this step, we will delay access and lose thousands of lives that now have a chance”, he argues.

Differences in immunization coverage between countries, however, are not just a matter of income. A new variable has come into play in recent months and threatens to become another Achilles’ heel in the fight against the pandemic: a significant portion of the population refuses to receive the vaccine. It is a problem, experts admit, as difficult to deal with as inequalities and is due to a complex mixture — which differs in each country — of distrust of Governments, ignorance and trends that are difficult to catalog.

In the United States, the first country, alongside the United Kingdom, to initiate mass vaccination, the pace of the campaign has lost momentum for months and only 51% of the population is fully immunized. Russia, which developed the Sputnik V vaccine, has only 24%. And Bulgaria, a member of the EU that has the same access to vaccines as Spain, is close to 20%.

custom strategy

Meanwhile, the debate over the need for the third dose is still open. Experts like África González believe it is not necessary in general. “There is no evidence that it is based on all those over 65 or all immunosuppressed. A tailored strategy with immunity studies would be more appropriate. The results would reveal that many people do not need it and others who have not developed antibodies with two doses will not do so with three because their problem has other causes. We would spend a lot of vaccines unnecessarily”, he ponders.

José Luis Alfonso, head of preventive medicine at the Hospital Geral de Valencia, defends the opposite position: “Clinical practice shows us that the immune response of many patients is not sufficient after two doses and that the presence of antibodies decreases over time . Furthermore, after 70 years of age, immunosenescence usually begins, a process that weakens the defenses. In a situation of availability of vaccines, I consider that the cost-benefit ratio is favorable”.

Alfonso is in favor of administering the third dose, as announced by France, Germany and Brazil, to all those over 65, in the case of the first two, and 70 in the last, in addition to the immunosuppressed, a group that in their different degrees of risk it comprises about 40% of the Spanish population, to give you an idea. Quique Bassat, on the other hand, defends a more restrictive criterion: “Certainly, the third dose would only be necessary in patients at higher risk [cerca de 8% da população]. Defining which patients are candidates is precisely the central issue now”, he concludes.

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