Humanity has faced few more global challenges in recent decades than the coronavirus pandemic. The response to the crisis 20 months and 4.5 million deaths later, however, does not show a more cohesive and supportive world, but rather one directed by national interests and in which inequalities between countries are consolidated. It happened in the first wave, when borders were closed so as not to share basic products. It happened again with the first vaccines, monopolized by rich countries. And now, with the debate about the need for the third dose open, those with higher income are preparing to use several hundred million vaccines than the World Health Organization (WHO) begs that they be sent to countries that have not yet been able to protect their most vulnerable groups. Less than 2% of the population of poor countries is protected, according to this body.
“A global vision has been lacking to face the pandemic,” laments Africa González, professor at the Center for Biomedical Research (Cinbio) at the University of Vigo. “If we did, the focus of the debate would now be how to increase vaccination coverage worldwide and not whether to give the third dose only in some countries. The risk is that variants will emerge that render all current vaccines useless ”, adds this 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 han anunciado el tercer pinchazo para toda la población adulta] they will go their way, but the key will be whether all countries follow them or limit it to the groups for which it has been accredited that it is necessary ”.
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Among the large European countries, France and Germany have announced that from September they will administer a reinforcement puncture to the most vulnerable population – in the first case with rather lax criteria – and to those over 65 years of age. Spain, for now, is waiting for the European Medicines Agency (EMA) to position itself.
The WHO, on the other hand, asks rich countries for a moratorium that delays the third puncture. “The evidence on the benefits of booster doses is inconclusive. We also face a moral problem when there is a large part of the world population unvaccinated. Rich countries may not use these doses so that others can dispose of them. We are all in the same boat and treating only a part of the people will not help to get out of the pandemic ”, pleaded this Wednesday the Director-General of the WHO, Tedros Adhanom Ghebreyesus.
Science and the pharmaceutical industry, with enormous public support – up to 10 billion euros, according to Doctors Without Borders (MSF) – have achieved unprecedented success by developing a dozen vaccines in a year and a half. Also, and despite initial problems, global production capacity has grown. On a planet with 7,800 million inhabitants, between 10,000 and 14,000 million injections were needed this year. Industry forecasts are that in December they will exceed 12,000.
Achievements that, however, still do not guarantee that the vaccine will reach all those who need it on time. According Our World in Data, coverage shows huge differences between countries. While several of the richest, including Spain, touch 70% of the population with the full pattern, many of the poorest remain below 1%. The world average that comes out of these great disparities is one in four protected inhabitants of the globe.
The Covax system, participated by the WHO and which aims to ensure vaccines for at least 20% of the population of the countries participating in the program, was the key to making it possible for rich countries to secure their doses as soon as possible — after Everything, they are the ones who advanced the money and where the big pharmaceutical companies have their headquarters – and that the vaccine would then reach the rest of the planet. But the initiative is not working at the expected rate and right now, when an increase in the vials available was in sight, the third dose threatens to reduce them. Covax should have already received 640 million vaccines (2 billion in the whole year), but only 160 million have reached it.
Irene Bernal, head of access to medicines at the independent organization Salud por Derecho, argues: “Covax has not received the funding it needed and it has not been considered a priority actor when it comes to acquiring vaccines. Governments have relegated it and have preferred to monopolize doses. The basic problem is that it is a program that depends on the political will of rich countries and pharmaceutical companies ”, he explains.
Resale of vaccines
The result is a planet turned into a veritable vaccine bazaar. In some cases, the doses are resold. This is what Poland has done with 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, purchasing several times the amount they needed. Spain has committed the shipment through Covax of more than six million doses to Latin American countries.
This situation, in which the least developed countries are relegated when it comes to having access to vaccines, is what 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, supported by more than 100 countries (including the United States), to release the licenses. The objective is not only to increase production, but to do so in the less developed countries to be self-sufficient.
Irene Bernal believes that “the third dose can cause a new bottleneck in vaccine production that must be tackled from several fronts”. “Patents are only a first step that must be accompanied by the transfer of knowledge by companies. If they are not willing to take this step, we will delay access and we will lose thousands of lives that today have an opportunity ”, he says.
The differences in vaccination coverage between countries, however, are no longer solely due to a question 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: the refusal to vaccinate important parts of the population. It is a problem, experts admit, as difficult to face as inequalities and due to a complex mix —different in each country— of distrust of governments, ignorance and tendencies that are difficult to catalog.
In the United States, the first country together with the United Kingdom to initiate mass vaccination, the pace of the campaign has lost steam for months and only has 51% of the population fully immunized. Russia, which developed the Sputnik V vaccine, only reaches 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 on the need for the third dose is still open. Experts like Africa González, consider that it is not necessary in a general way. “There is no evidence to support it for all those over 65 or all the immunosuppressed. A personalized strategy with immunity studies would be more appropriate. The results would reveal that many people do not need it and that 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 argues.
José Luis Alfonso, head of preventive medicine at the General Hospital of 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 with the passage of weather. From the age of 70, in addition, immunosenescence usually begins, a process that weakens the defenses. In a situation where vaccines are available, I consider that the cost-benefit balance is favorable ”.
Alfonso is in favor of administering the third dose, as announced by France and Germany, to all those over 65 years of age and immunosuppressed, a group that in its different degrees of risk amounts to about 40% of the Spanish population. Quique Bassat, on the other hand, advocates a more restrictive criterion: “Surely, the third dose would only be necessary in patients at higher risk [cerca del 8% de la población]. Defining which patients are candidates is precisely the key question now ”, he concludes.
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