In wealthier countries around the world, conversations and headlines are turning to the question of a COVID-19 vaccine booster: who needs one, when, and how soon people will get it?

But a question not yet being asked enough is what does this mean for global vaccine equity, with billions of people around the world not yet having received their first dose?

As Delta variant cases rise in the US, the White House announced on Wednesday that it is making an official recommendation for COVID-19 vaccine booster shots. The White House, in agreement with health officials and the Department of Health and Human Services, says it is making a preemptive move against controlling infections, citing studies published by the CDC of the efficacy of vaccines over time. 

The plan is still pending approval by the Food and Drug Administration (FDA), which is unusual. Normally the FDA, an independent agency, would approve something before it’s announced by the government.

Some experts have expressed concerns regarding the move to announce additional doses ahead of FDA approval. “In the heat of the moment and when we’re all dealing with a real public health emergency, it becomes almost doubly important that we continually reassess and have the normal processes in place. And I do worry that we've not put the cart before the horse,” said former chief scientist at the FDA, Jesse Goodman. 

As countries like the US, the UK, and Germany move forward with their booster plans, the World Health Organization and other experts, health agencies and NGOs are highlighting that the science on the need for boosters at this stage remains unclear and that rolling them out too soon will only serve to exacerbate the already extreme vaccine inequity globally.

So who is being encouraged to get a third shot? Why are extra doses being recommended now? What are the studies supporting these recommendations and ones that don’t? What does a third dose mean for global vaccine equity?

Here’s everything you need to know about COVID-19 booster shots.

Who’s Getting a Booster Shot and When?

Beginning Sept. 20, booster shots could become available to fully vaccinated individuals in the US who received their second dose eight months prior. Currently, a booster dose is only being recommended in the US for people who received mRNA vaccines such as the Moderna and Pfizer-BioNTech vaccines. 

This means that people who were fully vaccinated early on in the rollout, such as health care workers, high-risk groups like the immunocompromised, seniors, and those in nursing homes, will be among the first able to receive third doses as they become available in September. 

Because it was approved later than the mRNA shots, those who received the single-shot Johnson & Johnson vaccine can expect a booster announcement once more data becomes available, according to the New York Times. 

The US rollout plan is still pending FDA approval — unusual, as we highlighted above — but once the plan is authorized, 5 million Americans, those that received two doses of mRNA vaccines by the end of January, will reportedly be eligible to receive a booster shot. 

France, Germany, and Israel are also working on their own plans to provide booster shots while other European countries like Italy, Spain, and the UK have stated their intentions to distribute extra doses to certain groups. China, Hungary, the United Arab Emirates, and Russia have already started giving booster shots.

In Canada, a day before the official US announcement, Ontario became the first province to approve additional doses for at-risk people including those who have undergone transplant surgeries, people in long-term care facilities and retirement homes, and First Nation elder-care residences. Global News reported that of the 8.5 million fully vaccinated Ontarians, only 1,988 people have reported breakthrough cases since initial vaccinations began. Currently, 64% of Canadians are fully vaccinated and there have been no plans announced for the rest of the provinces to pursue a third dose course of action. 

In the UK, Britain is prepared to offer booster shots to people over the age of 50 starting in September.  Public Health England released an update on Aug. 6 that 99% of recent COVID-19 cases were Delta variant infections. Fully vaccinated patients accounted for 35% of hospitalizations. Mask mandates were lifted in July in England and since then, hospitals have reported an estimated admittance of 800 COVID-19 patients each day.

What Is a Booster Shot and Why Now?

Due to limited studies on the efficacy of vaccines against COVID-19 variants over time, booster shot plans are precautionary measures at the moment. Some early studies have led to recommendations from health experts and officials, such as the US Department of Health and Human Services and the US Surgeon General Dr. Vivek Murthy, for a third vaccine dose for fully vaccinated individuals.

Breakthrough cases of COVID-19 variant infections in some fully vaccinated people have led to questions about the efficacy of the vaccines over time, but the message remains that the vaccines are still highly effective against COVID-19, especially serious disease. 

According to Our World in Data, 24% of the world’s population has been fully vaccinated against COVID-19. Vaccine protection against hospitalization has been strong — with 97% of people hospitalized with COVID-19 in the US being unvaccinated — and most cases of infection have been recorded in those who remain unvaccinated. 

But because of the recent rise of breakthrough infections in the fully vaccinated and due to the continued spread of the Delta variant, health officials are making the case for an additional shot of the same vaccine to be administered to boost immunity. 

What Are Health Officials and Experts Saying?

