UPDATE: In the last week, we’ve seen some critical interventions from WHO, GAVI and others on the importance of ensuring development and distribution of a COVID-19 vaccine happens on an equitable basis worldwide.
As the world mobilises to develop a vaccine, some countries will struggle to ensure their citizens are protected against COVID-19 – unless work starts to prepare them now.
Those most at risk of being left behind? The poorest and most fragile countries. And those with weak institutions and poor public health infrastructure.
The great divide of the 2020s could be between the vaccinated and those denied access to immunisation. Beyond the obvious health implications, countries risk finding themselves cut off from the rest of the world, as richer and more stable countries protect themselves from secondary epidemics.
The global race to create a COVID-19 vaccine is well underway. Teams in the USA and China have already reached the first big milestone of Phase 1 clinical trials on humans, with others hard on their heels in Germany, the UK, and Australia. It’s going to take 18 months or so, and likely cost between $200 and $500 million, but the chances of a successful vaccine are high.
Yet this race is a relay, not an individual event. After vaccine development comes product registration, followed by securing the supply chain at global, regional, and national level. But the most vital push is when health ministries find ways to deliver vaccinations sufficiently widely among populations to ensure widespread immunity.
Every leg in this race is important, but it is typically the first that attracts the lion’s share of attention and resources.
It’s a certainty that scientists from one of a small group of rich countries will win this first leg. And that’s OK: the right vaccine is universally applicable. What is more concerning is the likely fate of many low and middle income countries and their citizens if governments don’t put the right types of preparation in place now with help from the international community to ensure they finish strong.
Take measles. A vaccine has been available since 1963, before which regular epidemics used to kill around 2.6 million people every year. For children under 5, measles is probably about as deadly as COVID-19, which presents us with a major ethical issue as we divert resources and attention towards this new threat. Because, almost 60 years on, measles is still causing many thousands of preventable deaths annually, 95% of which occur in low income countries with weak public health infrastructure.
Hitches in preparing for one or more of Legs 2, 3, and 4 of the immunisation race explain much about why under 5s in low income countries have such high mortality rates compared with their peers. These are lessons worth learning fast as we prepare to take on COVID-19:
Vaccine Registration: Low income countries generally experience major time lags in registering new vaccines. It has historically taken more than six years for new vaccines to be registered throughout Africa. Regulatory capacity is often low, markets are unattractive to developers, and the seemingly obvious strategy of adopting recommendations made by agencies in high income countries is not always feasible. For example, regulators in many African countries need to consider much more carefully possible interactions between a new product and conditions such as HIV.
Securing Supply: We have already seen the battle brewing between high income countries on cornering global supplies of a still undeveloped COVID-19 vaccine. Vaccine production moves slowly, and the political stakes are almost as high as the health ones. When stocks are limited, low income countries are very poorly positioned to take part in a bidding war against the economic might of those countries who will also likely argue it was they who funded vaccine development in the first place.
Rolling Out Immunisation: Even where countries find a path through registration and supply issues, the administrative, logistical, and cultural challenges of immunising the population will be significant. Low income countries typically suffer from weak institutions and poor public health infrastructure. And while much has been done to help strengthen immunisation against communicable diseases, this work focuses heavily on young children. The planning and logistical challenges of reaching either a whole population, or older adults as will be required for COVID-19 could be crushing.
In the case of the supply leg, the international community has been quick to act. The GAVI board has already made a strong statement about how it intends to support the countries it works in, using instruments ranging from re-allocation of existing grants at state level, to the Advance Market Commitment that could help accelerate access at volume to a vaccine once available.
The international community must provide a seat at the table for low income countries when it comes to discussing supply volume, as well as the specific technical requirements for developing vaccines to be used in extreme climates with limited refrigeration and poorly equipped health systems.
But this is about political leadership, as much as technical expertise. Influential countries, such as Pakistan, Nigeria, and Sierra Leone, where access to a vaccine is likely to be an issue, should use this time to debate and agree a consolidated set of asks from the international community.
Decisive leadership and advocacy will be essential. Critical players will include Dr Tedros Adhanom, with his experience as the head of WHO, and both health and foreign ministries during his time in government. Winnie Byanyima, newly appointed to lead UNAIDS, will also bring deep and vital understanding of how to ensure marginalized communities have a voice. Perhaps best placed of all to convene and steer this discussion is Ngozi Okonjo-Iweala, who would bring her expertise as finance minister, her long and distinguished career at the World Bank, and her current role as chair of the GAVI board.
Meanwhile, tackling the root problems of registration and rollout, will require a different, state-led, approach. When preparing for Legs 2 and 4, the emphasis must be on creating emergency plans that respect, but don’t fall victim to, the existing governance and administrative framework. The priorities should be:
1. Laying the groundwork now for rapid registration of a vaccine as soon as it becomes available. This may mean reviewing and revising the existing national legal framework to enable regulators to speed up the process by identifying and allowing appropriate international registrations.
2. Thinking through and solving likely administrative roadblocks to rollout once a vaccine is available. This work is likely to include planning to expand and deploy the available workforce of vaccinators temporarily, drawing in existing assets like community health workers. Officials will also need to consider issues like procurement, brokering legally acceptable exceptions to ensure people don’t die as a result of standstill periods or other safeguards.
3. Developing strategies for rolling out the vaccine that are geographically and culturally smart, as well as maximising efficiency and economy. All options should be on the table, including community led prioritisation, as well as focusing on older people, or those with underlying chronic health conditions. Even if low income countries manage to access vaccines, supply is likely to be constrained, so finding the smartest way to protect the most people is critical
4. Maintaining existing routine immunisation work as fully and for as long as possible. While it will be tempting to divert all attention and resources towards COVID-19, letting routine immunisation lapse would have catastrophic consequences. As Dr Tedros noted last week: “Even though we are in the midst of a crisis, essential health services must continue. Babies are still being born, vaccines must still be delivered, and people need lifesaving treatment for a range of other diseases.” Low income countries especially simply cannot afford to fight more than one epidemic at a time. The international community can and must support low income countries in this endeavour, even as donor countries prepare to run their own race. We cannot afford to cross our fingers and bet on demographics and the weather to avert a global health crisis.