Why donating COVID-19 booster shots isn’t that easy

Skipping a booster shot so it can be donated abroad may sound selfless, but experts say there are better ways to get vaccines to those in need.

After the Biden administration’s announcement that it will offer boosters to fully vaccinated people starting in late September, some felt unbridled glee that they could soon enhance their protection against the Delta variant.

Others, however, met the news with trepidation: Scientists remain divided on whether boosters are necessary, especially for the young and healthy. And amid cries for additional doses to be donated throughout the world, where more than 67 percent of people remain unvaccinated, some Americans may wonder whether getting a booster shot is the right thing to do when so many people aren’t able to get their first dose.

“The dilemma is that we are planning to distribute a booster—regardless of age—in the U.S. to reduce cases, while people around the world are dying and don’t have access to a vaccine,” says Ezekiel Emanuel, professor in the department of medical ethics and health policy in the Perelman School of Medicine and at the Wharton School at the University of Pennsylvania.

The U.S. Food and Drug Administration authorized booster shots for a limited group of immunocompromised people on August 12. By then, more than one million Americans had already gotten an additional dose, immunocompromised or not. Days later, on August 18, the White House announced its plans to give boosters to all fully vaccinated Americans.

To date, only 1.4 percent of people in low-income countries have received one dose of a COVID-19 vaccine, leaving swaths of the globe largely unprotected from the disease’s most severe outcomes. For some Americans, sparing their booster—in the hopes that it will be donated to those most in need—could seem like the noble thing to do.

But foregoing a booster won’t necessarily lead to leftover COVID-19 vaccines being distributed around the world. The donation process is stymied by complicated bureaucracy, concerns over legal disputes, and distribution issues within the countries receiving donated doses. What’s more, the program responsible for distributing vaccine donations is unlikely to accept doses once they’ve reached the pharmacies and hospital systems where you can take them.

Here is how vaccine donation works—and what you can really do to make a difference.

The complicated web of COVID-19 vaccine donations

The COVID-19 vaccine donation process is helmed by COVAX—a coalition of the World Health Organization, UNICEF, and two Gates-funded nonprofits, Gavi and the Coalition for Epidemic Preparedness Innovation—that negotiates donations and leads global delivery efforts.

As wealthier countries gobbled up COVID-19 vaccines, COVAX became crucial to ensuring less affluent nations could vaccinate just their highest-risk citizens, “let alone have the luxury of vaccinating lower-risk populations,” says Gian Gandhi, UNICEF's COVAX coordinator for supply division.

In a best-case scenario, the donation process through COVAX looks a little something like this: Countries flush with contracted vaccine supplies anticipate when they’ll meet their own needs, and commit to a specific date to donate a specified number of excess doses. COVAX picks up the vaccines fresh off the manufacturing line, then distributes them to other nations in need.

But that best-case scenario doesn’t always happen. According to Thabani Maphosa, managing director for country programs at Gavi, “the biggest challenge COVAX faces through dose donations is predictability. It is not uncommon to be given very short notice of new donations—and while these donations are very welcome, it is very hard to plan for their roll out.”

When countries offer donations in the moment, rather than in advance, doses can be too close to their expiration dates to use, says Gandhi. COVAX has a policy of not accepting vaccines with less than two months’ shelf life, in part “because countries often need time to plan and to muster the additional resources that they require to absorb and utilize doses,” Gandhi explains.

And even that best-case scenario faces a flurry of legal, administrative, and logistical hurdles.

To receive vaccines, the recipient countries must have their own regulatory authorization to use them—like the FDA has authorized the use of the Moderna COVID-19 vaccine, for example. And vaccine manufacturers require indemnity agreements with the recipient countries as well as the donor nation, to ensure they’re not held liable for any rare-but-adverse effects of the shots.

“Other practical issues can also come into play,” says Maphosa, such as relabeling doses in a nation’s native language, and ensuring the proper syringes, freezers, and transportation are available in the recipient countries. “Aligning all those things up is no small feat,” Gandhi says.

The U.S. has pledged to donate more than 600 million doses of COVID-19 vaccines. But as of August 3, it had shipped only 110 million of those shots. The European Union had donated 7.9 million doses—about 4 percent of the 200 million doses it pledged to send—by early August.

“Countries’ donations are critical in the effort to address global vaccine inequity,” Maphosa says. But he adds that it’s “crucial these pledges are turned into deliveries as quickly as possible. We need doses now, not later, because global demand still outstrips supply.”

How you can help

To curb the rise of the Delta variant and help end the pandemic, some well-meaning citizens might consider forgoing boosters in the hopes the doses will get donated.

But the reality is that if you reject a booster at a pharmacy or clinician’s office that is already available to you, “the higher risk is that you’re going to—while well intentioned—lead to [the dose] just being wasted and no one using it,” Gandhi says.

COVAX is unlikely to accept doses already distributed throughout a country, he explains, because it must ensure the quality and safety of the product from the time it was manufactured.

The COVID-19 vaccines are temperature-controlled products. If the vaccines dip outside their ideal temperatures, their quality can be compromised. “There is a risk that the product may not work as well,” says Gandhi. “It may be an infinitely small one, but it’s one that exists and that prevents us, most of the time, from accepting donations of products that have” left manufacturers.

But “that doesn't mean that we throw our hands up,” he adds. And Nancy Jecker, a professor of bioethics and humanities at the University of Washington School of Medicine, agrees: “I think it’s a personal responsibility of each and every individual to be a global good citizen,” she says.

Rather than declining a booster, you can send an email to your congressperson, asking the U.S. to increase its donation efforts. UNICEF has a form email you can fill out and send immediately.

Or you can make a donation to UNICEF to aid in the delivery of future vaccine doses.

“This is not just about global equity, as we’ve said many times,” says Gandhi. By leaving people unprotected and allowing the virus to continue circulating and mutating, “you end up with this self-fulfilling prophecy of needing more and more boosters in high-income countries, because you’re not addressing, in part, the root cause of the problem elsewhere in the world,” he says.

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