Minimal studies have been able to measure the long-term effectiveness of the COVID-19 vaccines, so the move to distribute booster shots is precautionary. The Centers for Disease Control and Prevention (CDC) has issued a joint statement with experts from the US Department of Health that recommends a booster vaccine for long lasting protection. 

While the current data suggests that vaccines are effective against severe cases of infection, government officials devised the booster plan due to growing concerns over breakthrough infections. 

The data supporting the recommendations has been limited as the COVID-19 vaccine rollout only began in December last year and studies and trials are few and at times conflicting. Data measuring breakthrough COVID-19 cases collected by states and news outlets has been varied, and the CDC has stopped collecting data on breakthrough infections. One study, conducted by the Israeli Health Maintenance Organization Maccabi, is being cited by health and governing officials in the case for third doses to increase efficacy over time. 

Pfizer meanwhile has submitted data to the FDA for recommendation of a third shot — although it’s important to highlight that pharmaceutical companies have a vested interest in recommendations for a third dose, and any decision on boosters shouldn’t be motivated by those with a financial interest in selling more doses. 

The CEO of Pfizer, Albert Boula, stated that the vaccine's efficacy declined in four to six months after the second dose to 84%. The study conducted by Pfizer, which is yet to be peer reviewed, recommends booster shots be administered for further protection against the Delta variant.  

What About the Millions of People Who Haven’t Yet Received a First Vaccine?

As wealthier countries go ahead with their plans for a booster shot, they are acting against the WHO’s call for a delay in preemptive booster plans. 

WHO chief scientist Soumya Swaminathan said: “We believe clearly that the data today does not indicate that boosters are needed.” An independent study conducted by the University of Washington found that the mRNA vaccines tested showed that immunization may last for years.  

The recommendation to hold off on booster rollouts around the world comes from concerns of ongoing vaccine hoarding by wealthy countries and widespread inequity in the distribution of vaccines. 

To date — according to an article written by Dr. Tedros Adhanom Ghebreyesus, Director-General of WHO, for Time on Aug. 12 — just 10 countries have administered 75% of the world’s vaccines, while low-income countries have received just over 1%. 

It means that, while wealthy countries are thinking about a third dose for additional protection for their populations, there are millions of frontline health care workers, older people, and other vulnerable people around the world being left entirely unprotected.  

“Anyone who thinks that vaccinating Americans with a third dose is not going to come at the expense of getting the vaccine to other places in the world — if that’s what you think, you’re just kidding yourself,” said Scott Hensley, whose work at the University of Pennsylvania Penn Institute for Immunology specializes in the study and research of viruses and vaccines. 

The WHO has called for a hold on booster shots until at least the end of September, to give more time to ensure the world’s vaccine supply is focused on health workers and other high-risk individuals in all countries. 

Global Citizen has joined other organizations like Gavi, the Vaccine Alliance, the ONE Campaign, and Médicins Sans Frontieres (MSF) in calling for prioritizing global vaccine equity over extra doses at this point.

So What Does This All Mean?

There’s a lot we still don’t know about whether booster vaccines are required and when, and there isn’t yet a consensus on the need for them among scientists, public health officials, and health agencies. As highlighted above, those wealthy countries planning and beginning booster rollouts are taking preemptive measures.

What we do know for certain is that there are millions of at-risk people around the world still going completely unvaccinated and unprotected. We also know that leaving communities unvaccinated encourages the emergence of variants, heightening the risk that a vaccine-resistant variant will emerge — and we’ve already seen with Delta how quickly variants spread around the world. 

It means that, until everyone is vaccinated globally, we all remain at risk. 

The WHO’s target is for at least 40% of people in lower-income countries to be vaccinated by the end of 2021. To approach global immunity, we ultimately need to hit a level of at least 70% in all countries. So far, however, only 1.3% of people in low-income countries have received a dose, let alone full vaccination.

Global Citizen continues to call on the G7, European Union, and other rich countries to share all their excess and unused doses with countries in need in coordination with COVAX — set up to help ensure vaccines reach low- and middle-income countries equitably. 

We’re calling for a billion doses to be redistributed by the end of September, and another billion by the end of this year — which can be done, as long as countries don’t reserve boosters for general use now when we need to prevent ever-more dangerous variants from emerging in undervaccinated parts of the world and ultimately end the pandemic. 

You can join us in this call by taking action here. We cannot end this global pandemic without cooperation and equal access to vaccines for all.  

You can join the Global Citizen Live campaign to defeat poverty and defend the planet by taking action here, and become part of a movement powered by citizens around the world who are taking action together with governments, corporations, and philanthropists to make change.

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COVID-19 Booster Shots: Everything You Should Know

By Kate Nakamura