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Scientific and above all ethical doubts about the appropriateness of the third dose for healthcare professionals

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by Salvatore Mazzeo

13 OTTDear Director,

a few days ago, AIFA and the Ministry of Health opened the possibility for health personnel to access the third dose of the anti-COVID 19 vaccine. Many colleagues and colleagues in these hours already have or are about to book their dose recall. However, as a staunch supporter of vaccines and in favor of mandatory vaccination, I take the liberty of raising some objections regarding the scientific substantiation of this decision and, above all, its opportunity in terms of global health.

However understandable the preventive approach in the style of “safety is never too much” may be, although it may be shared the hypothesis that after some time immunity may be reduced and we can again be subject to infection, the former remains a way of speaking, the second only a hypothesis. As women and men of science, we cannot limit ourselves to one or the other, but we must 1) stick to the evidence 2) act in the interest of the community.

Regarding the first point: if it has been shown that a third dose of vaccine (a few weeks after the second) promotes the development of immunity against the virus in immunocompromised individuals, it is not proven that a booster dose reduce the risk of infection in immunocompetent individuals. The data on which the drug agencies are based comes from a study of 306 subjects that showed that a third dose of the vaccine increases the antibody titer.

However, another study (the only one) carried out on health workers, while showing a reduction in antibody titer over time, reported only one case of symptomatic SARS-CoV 2 infection in 201 subjects monitored over 6 months. This would mean that a decrease in the antibody titre does not correspond to an increase in the risk of contagion. At the same time, no studies have yet shown that increasing the antibody titer with a third dose of the vaccine increases protection.

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In conclusion, there is no evidence at present demonstrating the usefulness of the third dose in immunocompetent subjects. The same FDA, in the statement announcing the authorization of the third dose in the immunocompromised, specified that “other fully vaccinated individuals do not need an additional dose of vaccine at this time”.

In addition, even assuming that a third dose may be effective in reducing the incidence of COVID-19 in immunocompetent people and that a study demonstrating it is published, it would still be fair to administer a third dose in subjects already immunized, when 97% of the population of low-income countries have not yet received a single dose? According to Mike Ryan, director of the WHO emergency health program, it would be like “distributing life jackets to people who are already wearing one, while letting everyone else drown without any protection whatsoever.” Personally I agree with him.

And here we come to the second point: as doctors and doctors, we are called to act in science and conscience, not only towards our patients, but towards the whole community. And by community I don’t just mean our clinic, our hospital or our country, but the entire world population. If in Italy 73.13% of the population has completed the vaccination cycle, in low-income countries only 2.5% have received at least one dose, with states in which values ​​are lower than one (https: // ourworldindata.org/covid-vaccinations).

In a period of continued global vaccine supply shortages, equity considerations at the national, regional and global levels remain an essential consideration in ensuring the vaccination of high priority groups in every country. Improving coverage of the first dose of vaccine should take priority over booster vaccination”.

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These are not my words, but those of the WHO (see full text), which continues as follows: “National vaccination program policy decisions to add a booster dose should take into account the strength of the evidence regarding the need for these doses, their safety and efficacy, as well as the global availability of vaccines. Offering booster doses to a large section of the population when many have not yet received even a first dose undermines the principle of national and global equity. Prioritizing booster doses over speed and breadth in starting dose coverage can also harm the prospects for global pandemic mitigation, with serious implications for the health, social and economic well-being of people globally. […]. In the context of current restrictions on the global supply of vaccines, large-scale administration of booster doses risks exacerbating inequalities in access to vaccines by increasing demand and diverting supply”).

In conclusion, the rush to the third dose for immunocompetent physicians could be an excess of individual precaution with detrimental effects on a global society level.

Vaccines, unfortunately, are a limited resource. The pharmaceutical companies that still hold the monopoly (despite the motions for the suspension of patents advanced in multiple locations, especially from poor countries and repeatedly sunk, especially from rich countries) continue to allocate their doses to the best bidders. In this dose-grabbing competition, low-income countries will forever be defeated. As doctors, we cannot be complicit in this unequal game. As doctors, we must aim for everyone’s health, regardless of their country of origin.

We must ask that vaccines are produced and distributed according to the needs of the world population and not submit to the logic of profit. We must rush to sign the ICE on the suspension of patents, not to book the third dose. We must take part and position, play our role not only as health workers but also influence the public debate as scientists. Not in favor of our category or the closest community to which we belong, but in the interest of the health of the population globally.

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Dr. Salvatore Mazzeo
Neurologist, PhD student in Neuroscience

October 13, 2021
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