Global COVID-19 vaccine inequity: Are we moving forward?

BY Kin Peng Soo, Community Engagement Project Office

Disclaimer: Due to the evolving nature of both the pandemic and COVID-19 vaccines, new information may continue to emerge. The following article is therefore accurate as of 20/05/2021.

Source: Getty Images
Introduction

With the development and distribution of multiple COVID-19 vaccines, the end of this pandemic is in sight; at least for wealthy countries. Variations in the rollout of vaccines being dependent on region and wealth has further highlighted the stark global inequities that have plagued the world for generations. Although many resource rich countries can look forward to being completely vaccinated by the end of 2021, many resource poor countries will likely be waiting until 2023. This is the direct result of many factors, including logistical difficulties, vaccine nationalism, and bottlenecks in supply.

Comparison of vaccine technology

An understanding of how the COVID-19 vaccines differ is imperative to grasping the conditions that give rise to logistical inequities. The two main vaccines that are currently being distributed in Australia are the Pfizer/BioNTech mRNA vaccine and the AstraZeneca/Oxford viral vector vaccine. Although they both aim to provide the same results, their approach differs greatly as the Pfizer vaccine is based on entirely new technology whilst AstraZeneca adopts an approach first developed in the 1970s. 

Our body’s immune system has developed over many millennia and is the most effective tool at clearing infections. Vaccines work by delivering the schematics of a virus or bacteria to the immune system so they can prepare for a real attack in advance. The various COVID-19 vaccines differ in the way they deliver these schematics. Pfizer’s mRNA vaccine when injected into the human body introduces instructions on how to make harmless SARS-CoV-2 proteins, which is the virus that causes COVID-19. These instructions, known as mRNA, will then enter some of our own cells which begin to produce the harmless COVID-19 proteins. Our immune system then recognises these COVID-19 proteins, thus priming it for any future attacks from real SARS-CoV-2 viruses. On the other hand, the Oxford/AstraZeneca vaccine uses viral vector technology, whereby a benign virus enters our cells to deliver these schematics for the SARS-CoV-2 proteins. Although the delivery mechanism is very different, the results should be the same in theory.    

Vaccine efficacy has been a very contentious issue over the past months with a continued influx of new data regarding each vaccine. We know from research published in the American Journal of Preventive Medicine that an efficacy rate of at least 80% or higher is needed to extinguish an epidemic without additional measures such as social distancing, quarantines, or mask use. The latest data suggests that in the prevention of COVID-19 transmission, Pfizer and AstraZeneca vaccines have efficacies of 95% and 76% respectively. However, due to the research being conducted at wildly different points of the pandemic and under different conditions, these numbers must be taken with a grain of salt. What we do know is that both vaccines are extremely good at preventing severe infections that lead to hospitalisation, intubation, and even death, which are the most important factors in reducing the burden on our health systems.

Logistics

A working vaccine is only the first step in moving past this pandemic as there is little use for a vaccine that cannot be distributed to those who need it. Due to the fragile nature of vaccines, a cold chain is required to maintain its potency. Most vaccines, including AstraZeneca’s, can be stored in fridges between 2-8oC however, the new mRNA technology requires continuous storage at temperatures of -70oC. At these temperatures, the vaccine is only guaranteed to last up to six months. Transporting the vaccine at these temperatures is almost impossible as they are moved in dry ice cooled shipping containers where they only last ten days. To worsen the issue, they are packed in containers of 5000 doses and only survive for five days when stored in standard vaccine freezers found at most vaccination centres. The challenge of distributing these 5000 doses within five days  is compounded by the need to coordinate a second dose within three weeks after the first dose. These logistical issues are difficult to navigate in resource rich countries such as America and Australia and are nigh on impossible for resource poor countries.

Adapted from Yale Medicine

The issue of cold chains is one element of a larger system of inequities between resource rich and poor countries. Most countries will not be able to distribute the Pfizer/BioNTech vaccine and will thus have to turn to more conventional vaccines such as AstraZeneca. Much like the personal protective equipment (PPE) crisis observed at the start of the pandemic, we are seeing immense difficulties in obtaining these critical products. The misuse of money and power derived from panic buying and hoarding continues to put many lives at risk.

