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Multiple Covid-19 vaccines are working their way through trials, but we haven’t yet figured out what to do when they get here. Distribution faces technical challenges — shortages of glass vials and syringes are already being reported — but there are also ethical supply quandaries. How do we decide who gets a shot first?
We’ve been here before. The last time vaccines were distributed amid a pandemic was the H1N1 outbreak in 2009. “In those circumstances, the distribution of vaccines didn’t happen in an equitable way at all,” says Mark Eccleston-Turner, lecturer in medical law at Keele University.
Then, wealthier countries bought up supply via advanced purchase agreements directly with manufacturers. That meant developing countries didn’t get the vaccine until four months after it started rolling out in richer nations — and that only happened as soon as it did because countries bought too much supply, as H1N1 turned out to be less severe than believed and only required a single vaccine dose. “And at that point they began donating vaccines to low-income countries through the World Health Organisation,” Eccleston-Turner says.
Efforts are underway to do better this time around. Countries can access a vaccine by manufacturing it themselves, or buying it in from overseas. The US is aiming to make 300 million doses by the end of next year via Operation Warp Speed, while the UK is setting up its own manufacturing via the new Vaccines Manufacturing and Innovation Centre, which will be able to churn out enough doses for the entire country in six months — but it doesn’t open until next summer. That means turning to overseas suppliers, such as India, which makes many of the world’s vaccines. “The best place to look in terms of increasing your capacity is to form a partnership with an Indian company,” says Rory Horner of the University of Manchester’s Global Development Institute.
But this time around, there’s another way to buy vaccines: the Covid-19 Vaccines Global Access (COVAX) facility, set up by the WHO and vaccine organisations including Gavi, the vaccine alliance started by the Bill and Melinda Gates Foundation, as well as the WHO and the Coalition for Epidemic Preparedness (CEPI).
Wealthier countries can donate directly to COVAX to fund vaccines for less well off nations — and the UK has chucked in £500m — but they can also opt to buy vaccines themselves, giving COVAX the capital to make necessary deals. COVAX aims to supply 2bn doses by the end of 2021, doling out a tranche of vaccinations to each member nation equal to 3 per cent of its population to cover key healthcare workers, followed by a further 20 per cent to cover the most at-risk people. From then on, COVAX will supply based on need, such as if a country has a serious outbreak or more at risk population. “The whole point of COVAX is to say, let’s do this as the world but recognising that the world has very different types of countries with very different abilities to pay,” says Alex de Jonquieres, chief of staff at Gavi.
COVAX has been agreed by countries covering two-thirds of the world’s population, including 92 low and middle income countries, and is supported by 76 wealthier nations, including the countries that make up the European Union, Canada, India and, at the very last minute, the UK — but not the US, Russia or China. The White House said in a statement that the US would not join the effort because it didn’t want to “be constrained by multilateral organisations influenced by the corrupt World Health Organisation and China.”
Rather than signing up for COVAX, the US is opting for an America First model, which is to say it is manufacturing and buying as much supply as it can, for use with its own citizens first, an idea dubbed “vaccine nationalism”. But so too is the UK, buying up 340 million doses across six different vaccine makers.
Can such apparent vaccine nationalism work alongside cooperative distribution? A spokesperson from the Department for Business, Energy and Industrial Strategy (BEIS) says that the UK buying in its own supply shouldn’t be seen as contradicting COVAX, as it’s still supporting that group-buying effort. But Eccleston-Turner suggests countries are treating COVAX as an insurance policy in case the supply they source doesn’t work out, or if their purchase isn’t front of the line — he calls it “double dipping”. Gavi’s de Jonquieres argues that accepting bilateral deals is worth it to get the necessary support to help lower-income countries. “We recognise that countries will be doing bilateral deals – I think that is inevitable,” he says.
That said, BEIS added that COVAX is working on an exchange mechanism to help distribute excess vaccines; if multiple vaccines are successful, the UK could end up exporting doses to the group. “The UK Vaccine Task Force is always quick to say this is not vaccine nationalism because whatever’s left over from the UK stockpiles will be given to other nations,” says Duncan Matthews of Queen Mary University of London. “That sounds like vaccine nationalism, but they say it’s not – the UK is kind of riding these two horses of supporting COVAX and buying their own.”
There are other ways that vaccines could be doled out. Some countries may share doses with allies first, notes Horner, pointing to India. There, the Serum Institute, the world’s largest manufacturer of vaccines, is set to make another 1bn doses of the AstraZeneca vaccine, of which half will go to low-income nations via COVAX and Gavi, with the rest staying in India. But close allies could also get moved up the priority list. “In various diplomatic fora, Bangladesh has been promised that it’ll get vaccines at a relatively early stage,” says Horner, calling it “vaccine diplomacy.”
