High-income and a few middle-income countries with vaccine production capacity such as India and Brazil have pre-ordered nearly 3.8 billion doses, and are negotiating options for five billion more for coronavirus disease (Covid-19), according to an analysis released by the United States (US)-based Duke Global Health Innovation Center.
India has pre-ordered 600 million doses of Covid-19 vaccine, with another 1 billion doses under negotiation.
India is second only to the US, which has pre-ordered 810 million and another 1.6 billion doses under negotiation.
This “vaccinationalism” will lead to some countries being able to vaccinate their entire populations — and some many times over— while denying low-resource regions such as sub-Saharan Africa access to Covid-19 protection until 2024, said Andrea D. Taylor, the assistant director of programs at Global Health Innovation Center, Duke University, who led the analysis.
Excerpts from the interview:
What is the global annual manufacturing capacity for Covid-19 vaccines?
This is unknown. What we do know is that capacity is dynamic and changes depend on a number of variables. Additional investments can open up more manufacturing capacity in three different ways: reserving capacity with existing vaccine manufacturers such as the Coalition for Epidemic Preparedness Innovations,(CEPI) has recently done, building new manufacturing capacity as the United Kingdom (UK) and many countries are doing, and retrofitting pharmaceutical manufacturing centres that produce therapeutics to be able to produce Covid-19 vaccines. The manufacturing capacity is not set in stone and we can indeed expand it to some degree with targeted investment.
How many people can get vaccinated by June 2021, assuming we need two doses for each person?
There are too many unknowns to answer this question. None of the current vaccine candidates are through the regulatory process yet. There is some hope that at least one or two vaccines will be approved and start to ship by March 2021, but again, we do not know what will happen. Some manufacturers, including the Serum Institute of India (SII), are manufacturing and stockpiling doses of leading vaccine candidates in a bid to have a jump start if the candidates are approved. This will help to ensure that millions of doses are ready to go if the vaccines do receive approval.
How have some nations managed to pre-order COVID-19 vaccines before others?
Our analysis indicates that there are four factors that have allowed countries to secure pre-orders of Covid-19 vaccines: capacity for vaccine development in-country, capacity for vaccine manufacturing in-country, large investment of public dollars into the development vaccines, and purchasing power to make large orders that assume some level of risk, given that the product is not yet approved. Primarily, it is the high-income countries that have most or all of these factors and have been able to secure enough doses to cover their entire populations and in some cases several times over. There have been some middle-income countries, including India, that are able to leverage their vaccine development and manufacturing capacity to secure pre-orders. Some other middle-income countries that do not have any of these factors have been able to support clinical trials and use that to leverage purchase deals. But our analysis shows that low-income countries have not been able to make any pre-orders and are losing out.
Which countries are the worst offenders?
In terms of numbers of confirmed doses, the US has pre-ordered the largest number at 810 million confirmed, with another 1.6 billion doses under negotiation, followed by India at 600 million doses confirmed, with another 1 billion doses under negotiation, and the European Union (EU) at 400 million doses confirmed, with another 1.565 billion doses under negotiation. But in terms of per cent of population covered by confirmed purchases, Canada has pre-purchased enough vaccine to cover 527% of their population, followed by the UK at 277%. Of course, it is important to remember that mostly likely only some of the vaccines purchases will come through, depending on regulatory approval.
How will Advanced Market Commitments (AMCs) set back access to vaccines in less and least developed nations? What will be the size of the global population denied access to vaccination?
We do not have the data to predict this, as the landscape is changing almost daily. What we do know is that, because of manufacturing constraints, AMCs reduce the number of doses available to partnerships like Covax that are committed to equitable access for the least developed nations. As a manufacturing powerhouse, India will play a critical role in ensuring that low- and middle-income countries (LMICs) do have access to the vaccine. India’s stated commitment to prioritising distribution not only within India but also to neighbouring LMICs is very important.
Do you have projections of morbidity and mortality as a result of equitable access to vaccines?
We do not have any data on this. Our study does not project morbidity and mortality. We may look at that in the future.
Can the World Health Organisation’s (WHO) Covax Facility ensure equitable global access to Covid-19 vaccines?
Yes, the Covax facility is our best opportunity to ensure global access for three reasons. First, it mitigates risk by investing in a portfolio of vaccine candidates to maximise the likelihood of having one or more succeed through the regulatory process. Countries are doing this individually, but it is generally only high-income countries that can afford large orders of multiple vaccines. For the rest of the world, Covax’s portfolio approach is critical.
Second, the Covax Facility, through partners CEPI and Global Alliance for Vaccines and Immunisation (GAVI) can reserve manufacturing capacity globally without tying it directly to a specific vaccine, ensuring that there will be capacity to ramp up production once a winner is identified.
Third, and this is most critical for equitable access, Covax can function as an air traffic controller, ensuring that vaccines ship out to all countries at the same time, rather than the first doses to the highest bidder. Through Covax’s coordination, all participating countries can receive initial doses to vaccinate frontline workers at the same time. There is no global coordination of distribution, as doses become available, without Covax.
Given that many countries are acting in national interest, what is the way forward to stop the spread of Covid-19?
It is understandable that countries are acting in their national interest; they are incentivised to focus first on the safety of their populations. But globally, this leads to a pattern of behaviour that will leave some countries with little to nothing, deepen existing inequities, and prolong the pandemic. Our research points to the need for countries and multilateral funders to unlock additional manufacturing capacity, particularly in the Global South, and invest in preparing countries for effective distribution of vaccines. High-income countries should also work with Covax, as a global coordinator, to ensure that, once their populations are covered, excess doses are redeployed where they are needed most around the world.