Science’s COVID-19 reporting is supported by the Heising-Simons Foundation.
GENEVA—Just a few weeks ago, the mood here at the headquarters of the World Health Organization (WHO) was still decidedly somber. WHO had pushed hard for equitable distribution of COVID-19 vaccines, yet a “grotesque” gap had formed between rich and poor nations, said WHO’s director-general, Tedros Adhanom Ghebreyesus. Whereas several rich countries had enough vaccine to start to vaccinate teenagers, who are at very low risk of becoming severely ill, nurses and doctors in Africa remained unprotected.
“Have you got anyone left to vaccinate in your places?” Bruce Aylward, a top-level WHO official asks facetiously. “Are we going to vaccinate the goldfish next?”
But a meeting of the G7, held in Cornwall, U.K., last weekend, has changed the gloomy outlook. The leaders of the seven big industrialized democracies committed to donating 1 billion doses—870 million more than previously announced—by the end of 2022. The vast majority will move through the COVID-19 Vaccines Global Access (COVAX) Facility, a nonprofit set up by WHO that Aylward is working with. COVAX has built a war chest of $9.6 billion solely for purchasing vaccine at discount prices for poor countries.
“It’s a tipping point,” Aylward says. Seth Berkley, who heads Gavi, the Vaccine Alliance—another key COVAX partner—says the new interest in helping poorer countries marks a long overdue “mindset shift.” “We’ve been talking about it from the beginning: You’re only safe if everyone’s safe,” he says. “But nobody was listening.”
There’s more good news: Vaccine manufacturers are still scaling up production, and Novavax, a U.S.-based biotech, reported stellar efficacy results for its low-cost, easy-to-store vaccine this week, further raising hopes that the gap between rich and poor can be narrowed. (Many had hoped a few hundred million more doses might come from CureVac this year, but that company yesterday reported disappointing results from an efficacy trial that may derail its candidate.)
So far, COVAX has struggled to obtain vaccines, and as of 15 June it had only shipped 87 million doses, a tiny fraction of the 2.4 billion doses administered globally. Its goal of delivering 2 billion doses by the end of the year seemed out of reach. Many developing countries purchase vaccine directly from manufacturers as well, but that can’t make up for the enormous rift: Forty-one percent of people in high-income countries have received at least one dose of a COVID-19 vaccine, versus less than 1% in low-income countries.
Even some upper–middle-income countries are in the have-not camp. Ana Maria Henao Restrepo, head of R&D at WHO, comes from Colombia, where only 18% of people today have received a single dose. In late April, her unvaccinated 78-year-old mother developed COVID-19 there and was hospitalized for nearly 2 weeks. “I felt this was unjust: Why can she not have a vaccine when other people her age can have a vaccine?” Henao Restrepo says. Her mother survived but still requires supplemental oxygen. “Even if my mother had not had COVID, I would feel equally passionate,” she adds.
Yet donations to COVAX have been slow to materialize. Many countries have vast vaccine surpluses but are holding onto them, just in case. Some are also worried that developing countries’ health systems may be unable to quickly distribute large amounts of vaccine, leading to waste. Already, South Sudan and Malawi had to destroy tens of thousands of doses they could not put into arms before the expiration dates. Aylward dismisses that concern. “You know what? If we waste a few doses in the fourth quarter of this year in places that never had anything in the first half of the year, fair enough.”
That’s why the new pledge from G7 countries to add at least 870 million doses to COVAX over the next year—at least half by the end of this year—has lifted spirits at WHO. “It’s not the end, but it’s a good beginning,” Henao Restrepo says.
“There is some progress, I have to admit,” even Tedros agrees. “But whatever is committed now is not enough.” And he worries substantial donations won’t start to flow until the summer’s end. “Those countries that have pledged should start giving the doses they have pledged now.”
COVAX had hoped to distribute 300 million doses by now, giving countries a chance to ramp up mass vaccination campaigns incrementally. “We didn’t want there to be a sort of dribble, dribble, dribble, dribble, and then a huge surge in supply, which is going to challenge any country,” says Kate O’Brien, a technical adviser to COVAX and director of WHO’s Department of Immunization, Vaccines and Biologicals. “But it’s where we are now, and everybody wants this pandemic to end. So it’s what has to be done.”
Fairness or need?
The likely surge of vaccines is fueling debate about how to distribute them. COVAX’s current approach is one size fits all: vaccinating 20% of each country’s population by the end of this year, with groups including heath care workers and the elderly getting the first doses. But treating all countries the same is “shortchanging nations in desperate need, while providing vaccines to others that have comparatively few cases or lack the ability to distribute them,” medical ethicist Ezekiel Emanuel and health lawyer Govind Persad argued in an essay in The New York Times published on 24 May. (The piece built on a September 2020 policy forum in Science they co-authored.) It doesn’t make sense that Ghana and Peru should receive the same amounts of vaccine, Emanuel and Persad argue, when Ghana has had fewer than 1000 reported COVID-19 deaths and Peru, with the same population, has had nearly 70,000.
