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New donation pledges won’t fill global COVID-19 vaccine shortfalls.

 Vaccine inequity is the greatest barrier to ending COVID-19 as an international health emergency. As we inch closer to the two-year mark of the pandemic, we mourn the 5 million lives that have been lost and fear that millions more may still be. This time the loss of life will predominantly be in poor countries. Deaths due to COVID-19 are no longer because we are defenceless, but because the world is divided.

More than 5.9 billion vaccines have been administered worldwide. But nearly three-quarters of them were in only 10 countries. High-income countries have 61 times more vaccinations per inhabitant than low- and middle-income countries. Yet only 3% of the population in Africa has been fully vaccinated.

When the pandemic started, the world was fully aware of the unequal access to resources, including the development of potential vaccines. That is why as soon as there was hope for a vaccine, the COVID-19 Vaccine Global Access Facility COVAX was set up.

The aspiration was to protect everyone from COVID-19, including the most vulnerable people in low- and middle-income countries. But due to what some would call a predictable design flaw, COVAX has failed. It remains underfunded. Further, wealthier countries negotiated directly with pharmaceutical manufacturers and acquired the lion’s share of global vaccine supply.

So, 18 months after COVAX was established, the platform is still 2 billion doses short of achieving its goal of vaccine coverage for 40% of adults in the poorest 92 nations.

Wealthy countries, most with more than half of their adult populations fully vaccinated, have now pledged to donate more doses of COVID-19 vaccine to poor countries. This renewed, albeit late, attempt to revive COVAX focuses on the need to end the pandemic for all through increased access to vaccines – with an emphasis on speed to combat ever emerging SARS-CoV-2 variants. Much of this effort includes shipping excess vaccines, including near-expired vaccines, to poor countries. While this serves as a stopgap measure, we argue that it is not a sustainable solution.

Logistical hurdles

High-income country tactics have led to global vaccine supply scarcity. They have left low- and middle-income countries struggling to find available vaccines to buy, even if they have the money to do so. Consequently, vaccine donation appears to be a necessary, though not sufficient, action.

Vaccine donations are unsustainable and often inefficient to scale when faced with a pandemic. They are a temporary solution to a systemic issue that was supposed to be preempted by a better version of COVAX, which also comes with its own issues.

Behind the commitments of the Group of Seven and other wealthy nations are legal and logistical realities to supply vaccines to recipient countries. The vaccines available from high-income countries are those that were hoarded. Canada infamously purchased enough vaccine doses to fully vaccinate each person living in their country five times over. The only vaccines that can be distributed are the previously contracted excess doses from countries that are already flushed with supplies.

However, there is often no clear pathway to donate all of the vaccines available. Federal countries often do not allow states to donate vaccines directly without approval from the national government. There are also liability concerns for pharmaceutical companies if their vaccines are used in another country. This means donated vaccines now being supplied to COVAX will come directly through the national stockpiles that sit with manufacturers. And, this is why countries across the EU and the US are throwing away millions of soon-to-be expired doses from pharmacies and hospitals – not shipping them to Africa.

The challenges of production scale up for key vaccines like AstraZeneca and Johnson and Johnson, and the threat of expiry of stockpiled vaccines also affect the supply of vaccines. Combined with legal and administrative challenges, the delay from commitment, to donation, to delivery of vaccines could mean months with people in low- and middle-income countries at grave risk of being infected and getting sick. For example, US President Joe Biden recently doubled the commitment to donate COVID-19 vaccines to poor countries to the staggering figure of 1.1 billion doses. However, only 300 million of these are expected to be delivered this year.

Still, if these commitments are met it would allow for COVAX to reach its first milestone —- to vaccinate 40% of people in all countries by the end of 2021. And yet, these commitments should be welcomed with cautious optimism, as this still leaves 60% of African adults unvaccinated. As booster shot programmes emerge in high-income countries the world has to wait, yet again, to see if rich nations will keep their word.

An alternative would be for high-income countries to release excess doses from contracts – not just donate them.

The demand side of COVAX is an important, but less discussed, part of the vaccine equity puzzle.

The “two months from expiry” requirement from COVAX is not about vaccine stability. It is there to allow recipient countries time to be logistically and legally prepared. Just processing and distributing vaccines can often take a few weeks. For example, in June Palestine rejected more than one million Pfizer-BioNTech doses from Israel due to a fast approaching expiry date that did not allow enough time for proper vaccine administration.

In September, millions of vaccines donated by Canada and the UK to the African Union were set to expire within a matter of weeks. This does not allow enough time for local health systems to accommodate context specific needs, such as getting vaccines to rural and remote areas, or to ensure that cold chain infrastructure is able to store the incoming doses.

To avoid the disruptive potential of poorer countries becoming a “dumping ground” for rich countries’ expired vaccines, there is a need to formulate a common approach on drug donations. This must include an understanding of recipient country’s logistical capacity and regulatory requirements.

Beyond the band aid

Global pronouncements to vaccinate 70% of the world by the end of 2022, public declarations of new vaccine donation vows, and the news that Serum Institute will be resuming exports in September 2021 – and fulfilling committed COVAX orders that were left empty during the Indian export ban – are all reasons to be cautiously optimistic. There may be relief from this pandemic, even for the poor countries, in the near future.

However, ultimately vaccine donations are a temporary response. They cannot replace long-term solutions to vaccine inequity. A real solution is to democratise vaccine production. There must be a particular emphasis on production capacity and increased access to technologies and knowledge transfer.

Equitable vaccine access will come when there is equitable vaccine production. The failure of COVAX illustrates, once again, that waiting on nations to be charitable is a poor emergency preparedness strategy.