Covid-19 experts agree: 2021 was a failure for vaccine distribution
- After effective vaccines were developed in record time, how shots have been allocated among rich and poor countries has been starkly uneven
- Advocates call to expand dose production worldwide as Omicron variant pushes wealthy nations to roll out boosters
Rich countries, poor countries, pharmaceutical executives and advocates for equitable access to medicines have been on different sides of the debate over what is needed to vaccinate the world against Covid-19. But they all agree on one thing: 2021 was a failure.
While 2020 brought record-speed development of effective vaccines and 2021 saw what has been called the largest immunisation campaign in history, how those shots have been allocated throughout the global population has been starkly uneven.
Last month, two former national leaders, Helen Clark of New Zealand and Ellen Johnson Sirleaf of Liberia – who also co-chaired a previous panel established by the World Health Organization to evaluate pandemic response – put it this way:
“The profit-incentivised, inequitable system for distribution of pandemic tools has led to a place where one of us lives in a country on track to fully vaccinate 90 per cent of the eligible population by Christmas, and one of us lives in a country where less than 10 per cent of people are fully vaccinated,” they wrote.
While vaccination is not the only measure needed to bring the pandemic to heel, experts agree it will not be possible to end the crisis until most of the world is vaccinated.
There are two hurdles: ensuring stable and sufficient access to doses, and overcoming challenges of distribution and hesitancy to get them into the arms of people worldwide.
It has become all the more urgent following the rise of the new and highly transmissible coronavirus variant Omicron.
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Since its identification in November, the variant has spread to more than 110 countries, and is driving a surge in cases in some parts of the world, with the US and Britain this week breaking records for new daily cases.
While data is only beginning to emerge on the highly mutated strain’s impact on vaccine effectiveness, experts agree that some protection is reduced.
This has raised the possibility that variant-specific booster shots could be needed, or that regular vaccine updates – akin to seasonal influenza shots – could be in store for the future.
The variant has already pushed countries to lean more heavily on booster doses to bolster protection – raising concerns about a replay of 2021, where some governments hoarded excess doses, while others had no choice but to send health care workers to the front line unprotected.
By the numbers
Last June, WHO chief Tedros Adhanom Ghebreyesus spoke before the leaders of the wealthy Group of Seven nations and presented a goal: to vaccinate 70 per cent of each country’s population by mid-2022, a feat that would require 11 billion doses of vaccine.
Some six months later, the world is on track to have produced that many doses by the year’s end, according to data from British analytics firm Airfinity. But 92 countries have yet to vaccinate 40 per cent of their populations, as most of the global supply has gone to wealthy nations.
There are signs of change. The Covax Facility – a fair distribution plan backed by the WHO along with the Coalition for Epidemic Preparedness Innovations (CEPI), and GAVI, the Vaccine Alliance – struggled for access to doses for most of 2021, but was able to significantly step up deliveries by the final months of the year.
This was achieved as countries that had stockpiled doses donated more, the facility’s manufacturing deals finally came through, and India eased an export ban that restricted supplies from what was meant to be a major global supplier.
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Pharmaceutical industry representatives, speaking at a vaccine manufacturers’ press briefing in December, said there were now ample supplies of shots against Covid-19, as they sought to shake off criticisms that they played a role in vaccine inequity.
“We have moved from supply constraints to absorption constraints,” said Thomas Cueni, director general of the International Federation of Pharmaceutical Manufacturers & Associations, which represents vaccine makers in developed countries.
“If part of the global production starts to be diverted into [Omicron-specific] vaccine production that will have a significant impact on the global vaccine production availability, as it takes time to shift over production and to ramp up production,” Hansen said.
And if countries rolled out boosters to all adults, this would lead to a 16 per cent reduction in surplus doses, as of March 2022, that could be donated by wealthy countries to poorer ones, though even this would not eliminate the surplus, he said.
“We also expect some producers could be taken out of the market as there might not be demand for them.”
Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law at Georgetown University in the US, said it was possible some doses – including those relied on by Covax – may not hold up well against Omicron, potentially putting more demand on production of those that do.
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He also pushed back on the argument that there are no longer global supply problems. “The vast majority of vaccine doses are still in high-income countries. They have promised to donate surplus doses but haven’t,” Gostin said.
“Donations aren’t predictable and many doses are delivered with short expiration dates,” he said, adding that it was still unclear how many booster doses will be needed in the future.
“The global need for more doses and the demand for the better vaccines will be huge factors in supply shortages going forward.”
Bottom up
“We need to completely rethink the way in which we manufacture, finance and deliver vaccines,” said Gavin Yamey, director of the Centre for Policy Impact in Global Health at the Duke Global Health Institute in the US.
Lower- and middle-income countries “cannot be relying on the charity of the rich world” for access, but need a “bottom up” manufacturing strategy and regional hubs, he said.
“Two years into this pandemic it is unconscionable that we do not have a people’s vaccine … [which requires] sharing vaccine patents, technology transfer, and globalised manufacturing.”
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A WHO initiative set up in May 2020, for the sharing of intellectual property, knowledge and data, was entirely ignored by vaccine makers.
Instead, for more than a year, a battle has been waged at the WTO with more than 100 nations calling for waivers of intellectual property protections for vaccines and other Covid-19 medical products. They are pitted against a handful of wealthy countries who are blocking the proposal.
Experts on both sides of the argument largely agree that to be effective a waiver would need to be accompanied by a transfer of technology and know-how to manufacturers in developing countries.
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There have been notable examples of pharmaceutical companies doing this via licensing arrangements throughout the pandemic. The Serum Institute of India, for example, produces its own version of vaccines developed by British-Swedish company AstraZeneca, and American firm Novavax.
Producers in Korea and Thailand also make versions of the AstraZeneca shot. More recently, German firm BioNTech agreed to work with partners in Africa on the continent’s first mRNA manufacturing facility.
Some 300 partnerships exist or are in the works between vaccine developers and manufacturers, according to Michelle McMurry-Heath, president of industry group Biotechnology Innovation Organisation.
But others say the existing scale of these arrangements falls short – especially as it is unclear what the ongoing need for vaccines will be as the virus evolves.
The long view
“If every country with every company that can make vaccines is not doing so, there is no solution in sight,” said Achal Prabhala, India-based coordinator of the AccessIBSA medicines access project.
A recent report co-authored by Prabhala and an expert from Medecins Sans Frontieres identified 120 manufacturers – largely in developing countries – with the technical requirements and quality standards to make mRNA vaccines, if they were given access to the tech and know-how from the developers.
Expanding production of vaccines using this cutting-edge platform is the best path forward, the report argues, as the technology can easily adapt vaccines for new variants and does not require high-containment labs or other biological processes to produce – opening the door for a far larger number of existing pharmaceutical manufacturers to get involved.
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While Prabhala acknowledged that setting up more collaborations between these suitable factories and the vaccine developers would take some months, there was no time to waste, he said.
“If we don’t do this now, there is something horrible around the corner,” Prabhala said, adding he had no idea when he himself would be able to access a booster shot.
“We’ve thought of vaccination for Covid as an event, but it’s clearly an ongoing, continual process that’s going to be with us for a long, long while.”
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While experts said regional manufacturing would help with future access and readiness, it would not eliminate challenges of getting doses to people in rural areas, or to those reluctant to get vaccinated.
This will need to be another focus of world leaders and community workers in 2022, they say.
“Countries around the world are facing huge logistical challenges with cold storage, transport and electricity, trained health workers, and vaccine education,” said Georgetown’s Gostin.
Like the other challenges, “the final mile demands highly focused attention and considerable funding”, he said.