A comment in the 8 June issue of The Lancet took the idea a step further. Health lawyer Thomas Bollyky of the Council on Foreign Relations and modelers Christopher Murray and Robert Reiner from the Institute for Health Metrics and Evaluation (IHME) used computer models to estimate expected COVID-19 mortality by country between 1 June and 31 August, based on presumed transmission rates, vaccine supply, and the impact of variants on immunity. They find that Latin America, Central and Eastern Europe, Central Asia, and South Africa have the greatest need. That’s where COVAX should deploy its doses, they argued.
Models, including ones from IHME, have been wide off the mark for COVID-19, but they’re “good enough” to make predictions a few months ahead, contends Emanuel, who says they’re a better way to allocate vaccines than solely based on population size. They also might reduce the incentive for countries most in need to plead with individual donor countries—such as China—for direct aid, Bollyky adds, which undermines COVAX. “If COVAX were applying an epi-based model for early doses, it would be harder for donor nations to justify circumventing them,” he says.
Natalie Dean, a biostatistician at the University of Florida, agrees “evolving epidemiology” should play some role, but cautions that lower income countries often have difficulty with surveillance, which makes models less reliable. And she likes that the current COVAX strategy is “simple, transparent, and objective.”
So far, COVAX has seen no need to change its system, but it may eventually do so when supplies increase, says WHO Chief Scientist Soumya Swaminathan. Henao Restrepo says she’d like to see small-scale experiments to see how well model-based vaccine allocation works.
More doses coming
The main reason COVAX has missed its target so far is that it had little money last year to purchase vaccines, and it relied heavily on the Serum Institute of India to supply doses until more companies offered proven products at discount prices. But Serum stopped exporting promised doses in March, when COVID-19 cases in India exploded. That surge has now peaked, and the company has ramped up its production from some 60 million doses of the AstraZeneca vaccine per month to 100 million doses this month. Capacity may reach 250 million doses monthly by the end of the year, the company tells Science. COVAX leaders hope the company may resume exports as soon as September.
Novavax, which just reported that its vaccine had 90% efficacy in a major trial funded by the U.S. government, has joined forces with Serum as well. Together, the companies could bring 1.1 billion doses to COVAX in 2022 that could start going into arms this fall if the Novavax jab passes muster with regulators. Biological E, another Indian manufacturer, plans to provide COVAX with 200 million doses of the already authorized Johnson & Johnson vaccine, which should begin coming off production lines in September.
The vaccines produced by the Pfizer-BioNTech collaboration and Moderna may play a bigger role in COVAX than expected, too. These companies make vaccines with messenger RNA, which requires subzero temperatures during transport and then can only stay fresh in regular refrigerators for a month. Conventional wisdom long held that those requirements, along with the vaccines’ high price tags, meant they couldn’t be used in much of the world. But on 10 June, the U.S. government—which has given COVAX $2 billion—announced it would donate 200 million doses of the Pfizer vaccine to COVAX this year and another 300 million by June 2022, with the UPS Foundation donating freezers to countries that need help with storage. (It’s unclear whether this donation may be in lieu of the U.S. government’s pledge to give COVAX an additional $2 billion.) Moderna cut a deal with COVAX to sell up to 500 million doses of its vaccine by the end of 2022.
Huge amounts of vaccine may come to COVAX from yet another source: China. WHO recently granted “emergency use listings”—required for COVAX—to two Chinese manufacturers, Sinopharm and Sinovac Biotech, which have produced roughly half of all the vaccines administered around the world to date. Berkley says his team at Gavi, which makes purchases for COVAX, is negotiating deals with both companies.
Despite the positive news, it’s hard for WHO officials to shake their disappointment about the fact that rich countries have cornered the vaccine market—and the way companies have behaved. A lack of doses isn’t the main reason for the “ridiculous disparity,” Swaminathan says. “Clearly, they have the production capacity,” she says. “Some companies have sold hundreds of millions of doses in bilateral deals and then have given us droplets in COVAX,” she says, adding that there’s no transparency in pricing. “That’s what makes me really, really angry,” she says. “And then they want credit for working with COVAX.”
Even with the increased help from wealthy countries and manufacturers, Berkley points out, many developing countries will, for the next few months, scramble to find enough vaccine to prevent disease and death in their most vulnerable populations and stop hospital systems from collapsing. Bringing cases down to very low numbers, as Europe and the United States are doing, will take much longer. “The world is doing better,” Berkley says. “But it’s not where it should be.”