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COVID-19 vaccine boosters could present equity, pricing issues

Familiar problems could arise if extra shots are needed to fight coronavirus variants

Convincing Americans to take COVID-19 vaccines, distributing the shots, equitably prioritizing people for vaccinations and negotiating fair prices has been a herculean task. The federal government and states may need to do it all again for booster shots to stop the spread of contagious mutations — but the Biden administration has not yet released a plan, and experts warn that the United States could repeat past mistakes unless the country starts planning now.

Pfizer, Moderna and Johnson & Johnson are all working to develop COVID-19 booster shots to help fight variants. So far, all three vaccines have shown some efficacy in protecting against the variants that are already here. However, scientists are concerned that the virus could mutate further, and it’s still unclear how long immunizations will last.

“The most obvious threat … is the scenario where we are all already vaccinated in the fall and life is pretty close to normal, and we’re seeing large outbreaks in places like Brazil. And you see a new variant that is truly resistant to our vaccines, and the entire American population is a sitting duck,” said Ashish Jha, dean of the Brown University School of Public Health.

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The U.S. would need to distribute coronavirus boosters if a powerful COVID-19 mutation from another country reaches our shores, or COVID-19 becomes endemic in society and people need annual booster shots, much like seasonal flu shots.

It could take three to four years for the rest of the world to get vaccinated for COVID-19, Jha said, so this could be an ongoing issue. 

Variants and mutations

Several COVID-19 variants and mutations are currently in the U.S., and scientists expect the variant from the United Kingdom, B.1.1.7, to soon become this country’s dominant strain. But scientists are more concerned about the vaccines’ effectiveness against the B.1.351 strain from South Africa and the P.1 lineage from Brazil.

The Centers for Disease Control and Prevention has stepped up its genomic sequencing efforts to rapidly monitor how variants are spreading in the United States, and the recently passed congressional pandemic relief package includes $1.75 billion for viral sequencing. 

Scientists say they will have a better understanding of the spread and scope of variants by April or May, and public health officials agree that policy decisions regarding vaccine boosters should follow by early summer, even though the boosters may not be ready or needed until the fall.

If there’s a need for these shots, the Biden administration will have to deal with familiar problems, including preparedness, distribution, equity and pricing.

“It’s not as much about what as it is about when you do these kinds of policy decisions. Doing it early and having a playbook really early might help states iron out the kinks,” said Saad Omer, director of the Yale Institute for Global Health. “We haven’t managed to have a coherent strategy as a country beyond lip service to convince people to take the first couple of doses, let alone the third dose.”

When asked about the Senate Health, Education, Labor and Pensions Committee’s approach to COVID-19 vaccine boosters, Chair Patty Murray, D-Wash., said senators would use the lessons learned from the pandemic thus far to make sure that future vaccine distribution is equitable and that cost isn’t a barrier to inoculation. But when pressed for details, she said they do not have any quite yet.

“We’re all in the middle of trying to get vaccines out right now. … I know the administration is thinking about it as well,” Murray told reporters last week.

Administration officials declined to comment on the record.

Distribution issues

The CDC created its initial vaccine allocation recommendations one week before states received their first round of COVID-19 doses. This gave states little time to prepare and determine who in their state should get the vaccine first and how to reach them, Omer noted. The sooner states get this information, the smoother vaccine distribution will be.

Once scientists learn more about how the variants interact with vaccines, that will determine distribution, experts say. For example, if one COVID-19 variant can overpower mRNA vaccines like the ones made by Pfizer/BioNTech and Moderna, but the Johnson & Johnson vaccine already works against the variant, people who received mRNA vaccines would be prioritized for boosters. Or if one variant targets seniors or people with diabetes, for example, the boosters ideally would go to those populations first.

Adam Beck, a vice president at America’s Health Insurance Plans, says insurers want to help. Insurers have consumers’ vaccination data, so insurance providers could work with the CDC to determine how many people would need boosters and reach out to enrollees who would need to get the extra shot.

One thing the government can do now is work on gaining public trust, said Arthur Caplan, head of the New York University School of Medicine Division of Medical Ethics. Much of the hesitancy that came with the initial COVID-19 vaccine rollout had to do with concerns that the vaccines were developed too quickly or were not safe. 

Much of this effort will be driven by the administration, Beck said, but insurance providers would like to help counter booster shot vaccine hesitancy.

“Knowledge is power here. And hearing from a health insurance provider who might understand your other health needs and be able to explain, ‘Here’s what happened between the development of these vaccines and new boosters for a variant’ … is important,” Beck said.

Pricing problems

Unlike the first round of COVID-19 vaccines, the booster shots could end up becoming a lucrative business, say experts. The shots are not being developed under federal contract, and the U.S. government has not agreed to purchase any in advance, so pricing isn’t guaranteed.

Under the COVID-19 public health emergency, coronavirus vaccines are free to all Americans regardless of insurance status. If boosters become necessary after the emergency pandemic period ends, the uninsured may not be able to afford the shot.

Advocates are already gearing up to ensure access. Steve Knievel, an advocate for Public Citizen’s Access to Medicines Program, said the U.S. government could have the leverage to rein in pricing when crafting purchasing agreements with vaccine makers. The Trump administration did not include taxpayer protections in some of its vaccine contracts, he said. 

The COVID-19 vaccine contract with Pfizer excludes typical intellectual property provisions, and that could allow the government to step in and prevent price gouging. The Pfizer vaccine was developed without federal dollars, and then the government purchased large quantities of shots — similar to how policy experts say the boosters pricing arrangement may play out.

“The government should be really ensuring that any products we support are available at a reasonable price, they are licensed enough to be produced in a sufficient quantity, and we don’t allow for private interests to have all the control,” Knievel said.

Caplan said it’s likely the government would feel pressure to step in and lower prices because vaccine makers could make big bucks on COVID-19 boosters, especially if they become a yearly routine.

“Boosters are coming in at a time when the pandemic may not be top of mind,” Caplan said. “It’s easier to get everyone to play ball when you’re in the middle of the plague.”

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