Managing vaccine inequality – Covid-19 vaccines as a global public good
Managing vaccine inequality – Covid-19 vaccines as a global public good

Managing vaccine inequality – Covid-19 vaccines as a global public good

The first peer-reviewed clinical trial evidence that a Covid-19 vaccine provided robust protection against SARS-CoV-2 infection was published in Journal in December 2020,1 less than one year after the sequence of the viral genome was reported. This unprecedented rapid development of vaccines was a scientific triumph. In the year since, about 62% of the world’s population has received at least one dose of a Covid-19 vaccine, and 54% have completed the primary vaccine series.2 This seems to be a landmark success in global health mobilization.

Covid-19 vaccine doses administered in countries categorized by income level, 2 December 2020 to 20 February 2022.

Income categories are those defined by the World Bank. All doses, including boosters, are counted individually; since the same person may receive more than one dose, the number of doses may exceed the number of persons in the population. Data is from our world in data (

The truth, of course, is very different. The availability of Covid-19 vaccines varies widely across the globe (figure 1). While several rich countries have exceeded 90% vaccine coverage, only about 11% of all people in low-income countries have received at least one dose, and only 25% of our health colleagues in Africa were fully vaccinated in November before the omicron wave.3 Approximately three billion people worldwide have not received a single dose. The gap in vaccination rates according to national income is overwhelming despite the fact that a number of the key Phase 3 trials that led to vaccine licensing were partially conducted in some less developed countries. Poor countries without the capacity to produce vaccines joined the end of the queue, as countries with production capacity prioritized local supply, and richer countries bought the vaccines. We should not be surprised by vaccine nationalism; The company’s executives and boards have a responsibility to maximize their share price, and politicians are elected to put the interests of their constituents ahead of populations in other nations, despite compelling arguments to prioritize vaccinations globally for the vulnerable and for health professionals.4

And a new challenge for the global vaccine supply has emerged: data from several in vitro studies and real-world studies published in Journal has shown that antibodies to SARS-CoV-2 decrease within a few months after vaccination, results that emphasize the need for a booster to restore high antibody levels both to reduce infection with new variants and to minimize hospitalization and death.5 In developed countries, the rapid emergence of the omicron variant has increased the intrusion of these booster doses. Israel, a frontrunner in delivering booster doses, is now testing the effectiveness of yet another fourth dose of vaccine, and additional boosters and redesigned vaccines are likely to be needed over time. This development guarantees that existing vaccine supplies will be directed to rich countries, further delaying their availability in poor countries. Appeals from the World Health Organization (WHO) to postpone booster doses to prioritize the first doses to the world’s three billion unvaccinated people have gone unnoticed in countries that see boosters as the way to open their economies and end unpopular social interventions. There is also a risk that “old vaccines” will be dumped on poorer countries when the rich switch to second-generation redesigned vaccines.

COVAX (Covid-19 Vaccines Global Access) program, created as part of the ACT (Access to Covid-19 Tools) Accelerator and led by GAVI (Vaccine Alliance), CEPI (Coalition for Epidemic Preparedness Innovations) and WHO to support equal access was established in anticipation of this problem. However, the impact of COVAX has been dampened by supply chain issues, vaccine nationalism, the decision by some countries to stop vaccine exports and queues from affluent countries, which has significantly reduced their initial projections of vaccine availability.6 The two largest countries in the world, China and India, improved the situation by vaccinating their populations through their national production. However, most countries have no local production capacity and are completely dependent on external procurement, vaccine diplomacy or donations. Developed countries that send batches of vaccine that are about to expire to poorer countries are not doing much to address inequalities.

In addition, different vaccines have different effects against disease, and the half-life of this effect, together with the supply, would ideally be included in any global vaccination strategy, but this can not happen when the different vaccines vary in price and availability. Fortunately, even a dose of most vaccines seems to boost those who have had a primary infection, suggesting that even a single vaccination may be a beneficial bridge to implementing a primary series in countries where the prevalence of antibodies due to primary infection are high.

It has become an article of faith that “no one is safe until everyone is safe,”7 but in countries that can vaccinate a very high percentage of their populations and deliver boosters, and perhaps boosters-on-boosters, Covid-19 can become a controllable infection (although the emergence of immune-escape variants remains an ever-present threat and immunosuppressed people remain at risk). However, in countries with low vaccine coverage, SARS-CoV-2 will still cause high morbidity and mortality, strain health systems, sick health workers and cause economic disruption, and will potentially provoke intermittent travel bans when new variants emerge. When developed countries accumulate boosters in response to virus variants, when will less developed countries find a timely and secure supply of Covid-19 vaccines?