But it’s not just the vaccine itself. “We are focusing on and obsessing on discovery, and ignoring all of the other aspects that we need for equitable distribution,” says Eccleston-Turner. We’ll need glass vials and syringes to administer a vaccine, an organised air freight network to delivery doses, as well as cold storage as most need to be refrigerated — the version under development at Moderna must be shipped at -20 degrees Celsius, while the vaccine under development by Pfizer and BioNTech must ship at -70 degrees Celsius. “Those types of storage and distribution conditions mean that traditional methods of distributing medicines through pharmacies or normal hospital conditions is simply unviable,” says Matthews. “The infrastructure needs to be there.”
This is part of what Gavi does: set up infrastructure to deliver vaccines in low-income countries, so much of that infrastructure is already in place. “It’s a very large number we’re aiming for with COVAX, but it’s not a totally different order of magnitude,” from what Gavi and its partners already manage, says de Jonquieres. Within COVAX, CEPI has secured 2bn vials of glass, while the WHO’s UNICEF is organising waste disposal equipment and airfreight capacity. Cold storage will be a challenge for the most extreme low-temperature vaccines; that’s a challenge that’s been faced before with the Ebola vaccine, but that addressed just six countries. For the vaccines up to the -20 degrees Celsius range, most countries already have the necessary cold chain, de Jonquieres says, with some designed to be solar powered to reflect local requirements.
And that’s no easy task, one even the UK is struggling with, with a report in iNews claiming the government hasn’t done enough to set up a supply chain for required vaccination equipment. “The NHS is well-versed in delivering widespread vaccination programmes and we are confident we have adequate provision or transport, PPE and logistical expertise to deploy a Covid vaccine across the country as quickly as possible,” says a spokesperson for the Department of Health and Social Care (DHSC), adding that it the government currently has enough critical components to fill 28m doses, with an additional 16m by the end of October, and a further 11m vials stockpiled for flu pandemics.
In 2009 with H1N1, countries weren’t just held up by a lack of doses, but liability concerns — a vaccine maker doesn’t want to get sued because a poorer country’s lack of infrastructure led to an adverse reaction. “Some countries simply could not afford to take out the insurance which was required to insure against any harms with the vaccine,” says Eccleston-Turner.
Once vaccines and distribution networks are in place, there’s yet another challenge: local distribution. Gavi and COVAX are leaving this for countries to decide on their own, though de Jonquieres notes that existing vaccine programmes focus on children, rather than the older adults worst hit by Covid-19. “Just figuring out how many of these people there are in these countries, getting registries, and then tracking who has been immunised and who hasn’t, is going to be an important part of the work,” de Jonquieres says, adding that vaccines will need to be traced to ensure they end up going to the right people.
And those existing vaccine programmes could be put on the back burner to fight the pandemic, warns de Jonquieres. “There’s certainly a risk, and it’s one we have to actively manage,” he says, adding that the vaccine infrastructure being rolled out for Covid-19 will help support those programmes in the future. “This is an opportunity for us to really strengthen those systems,” de Jonquieres says.
In the UK, the vaccine priority strategy is developed by the Joint Committee on Vaccination and Immunisation (JCVI), a group of academics who advise the government. In June, JCVI issued its first round of interim advice to the government. That called for two priority groups: frontline health and social care workers, and those at higher risk of serious disease and death because of age or other risk factors. That included other health conditions (known as comorbidities), as well as deprivation and ethnicity. Research has shown that people from BAME backgrounds are more likely to be hit harder by Covid-19.
But in September, the JCVI updated that interim advice, dropping previously considered factors such as race and deprivation in favour of focusing on age. “The committee strongly agrees that a simple age-based programme will likely result in faster delivery and better uptake in those at the highest risk,” the JCVI said in its most recent update. Now, the first priority is older people in care homes and the staff supporting them, followed secondly by healthcare and social care workers. Then, vaccines will be doled out by age: first people over 80, then over 75, and so on until 65. At that point, high-risk adults under the age of 65 will get a vaccine, followed by moderate risk people 65 to 50. However, the committee is still working on what underlying health conditions constitute a high risk or moderate risk, and priority for people under 50 is yet to be determined.
Whether that priority list is followed is for ministers to decide, according to a spokesperson for Public Health England. “Further work is being undertaken to understand more about the groups most at risk of serious disease and death from Covid-19 infection,” says Wei Shen Lim, Covid-19 chair for JCVI, in a statement provided by PHE. “Any advice will of course need to be modified depending on the characteristics of the vaccines, when these become available.”
From global organisations down to local distribution, there’s plenty of ways Covid-19 vaccines could miss getting to the people who need them the most — but this is the most effort we’ve seen to make that happen equitably during a pandemic.
And even if ideals of fairness, protection of all human life, and other moral considerations don’t motivate you or your government, this vaccine still needs to reach the widest range of people possible. Because once the richest people in the richest countries are vaccinated, the world won’t simply go back to normal. “You can’t simply vaccinate your own population, because it’s going to affect your economy and overseas markets,” says Matthews. “The only way out of this, the only solution to the pandemic is going to be a global solution.”
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