Less than a month ago, the omicron variant, first detected in South Africa, was labeled a “variant of concern.” Since then, the world has braced for another wave of coronavirus, as Covid-19 is spiking across Europe and, now, the United States.
A lot of these countries — particularly the United Kingdom and the United States — are pushing aggressive booster campaigns in response. Three shots, rather than two, is becoming the refrain of many public health experts.
Yet the rest of the world is still woefully under-vaccinated. Not just booster shots, but first doses. Close to 60 percent of the world’s population has received at least one shot, according to New York Times data. But it’s an unequally distributed feat. About two-thirds of those doses have been administered in high or middle-income countries. According to the Africa CDC, only a little more than 8 percent of the continent is fully vaccinated. The One Campaign, an advocacy group, estimates that there are more than eight times as many boosters being given in high-income countries compared to first doses in low-income countries.
Omicron has offered another, if somewhat predictable, hiccup. According to some early data — and of course, these things are still evolving — omicron is pretty good at evading the two-dose regimen for a lot of the vaccines given worldwide. Vaccination still offers protection from severe illness, and some data suggests severe illness may be less likely with omicron on an individual level. But the mRNA vaccines — specifically Moderna and Pfizer — coupled with a booster, appear to be the best bets at preventing infection. Most of the world isn’t getting those vaccines.
Though there’s still a lot scientists don’t know about omicron, it is unlikely to be the last variant that emerges from this pandemic. The question is whether omicron will now force the global vaccination campaign to recalibrate, especially if the definition of fully vaccinated begins to evolve from generally two doses, to three.
To get a better sense of the broad challenges, Vox spoke to Wafaa El-Sadr, an expert on infectious diseases and global health at Columbia University. The bottom line: Omicron complicates an already complicated process. And unless the rest of the world acts (and invests) in vaccination, the one truism of the pandemic will persist: Coronavirus spread in one place poses a threat everywhere.
The conversation, edited and condensed for clarity, is below.
Beyond needing to do more, does the emergence of this new omicron variant change the global vaccination picture?
I think it does, in terms of the choice of vaccines. Not only the choice of vaccines, but also the need for booster doses. So it gets even more complicated.
We’ve seen data now that are pretty convincing that certainly, getting the third dose, a booster dose is associated with an increase in protective antibodies, as well as evidence of just the clinical protection from just getting sick or dying from Covid-19. And that adds complexities, of course, because now we not only have to make sure that people get the primary regimen of vaccines, but also the third dose, the booster dose.
As you said, so many places are still struggling to deliver the first doses of vaccines. But there is also evidence that vaccines that aren’t mRNA (Pfizer and Moderna) — such as Johnson & Johnson, Oxford-AstraZeneca, or China’s Sinovac and Sinopharm, or Russia’s Sputnik — may not be effective in preventing omicron infections. So do should we even be giving people those vaccines, or is something better than nothing at this juncture?
This complexity with omicron is exactly what you’re talking about. Evidence shows that the boosting of mRNA vaccines provides potentially superior protection against omicron. This, of course, complicates the picture even further, because there are lots of other vaccines that are being largely used globally.
Of course, it depends on the magnitude of the strain of omicron. Is this going to dominate in every country all over the world? Or is it going to be mostly the prevailing dominant variant in some countries, but not others? That’s what’s going to largely determine what can we do about the use of current vaccines.
It’s still sort of “wait and see” mode. But in terms of increasing access to mRNA vaccines, are there things we could be doing that we’re not doing to increase their dominance in global vaccination efforts?
There are things that can be done. One is, obviously, to increase the production of these vaccines. That will require substantial investments and resources to be able to scale up production. If there’s commitment to doing it, then it’s quite doable, and I think that’s probably the fastest way to get more supply of these mRNA vaccines.
Now, there were also discussions, of course, about, establishing regional hubs for production of these vaccines, and technology transfer, and so on. But I believe that the fastest way to get vaccines into people’s arms is to immediately work hard at increasing the production of the vaccines by expanding factories where they’re currently being produced, or redirecting current factories to be able to do this.
