Maintaining Perspective on COVID Vaccine Rollout
By Laird Treiber
On April 19, 2021, the Director-General of the World Health Organization, Dr. Tedros Ghebreyesus, gave a press conference in which he noted both that the world can bring the COVID-19 pandemic under control within “a matter of months,” and that the number of infections globally has risen each of the last eight weeks, producing 5.2 million new cases. Much of that rise has been driven by the continued emergence of variants.
These comments neatly capture the two major aspects of the pandemic. On the one hand, we continue to face one of the deadliest pandemics humanity has ever encountered, with surges in caseloads in India, Brazil and continued upticks in the United States, Europe and parts of Asia. On the other, the world has seen the fastest development ever of vaccines, including some simply stunning new technologies, which are now giving countries some real hope that they can protect their populations – if they can only vaccinate faster than variants can develop.
Ideally, the world would have been better prepared to respond to this pandemic. There would have been more companies capable of producing vaccines (and just as importantly, the 100+ component parts and supporting materials, like glass vials and syringes), and they would have been more evenly distributed around the world so that each region would have had faster, more reliable access as they were developed. Ideally, there would have been some standard financial instrument available to fund not just the purchase of vaccines, but all the ancillary costs of distribution and vaccination and produce the long-term market stability companies need to invest the billions required to develop new production facilities. And, just as importantly, there would have been near universal understanding and acceptance of the science behind the virus, the importance of getting vaccinated, and agreement on public health measures to minimize the incidence of illness while vaccinations could take their course.
Unfortunately, none of those elements were in place in January 2020, when COVID began to spread around the world. Thankfully, solutions have emerged to address or at least improve most of those elements.
For now, in early May 2021, most people around the world are focused on when they will be able to get a vaccine for themselves and their families. While it is remarkable that over a billion doses have been delivered into arms in less than one year, these have been delivered in an uneven fashion, with 86% of injections in developed nations, raising important questions of vaccine equity and generating calls for measures to improve access to vaccines, including waiving patent rights. It may be hard to accept this proposition today, but within just a few months, delivery of vaccines is likely to even out in terms of global distribution. The developed nations that have led the way on vaccination rates to date are rapidly reaching the point where they will have more supply available than daily demand. “Vaccine hesitancy” is an increasingly mentioned factor concerning medical authorities as they rush to reach vaccination levels that hopefully will provide ‘herd immunity- - and before yet more variants will develop. There are also increasing press reports of local authorities in the U.S. and other developed nations having to adopt novel ways to get people to sign up for unfilled vaccine appointments.
Adding to this picture, companies are beginning to significantly ramp up production. The seven companies that have received distribution authorization in one or more countries (Pfizer/BioNTech, Moderna, JNJ, Astra Zeneca, Sinovac, Sinopharm and Sputnik) estimate they will deliver roughly 11 billion doses by the end of 2021. This is just the tip of the iceberg in terms of what is being developed. While most of the 252 different vaccines under development are unlikely to reach the market, sixteen of these are in stage III trials around the world, with some, like Novavax and GSK/Sanofi, believed to be close to final regulatory review before applying for emergency use authorization. There are 13 companies working on nasal spray vaccinations, five of which are in early human trials. There are also five companies working on vaccine pills, two of which are in Phase I trials. This is in addition to 326 treatments under development around the world (such as anti-bodies, anti-virals, cell-based therapeutics and medical devices, like filters); those that make it to markets will improve the capacity of hospitals to combat more severe cases.
The CDC estimates that, by the end of July, more than 70% of Americans will have received their vaccinations, which is already raising the possibility that the U.S. could have 300 million or more doses available for sharing/export by August. Other developed countries are likely to soon be in the same place. To put this in perspective, this is on the same scale as the estimated 400 million most vulnerable populations in Low Income Countries worldwide.
