‘Some people in all countries, not all people in some countries’
With good news gracing our screens this week regarding successful results from the large-scale Moderna trial, the approval of a safe and effective COVID-19 vaccine seems imminent. Yet, despite pre-emptive purchasing agreements of almost 4 billion doses of vaccines, they will likely be in short supply for the first few years, with enough doses to immunise only a small percentage of the population. Although there is little dispute over the vulnerable and healthcare workers receiving the first available doses; there remains concern over equitable access to the vaccine in high and low-income countries, and how this will affect the course of the pandemic. A team of scientists supported by the Bill and Melinda Gates foundation estimated the outcomes of two different scenarios involving vaccine distribution. The models found that only 33% of deaths would be averted if high-income countries received the vaccine first, compared to 61% of deaths averted if the vaccine was distributed to all countries proportional to their populations (1).
Set up in 2000, the Global Alliance for Vaccines and Immunisations (GAVI), aids Low and Middle-Income Countries (LMICs) in immunisation programme design and delivery. In the wake of the COVID-19 pandemic Gavi has joined forces with the World Health Organisation (WHO) to set up CoVax, a COVID-19 vaccine allocation plan that ensures equal distribution of new vaccines between rich and poor countries. CoVax aims to deliver two billion doses by the end of 2021, requiring an investment of 2 billion dollars, 90% of which has been committed so far. Nine candidate vaccines, including the Astrazeneca (AZ) vaccine developed in collaboration with Oxford, have committed to delivering millions of approved doses to CoVax in return for funding. In addition, AZ has agreed with The Serum Institute of India to supply it with 1 billion doses and has ‘committed to operating on a non-for-profit basis during the […] pandemic’.
Equitable access to the vaccine, highlighted by the formation of CoVax, goes beyond moral and ethical obligations stated in the Sustainable Development Goals. In just one short year SARS-CoV-2 has devastated the global population, claiming over one million lives and disrupting the lives of billions more. Physical, mental and socioeconomic statuses have been adversely affected across the globe, a large proportion of which can be seen in LMICs, termed Covid collateral. Included in this are disruptions in at least 44 vaccine campaigns that were planned to take effect in 2020 by GAVI. The withholding of a COVID-19 vaccine from LMICs, where majority of programmes were set to take place, will not simply prolong the effects of COVID-19, but further impact the delivery of vaccines for several other infectious diseases, risking many more lives.
In addition to the health of many populations, the global economy will also suffer from delays in LMIC vaccine access, associated with the globalisation of large companies who control a large amount of their workforce from overseas. Furthermore, trade between countries will remain stunted, preventing economic growth and exacerbating the impact of COVID-19. Finally, travel, an important source of income for many LMICs, will remain infringed, indicating the indirect impact of limited vaccine access. However, the delivery and implementation of a COVID-19 vaccine is dependent on several crucial factors, namely access, price and availability.
Each vaccine requires specific transport and storage, impacting who the vaccine can be appropriately delivered to. With the Pfizer vaccine requiring specialised equipment to ensure vaccine stability, cold-chain infrastructure must be in place; a great expense for many countries. Moreover, the optimisation of cold-chain equipment has been delayed thus far as a result of additional costs incurred as a direct result of the pandemic. Without supplying LMICs with the necessary equipment and infrastructure required for vaccine implementation, COVID-19 costs will continue to rise. Conversely, Moderna can be stored in refrigerated conditions for approximately a month, and the AZ vaccine has been indicated as fridge safe, albeit requiring an additional ingredient. Which vaccines LMICs receive may therefore not be at their discretion, and sensitivity to infrastructure is necessary.
Secondly, the price of vaccine candidates varies hugely with the Moderna vaccine priced at approximately 10 times the price of the AZ vaccine, which when operating as a non-profit has a market price of $3-4. Furthermore, each vaccine requires two doses. A single dose vaccine priced at approximately $10 from Johnson & Johnson, is another hopeful candidate with similar technology to the AZ vaccine which could significantly lower the price. In the case where vaccines are bought by CoVax for delivery in LMICs, the price of the vaccine will hugely impact the proportion of the population that can be immunised.
Finally, the availability of each companies’ vaccines is suspected to be initially low, possibly having the largest impact on delivery. Despite CoVax, pharmaceutical companies have struck direct deals for millions of doses of the virus, reducing the number of vaccines available for LMICs. A first come, first serve vaccine will leave many susceptible to a reduced chance of receiving it.
The start of the pandemic did not present much hope for an equitable share of COVID-19 impact with each country fighting for themselves, witnessed in France requisitioning the nations supply of masks and the USA redirecting planes carrying supply loads in order to obtain ventilators. This type of global division is not an encouraging indicator for what we might see in the delivery of a vaccine. However, hope in humanity often prevails with Australia promising doses to poorer neighbouring countries and Covax having obtained the majority of its target funds to ensure equitable access.
Much remains unknown about how and when an optimal change in the course of this pandemic may come about, but one point prevails above all, a cure for some will not be effective in halting the virus in its tracks and to help our own we must too help others.
By Sarah Baum
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