Booster shots could extend India’s vaccine export ban that’s starved the world of doses

September 15, 2021, 2:56 AM UTC

India was once the world’s leading hope to equalize global access to COVID-19 vaccines. But India has for months virtually banned exports of COVID-19 vaccines in favor of supplying its domestic rollout, and now the prospect of booster shots in India threatens to further starve other countries of the Indian-made doses they desperately need.

In recent weeks, the World Health Organization (WHO) has come out firmly against countries recommending booster doses. “We do not want to see widespread use of boosters for healthy people who are fully vaccinated,” said Director-General Tedros Adhanom Ghebreyesus in early September, arguing that countries should donate or sell any leftover doses.

A study in the Lancet medical journal published Monday appeared to back the WHO’s position. “Current vaccine supplies could save more lives if used in previously unvaccinated populations than if used as boosters in vaccinated populations,” a group of 18 scientists wrote. On the other hand, Israel is set to publicly release data this week that reportedly shows that the Pfizer-BioNTech vaccine wanes in efficacy against deaths and severe disease. The Israeli study, which U.S. regulators are reviewing, is helping shape the U.S.’s planned rollout of booster doses, which is dependent on Food and Drug Administration approval.

India’s own decision to supply booster shots may be months away; the country is still working to get people injected with their first doses. India has provided one dose to 41.2% of its total population as of Tuesday and fully vaccinated 12.9% of its 1.4 billion citizens, according to Bloomberg.

But India’s leading vaccine maker has recommended that people injected with its vaccine get booster shots. If followed by the government, the move could extend India’s ban on vaccine exports for the foreseeable future.

The Serum Institute

The Serum Institute of India (SII), the world’s largest vaccine maker by volume, was supposed to be the chief manufacturer for COVAX, the global initiative supplying lower- and middle-income countries with COVID-19 vaccines.

The SII partnered with the U.K. pharmaceutical giant AstraZeneca to produce AstraZeneca’s vaccine in India under the name Covishield. The SII also signed an agreement to supply COVAX with 1.1 billion vaccine doses, with at least 100 million doses coming in the first half of this year.

But the SII has failed to fulfill those promises due to what it says are export restrictions imposed on it by Prime Minister Narendra Modi’s government.

Meanwhile, the SII’s Covishield vaccine has become the backbone of India’s COVID-19 vaccine campaign. By the end of August, Covishield doses made up 600 million of the 650 million doses India had administered to its citizens, according to the government.

But with the SII unable to ship its vaccines outside of India, the global rollout is lagging.

On Sept. 9, COVAX cut its supply forecast for 2021 by 25% to 1.42 billion shots from the 1.86 billion it projected in July. COVAX said the lack of shots from the SII was a main reason for lowering the projection.

“Continued export restrictions from India are leading to further supply delays, with the current most likely scenario assuming no SII supply to COVAX in 2021,” COVAX wrote.

Amitendu Palit, senior research fellow at the National University of Singapore’s Institute of South Asian Studies, says that the SII will likely resume exports once the domestic campaign is satisfied.  

“I would expect [exports] to resume as soon as India has achieved a minimum domestic vaccination target and is assured of enough vaccines for minimizing the impact of a potential third wave,” he said.

India’s booster shots

But talk of booster shots means that minimum target is a moving one.

Earlier this year, India set a goal of fully vaccinating all adults 18 and up with two shots by the end of the year. India’s government reports that 60% of adults have gotten at least one jab and 18% are fully vaccinated. At its current rate of administering 7.5 million doses per day, India would not fully vaccinate its adult population with two doses before March of next year.

The Hindustan Times reports that India is not likely to resume exports until at least the start of next year, and the calculus could change if the government decides some people need three doses instead of just two.

India’s health regulators say that they are studying the needs for booster shots. Priya Abraham, director of the government-affiliated National Institute of Virology, said in August that “recommendations for boosters will definitely come” in the future.

The SII, a firm that makes money by manufacturing vaccines, is recommending that people get booster doses.

“After six months, the antibodies go down and that is why I have taken the third dose,” SII chairman Cyrus Poonawalla said in August, explaining that 7,000 to 8,000 SII employees had received third-dose boosters.

A SII spokesperson did not respond to Fortune’s request for comment.

Ashley St. John, associate professor of immunology at Duke-NUS Medical School, says a decision to recommend booster shots could slow India’s domestic vaccination campaign as well as rollouts elsewhere in the world.

“For now, I don’t think there are data suggesting that vaccine boosts are needed in the general population,” says St. John. “I think the focus should be on vaccinating the naïve first to slow the spread of disease further” in India and around the globe, she said.

Palit says that an increase in vaccine production in India in the latter part of this year could help alleviate concerns about exports and booster doses. The SII is currently delivering 110 million doses per month to India’s domestic campaign and is responsible for the vast majority of the country’s supply. But hundreds of millions of additional doses of Bharat Biotech’s Covaxin and Russia’s Sputnik V may help raise India’s vaccine capacity to 360 million doses per month by the end of this year.

“If enough different vaccines are available at home, then [India’s] exclusive reliance on SII would be less,” says Palit. Once supply increases, “the SII’s ability to export would not be affected by booster shots,” he said.

A decision on India resuming vaccine exports may come soon.

This week, U.S. President Joe Biden is expected to pressure Modi to restart COVID-19 vaccine exports and even offer Modi a “higher-profile role” at the upcoming COVID-19 global summit in New York if the Indian prime minister agrees to Biden’s request, reports Axios.

The U.S., meanwhile, has a stockpile of at least 100 million unused vaccine doses that the Biden administration has earmarked for booster doses, undercutting, to some degree, Biden’s request that India loosen its grip on its vaccine supply.

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