Thus, as early as the end of summer, the real issue will not be access to vaccines at the global level, but the ability of countries to distribute vaccines within their borders, and then to get these doses safely into the arms of their people. This has been a major challenge all around the world. Despite months of preparations, the United States had to mount a sustained push from the Federal Government to mobilize resources to distribute vaccines as they started arriving from factories, enlisting the Federal Emergency Management Agency and elements of the Defense Department to supplement local capacity to manage crowds, access patients and vaccinate people. This distribution challenge is likely to be the major story of the second half of the year. Thirty two of the 47 African countries that have started vaccination campaigns report they have used less than 50% of the doses they have received, primarily because they report encountering significant challenges implementing their distribution plans to deliver vaccines, particularly to rural populations. Challenges range from finding enough trained vaccinators to securing required supplies (like cotton balls) and local transportation issues (like the advent of rainy season), as well as instances of vaccine hesitancy and/or low demand for vaccines that are delivered – echoing challenges already experienced in developed countries. Distribution within countries also costs an estimated five times what it costs to procure vaccines.
There is a lot that countries can do, including bringing together all elements of society, including the private sector, to augment the effort. Private sector distribution of vaccine in Africa is critical as COVAX supplies are intended to cover only 20% of Africa’s population – i.e., only frontline workers. Africa has already developed some innovative solutions that allowed it to crack a similar supply and distribution challenge with personal protective equipment last year when it set up the African Medical Supply Platform. In a matter of months, AMSP created a market-friendly mechanism that allowed African countries to move from critical shortages of personal protective equipment and ventilators to surpluses. AMSP astutely resolved a lot of the commercial and logistics barriers to supplies by arranging for the transportation and creating a payments system covering all African countries rather than individual national efforts which experienced serious problems. It also provided a transparent platform on which companies could respond to consolidated African demand and compete with one another, enhancing predictability and resulting in lower prices with faster delivery. It is a great illustration of what can be done working with the market to create new solutions that are in everyone’s interests, while also providing an efficient platform that has allowed African companies to compete and expand their own capacity. AMSP has already worked with the AU on COVID vaccine acquisition and is also working with countries to expand purchasing capacity through the African Vaccine Acquisition Task Team (AVATT).
For the longer term, there is no question that Africa needs to have more capacity to produce the vaccines its people need on the continent, if nothing else, to address potential supply chain security and accelerate the delivery from factory floor to patient. South Africa’s Aspen is already contracted to JNJ to produce 850 million doses of its COVID vaccine. That’s a great start, but there need to be another 5-10 Aspens across the continent. It would also help to have more African producers of the key supply ingredients and ancillary equipment (e.g., sterile bags for mixing vaccines, filters, syringes, glass vials and cotton balls), although African companies are already looking to fill these critical gaps, much as many re-purposed their production to fill critical voids in PPE and ventilators last year. For the long term, getting more stakeholders together to flesh out and improve the capacity of African health systems to handle all aspects of service delivery is also a critical part of the solution. Expanding the number of African airports with industrial cold storage beyond today’s four, setting up better logistics and transportation infrastructure, improving record keeping and training workers are all good places to start. Accelerating development of the regulatory infrastructure is also important, including harmonizing licensing and market access provisions, patent reviews, clinical trial applications, etc., ideally by accelerating the process of ratifying the AMA treaty and staffing it up with the same high-quality personnel that the African CDC has done.
While Africa certainly faces challenges, it presents the greatest opportunities internationally to manage the next phases of the COVID pandemic and laying the groundwork for a much more sustainable international response to future pandemics. The U.S. should consider working with African partners, and with American and African companies, to match its pledge to ASEAN and ensure that it will help set up the capacity to manufacture one billion vaccines doses in Africa by the end of 2022. This would provide a critical reserve capacity for future COVID outbreaks, including from new variants, as well as lay the groundwork for the booster shots that increasingly seem likely to be an annual requirement. The U.S. could also invest in increasing production in Africa of critical support materials, including filters bags and vials for vaccines, syringes and PPE. Implementing this kind of program quickly would accelerate the creation of true global health security, not just for COVID 19 but for future pandemics. An important part of improved global health security will be facilitating greater collaboration and partnerships with the private sector. The Corporate Council on Africa, through its U.S.-Africa Health Security and Resilience Initiative, has set out an impressive agenda to pursue strengthening of African health systems, not just in disease management, but also in strengthening Universal Health Care and improving the trade and investment framework. This is exactly the kind of initiative that will help deliver tangible results both in the current crisis, and in mitigating future ones.