Overseas Situation Report Monday 21st June 2021
By Mike Evans
“If you think you are too small to make a difference, try sleeping in a room with a mosquito.” – Lisa Lieberman-Wang
With the launch this week of the Digital Covid Vaccination Certificate in Portugal, it is perhaps an opportune time to look at the countries around the world where this tool, which will enable us to travel easily throughout Europe, is something that is a long way off as so many countries are still struggling to get the vaccines to help slow the virus.
In this report we are looking at where the COVAX organisation is with regards to helping the poorer nations in the world access vaccinations.
Just a few weeks ago, the mood at the headquarters of the World Health Organization (WHO) was still decidedly sombre. 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 vaccines to start to vaccinate teenagers, who are at very low risk of becoming severely ill, nurses and doctors in Africa remained unprotected.
But a meeting of the G7, held in Cornwall, U.K., last weekend, has changed the gloomy outlook. The leaders of the seven large 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 non-profit set up by WHO, that Aylward is working with. COVAX has built a war chest of $9.6 billion solely for purchasing vaccines at discount prices for poor countries.
According to Seth Berkley, who heads Gavi, the Vaccine Alliance – another key COVAX partner, “It’s a tipping point,” and he 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 vaccines 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 vaccines, 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.”
The likely surge of vaccines is fuelling 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 health care workers and the elderly getting the first doses. But treating all countries the same is “short-changing 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 was 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.
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 autumn 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 sub-zero 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.
The virus does not recognise individual countries so the vaccines must be available to everyone no matter where they live. This is one issue in which the world as a whole could come together and work to eradicate this virus. It has been done in the past with other diseases like polio and typhoid, so why not Covid?
Until the next time, Stay Safe.
Total Cases Worldwide – 179,028,681
Total Deaths Worldwide – 3,877,051
Total Recovered Worldwide – 163,552,736
Total Active Cases Worldwide – 11,598,894 (6.5% of the total cases)
Total Closed Cases Worldwide – 167,429,787
Information and resources:
https://www.worldometers.info/coronavirus/
https://www.sciencemag.org/news/2021