It is argued that the self-interest of rich countries should lead them to help vaccinate poorer countries because the uncontrolled spread of SARS-CoV-2 could promote the emergence of escape mutants that would disrupt their vaccine-induced protection against infection, hospitalization, and death. However, although such uncontrolled viral replication and transmission increases the risk of new variants, SARS-CoV-2 evolution in immunosuppressed patients can create new variants everywhere, including the developed world.8 Since current vaccines do not provide sterilizing immunity to infection with new variants such as omicron, SARS-CoV-2 will continue to circulate and possibly mutate, even in highly vaccinated populations. The issue of global vaccine equity can not only rest on a defense against escape mutants. Moral and social justice argue that Covid-19 morbidity and mortality and their impact on economic and health systems should be prevented in all countries, rich and poor, around the world.

In the short term, poorer countries will have to compete for vaccines in the global marketplace and hope that the COVAX mechanism can radically accelerate and increase supplies, despite COVAX CEO’s assessment that “what we do not have today are the resources to help countries adapt to the new challenges that we know Covid-19 will create in 2022. “9 Meanwhile, a potential solution, a waiver by the World Trade Organization’s TRIPS of intellectual property rights due to a public health emergency, has been blocked for over 18 months, despite the support of the WHO, the US President and over 100 governments,10 including India, South Africa, Russia and China. The Oxford-AstraZeneca ChAdOx1-nCoV-19 vaccine and some others have been voluntarily licensed to several countries for upscale production. Baylor College of Medicine has made the formula publicly available for a protein subunit vaccine that has been licensed for use in emergencies in India.11 But the mRNA vaccine strategy, which can most flexibly accommodate antigenic changes, remains heavily protected by the companies involved, despite being based on decades-funded research from public money. In the early months of vaccine production, the argument that supply chains for the 280 ingredients needed to make mRNA vaccines could be disrupted by any change might make sense. However, continued exclusivity has meant that few public funds have gone to upscale the production of these ingredients, a situation that maintains these constraints in the supply chains. It’s long overdue to break this stalemate.

The medium to long-term solution is ready. Less developed and smaller countries need access to local or regional capacity to produce vaccines because they cannot rely on the excess production capacity in richer countries for vaccine supplies in this or future pandemics. A report in 2017 estimated that over 99% of the vaccines used in Africa were imported, and surprisingly, although around 55 countries in 1997 had vaccine production capacity, commercial and regulatory pressure in 2015 had reduced this number to less than 20 .12 This situation is in contrast to the objectives of the Global Action Plan on Influenza Vaccines, developed by the WHO, which has emphasized and supported the regional production of influenza vaccines.13 CEPI plans to develop an international network that will reduce the time it takes to produce a vaccine against a new epidemic pathogen to 100 days.14 but the immediate test case is how to increase the production of the most effective Covid-19 vaccines today.

Sustained efforts to develop and increase regional vaccine production capacity are needed to reduce reliance on business plans for a handful of commercial entities. This should include licensing and technology transfer schemes such as those developed by the WHO and the Medicines Patent Pool, which have successfully made antiretroviral therapies widely and cheaply available for the treatment of AIDS, even in the poorest countries. WHO has gone further and created vaccine hubs, such as mRNA vaccine hubs in South Africa and five other African countries,15 which keeps the promise of locally developed and manufactured vaccines for Covid-19 and future pandemics. The President of the International Monetary Fund maintains that the financing of vaccine production in Africa is “good for the world”, as the investment required is small compared to the global economic impact of Covid-19.16 An alternative, giving loans to poor countries to buy Covid-19 vaccines, only maintains indebtedness. Finally, as new vaccines are developed, regulatory mechanisms need to adapt to changing circumstances; where a high proportion of people have partial immunity to natural infection, vaccination or both, phase 3 trials aimed at demonstrating the superiority of a new Covid-19 vaccine become impossibly large, making noninferiority studies the preferred opportunity to increase the diversity of approved vaccines.

Vaccine inequality is symptomatic of the failure of global pandemic management. The haphazard way in which vaccines are currently being distributed needs to be addressed as part of a global vaccine strategy that includes a system of intellectual property management, manufacturing and distribution that ensures that vaccines are made available on an equal footing around the world. Vaccines against pandemic diseases, and the ability to produce them, must not be a sequestered asset that maximizes the return on drug executives and shareholders or increases the eligibility of politicians. They must be a global public good.

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