Opinion: To deliver a COVID-19 vaccine equitably, we must start planning now

Think of a vaccination — what image comes to mind? Most of us, I would wager, think of a squirming infant in the arms of a parent, with the “jab” coming toward their small upper arm or thigh.

But what about a vaccine against COVID-19? Whose arm are we looking at — an elderly woman or man? A health care worker? Where is the person located? These are the kinds of questions that we, as a global community, need to be answering now, as efforts to develop a vaccine are still in their early stages.

One thing is certain: We will not reap the full benefits of a potential COVID-19 vaccine’s protective power unless we plan now to ensure it is made available globally in an equitable way.

We are off to a great start. Advances in vaccine-development science have paid off, and we are seeing vaccines make their way into development with unprecedented speed, buoyed by massive investments from private and public funders. We were pleased to see global leaders, led by the World Health Organization, coming together to launch the Access to COVID-19 Tools Accelerator, with a commitment to equitable access for all coronavirus technologies, and just this week to see about $8 billion raised at the COVID-19 pledging conference hosted by the European Union.

To make those commitments real, we must start planning now. For vaccines specifically, even as many candidates are currently being evaluated, we need to begin identifying manufacturing locations and delivery technologies to ensure we have sufficient volumes as quickly as possible.

Equally important is to plan how the vaccine will be distributed and who receives access first. We need to think globally, with special consideration for the needs of those living in the world’s poorest nations, where health systems are fragile and COVID-19 has the greatest potential to evade containment and cause tremendous suffering.

Historically, we have seen lags of a decade or more between the time a vaccine becomes available in wealthy countries and when it is routinely used in low-income countries. While the work of Gavi, the Vaccine Alliance, with UNICEF and others, has cut that time significantly, cost, cold-chain limitations, and struggling regulatory systems still delay the delivery of lifesaving vaccines to many people around the world. For a COVID-19 vaccine to be delivered equitably, it must reach all countries as quickly as possible once it becomes available.

A business-as-usual approach will not do. Not only is there an urgent need to stop the pandemic, but vaccines are also inherently more difficult to deliver at scale to adults, who do not have the advantage of regular preventive appointments like children do.

Take influenza, for which less than half of U.S. adults received a vaccine in 2018-2019. One systematic review found that in most parts of Africa and Asia, less than 1% of people are vaccinated against influenza. We will have to solve this challenge to ensure that a COVID-19 vaccine has the greatest possible impact.

And we can. The response to COVID-19 has been amazing thus far: trillions of dollars unleashed to treat the seriously ill and protect people against the threat of infection, as well as homelessness and hunger. We need to mobilize this same sense of urgency to support the use of a vaccine across borders, across age groups, and at scale.

What it will take to succeed

While we have never faced a challenge exactly like this, we know from decades of experience in vaccine development that a number of factors are critical to success.

Focus on those most at need. Ramping up manufacturing capacity will take time, so we need decision-making mechanisms to ensure that the first vaccine supplies go where they are needed most. Someone like me — able to work remotely and with the resources to provide for my family — is probably not at the top of that list.

Rather, we need to focus on protecting those for whom social distancing or staying at home is not an option — especially those who perform critical services, such as front-line health care personnel and agricultural workers — on a worldwide basis. We must also consider the needs of geographies where the pandemic is most acute.

One size will not fit all. Global guidance will need to be adapted to local conditions. What makes sense in a wealthy country such as the U.S., with one-third of its population over age 50, may not make sense in poorer countries where more than half the population is under age 25 and the economic structure is very different.

The definition of who is most in need will vary and must be decided at the country level. We will also need to address differences in logistical capabilities. For example, a vaccine that must be kept at a consistent temperature may not be suitable for use in settings without reliable electricity or delivery methods.

Everyone must have a voice at the table. To support the translation of global guidance into local policies — and the systems to deliver on those policies — a wide range of stakeholders must be involved. WHO and country decision-makers are key, but so are philanthropic and public sector donors; biopharmaceutical and supply chain companies; the Coalition for Epidemic Preparedness Innovation, Gavi, The Global Fund, and other key alliances; as well as nonprofit organizations such as PATH that have experience in vaccine introduction and scale-up.

Build on — and strengthen — the systems and services we have. We will need to piggyback on programs that already have contact with those we are trying to reach. Can we turn immunization clinics for kids into points of vaccine delivery for their parents and caregivers? Do we make sure that every kiosk that can deliver a condom can deliver a vaccine? Do bingo evenings become vaccination events? Can we add vaccine delivery to mosquito net distribution campaigns? And how do we do all of this systematically?

Start now. Investments in medical research and development must be matched by investments in delivery. Each dollar, euro, yen, or yuan being invested in vaccine development should be matched by similar investments in access and delivery systems, including not only critical infrastructure such as the supply chain but also the necessary decision-making mechanisms. If we wait until the vaccine is ready to roll out to start solving the how, where, and who of distribution, the world will not be ready.

We can do this. While investments in pandemic preparedness over the past two decades have not kept pace with developments, the world has more capacity than ever to develop and deliver a vaccine against COVID-19. We are armed with scientific know-how, support for increasing manufacturing capacity, and decades of experience making vaccines, including in epidemic situations. We will need political commitment — and wisdom — to ensure that a COVID-19 vaccine is delivered globally and equitably.

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