Justice, morality, and the benefits of an equitable distribution

“Rich nations representing just 14% of the world’s population had bought up more than half (53%) of all the most promising vaccines”

BBC News

When faced with crisis and adversity, the natural human response is one of greed and selfishness in an effort to protect one’s interests. Vaccine nationalism is yet another example of how resource rich nations continue to serve their own interests at the expense of the resource poor. However, this moral injustice leading to the unnecessary death of thousands will have reciprocal deleterious effects on the rich. After globalisation, the economies of the rich and poor became increasingly intertwined. Indeed, many global supply chains are reliant on the goods and services provided by lower income countries. The longer the delays in vaccine rollout for these countries, the longer these lockdowns will last, thus exacerbating any current supply bottlenecks. COVID-19 is estimated to cost the world economy between $1.8 trillion and $3.8 trillion, with rich countries set to take more than half of this pain. It is therefore in the best interest of all countries to ensure an equitable distribution of vaccines.

The achievement of an equitable distribution is being tackled by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi (The Vaccine Alliance), and the World Health Organisation (WHO) in a co-led initiative known as COVAX. It has currently been able to deliver 38 million doses to 98 countries (source). While this represents a positive start, America alone has been able to deliver 265 million doses (as of 12/05/21). The supply bottleneck of vaccines presents a significant distribution challenge. This can largely be attributed to the intricacies of patent law hampering global production of vaccines. Many countries such as India, China, and the Philippines with large-scale vaccine production capabilities  do not have the rights to manufacture and distribute them to countries in need. In this time of crisis, a mutual agreement needs to be made wherein these capable countries are able to produce vaccines while ensuring patent holders are adequately compensated.

See here for a more in-depth look into the patent law.

In conjunction with these issues, COVAX faces further challenges following the plausible link between the AstraZeneca vaccine and rare blood clots. As more affluent countries scramble to get their hands on more Pfizer vaccines, COVAX — which is heavily reliant on AstraZeneca due to the aforementioned logistical difficulties of delivering Pfizer — is facing further delays in rollout. Several countries involved with COVAX have already decided to suspend the use of AstraZeneca citing possible side effects. This isn’t a reasonable cost-benefit analysis as the risk of patients dying from COVID-19 in many countries heavily outweighs the risk of developing one of these rare blood clots. However, this unfortunate link will remain a roadblock and will likely cost the lives of many.

Along with the moral and economic benefits that equitable vaccine distribution provides, China and Russia are also using their vaccines as a form of diplomacy. China and Russia are filling a gap other rich countries have left during their preoccupation with vaccine nationalism. China has learnt from its failed attempt at PPE diplomacy which was plagued with quality control issues, and is successfully donating their vaccines in a bid to strengthen ties and forge new partnerships. Meanwhile, the US and EU lag behind, only pledging donations to poorer countries and regions recently.

Source: Getty Images

COVID-19 has brought to light the difference in access to quality healthcare between low and high income countries. Epidemics are not uncommon phenomena with many regions and countries being ravaged by them. The difference between COVID-19 and other diseases such as tuberculosis, Ebola, and malaria are that it impacted not only the poorer countries but the more affluent ones as well. If we compare the responses to COVID-19 and tuberculosis — a disease that claimed the lives of 1.4 million people worldwide in 2019 — rich countries were able to source, develop, and mobilise PPE, life saving drugs, and vaccines at unprecedented speeds. Meanwhile tuberculosis — which has a readily available vaccine and treatment regime — consistently appears in the top ten causes of death in low to middle income countries.

Conclusions

The inequitable distribution of resources is a long-standing issue that has been exacerbated by the COVID-19 pandemic. Vaccines have been the latest addition to this growing list of life saving measures that remain out of reach for lower income countries. Richer countries must recognise that altruism is not the only reason to support others during this pandemic as there are tangible economic and political advantages to be gained. Addressing the larger long-standing issues of health access in poorly resourced areas is more challenging and complex, which requires structural changes. This would involve an increase in human, material, and financial support through collaboration in addition to changing the internal environment through education, training, and leadership.

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