Israel to give fourth COVID-19 vaccine dose: What are the implications for the unvaccinated and global vaccine equity?

On Dec. 21, Israel announced that a fourth dose of COVID-19 mRNA vaccine will be made available to help control an Omicron wave of infection. The initial focus will be persons over age 60, health care workers and those who are immunocompromised. Only 3 months will be required since the third dose. The rollout could begin as early as this Sunday, Dec. 26, according to reporting in the Times of Israel. During this ongoing rapid surge due to Omicron (now in all 50 U.S. states and 106 nations) the contrast in vaccine immunity will increase further between the unvaccinated and those who will have four doses by January to February 2022.

Absent a much higher availability of mRNA vaccines worldwide in early 2022, especially in low-middle income nations, global vaccine inequity will worsen as more fourth doses are given. And more variants of concern may arise in individuals with inadequate immunity as a result of this global vaccine inequity.

All five variants of concern (Alpha, Beta, Gamma, Delta and Omicron) have first been recognized outside the USA. Each of these variants later appeared in the USA where Alpha, Delta and now Omicron became dominant. 

For unvaccinated persons who have chosen not to be vaccinated despite having access to vaccines (e.g., in the USA) the current timeline to go from first to third dose is 7 months (doses at 0, 1 and 7 months). In Israel, even if the time is less than 6 months between the second and third dose, and then between the third and fourth dose, the timeline needed for the unvaccinated to reach four doses is likely to be long after their peak Omicron surge.  

A high risk of global vaccine inequity also exists for novel Omicron-containing monovalent and bivalent vaccines as well as future N+1 variant-specific vaccines. Today Germany was reported to have ordered 80 million doses of an Omicron-containing vaccine from BioNTech with delivery estimated in April to May 2022, according to reporting in DW.

At least four companies have made known they are developing nascent Omicron-containing vaccines: Moderna, Pfizer/BNT, AstraZeneca and Novavax. It would be surprising if the multiple other vaccine companies, e.g., in China, Russia, India, Europe, South America and Australia, are not doing the same, especially if Omicron is anticipated to be the dominant variant in 2022.