If it’s going to take resources, where are those resources coming from?
I think it has to be from the wealthy countries of the world. There’s no getting around that. It is also in their self-interest. It has to become the number one priority now. It is going to be incumbent upon wealthy countries to be able to make that happen, especially because of the urgency of the situation.
You mentioned technology transfer. A lot of groups have been advocating for a TRIPS waiver, which would temporarily loosen intellectual property rights for Covid-19 vaccines and treatments, which would allow other manufacturers to produce vaccines. Where do you see that fitting in?
It’s a longer-term strategy, but it definitely should be part of the strategy. It won’t get us to the current, immediate needs. The current immediate needs are increased production. But we need to be building regional factories and we need to tackle the issues around patents.
I wonder if you are a clinician in a place where vaccines are in short supply, how do you approach this news that some vaccines might not be as effective against omicron? Or that you might need more doses? What does this do to already challenging, large-scale vaccination efforts?
We’re facing the same thing, even in this country. There’s always been this misconception or misperception that getting vaccinated means you are absolutely protected from ever getting infected with SARS-COV-2. That was never the case, from day one.
We’ve been struggling with the messaging all along in terms of what do these vaccines do and what they don’t. That’s a major issue. We need to have clear messaging and go back to basics and say, “these vaccines decrease your risk of getting infection, but it doesn’t go down to zero. They certainly decrease your risk of getting very sick and hospitalized, but it doesn’t go down to zero, either.” But that’s been a struggle all along.
I think we don’t know — I haven’t seen data say, if you’ve got an AstraZeneca, for example, and you get a booster with mRNA, would that protect you against Omicron? We don’t know that as of yet. In the context of omicron, the data I have seen have been largely people who got Pfizer, and they got a booster from Pfizer, or they got Moderna and got a Moderna booster.
We’ve seen other data earlier that showed that, yes, if somebody got Johnson & Johnson and they got an mRNA boost that they did get a pretty robust response. But we don’t know whether that’s protective against omicron — I don’t see why not, but we haven’t seen those experiments. So it’s possible that for people to receive their primary vaccination with a non-mRNA vaccine, that getting a booster with an mRNA vaccine could offer them protection against omicron. Then the message is not like your vaccination was wasted. There’s waning of immunity and therefore the need for boosting. Having a new variant coming around, that also is the second reason why boosting is important.
I wonder about the infrastructure for the mRNA vaccines — extreme cold chains, and the like. Does that remain a challenge if we want to include more mRNA vaccines in the global repertoire?
That’s why I always say that first, it’s necessary to have those vaccines, but it’s not sufficient. You have to have the resources, the systems to get the vaccine into people’s arms. You need to have the effective vaccination program, and not just sufficient supply of vaccines. That’s not enough.
I think we have to also put in the resources to help specific countries to be able to do it. That may involve training of the workforce, it may involve messaging communication to make sure that there are no misconceptions or misperceptions about the vaccines; it may include the need for vehicles and gasoline; it may mean the need for refrigerators and freezers. That’s all part and parcel of having an effective vaccination effort.
It does seem as if the global infrastructure failed us on this one. Knowing what we know know, what do we need to put in place now to prepare for the next big one?
There are so many things. How many hours do you have?
When you think back, from day one, this pandemic was politicized. And from that really emanated all the pitfalls and all the sadness we’ve had, because of the politicization and, as you recall, the antagonism to the World Health Organization, the lack of support to the WHO. Then, again, once your country was purchasing large amounts of vaccines for their own population, [there was a] lack of a global response, incoherence, all the travel restrictions that are popping up right and left without any rhyme or reason.
[There have been] poor investments in vaccine production and vaccine technology; I think we have a chance now with the mRNA technology to do better. We need to do better in terms of overall investments in public health overall, and surveillance systems, in laboratory systems. I feel like [we need] all of these bits and pieces of having strong public health systems to enable rapid and effective response.