More than half of the population in over 60 countries across the world have not yet been vaccinated against COVID-19. The majority of them are in Africa, as well as conflict-affected countries such as Afghanistan and Myanmar, and Pacific island nations such as Papua New Guinea.
“December marks one year since the first doses of the vaccine were administered in rich countries. People in these countries are now onto their third dose while the majority of people in poorer countries haven’t yet even had their first,” UNAIDS Executive Director Winnie Byanyima wrote to Devex. “This is inequality at its harshest.”
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The low vaccination rates, mainly due to countries’ limited access to doses, have left lower-income countries largely unprotected as waves of infections have ripped through them.
According to World Health Organization Director-General Tedros Adhanom Ghebreyesus, there were enough vaccines produced this year, that if they had been distributed equitably, every country could have reached the 40% target by September.
Instead, as of Dec. 21, 76% of populations in high-income countries were fully or partially vaccinated and only 8.1% were vaccinated in low-income countries, leading to a global outcry against vaccine inequity.
Experts say dose hoarding by high-income countries, export restrictions, manufacturer delays, slow in-country rollouts, and dose donations with short shelf lives have left significant portions of low-income countries’ populations vulnerable to COVID-19. Others also argue that blocked proposals to broaden manufacturing through the voluntary sharing of intellectual property or a temporary waiver of intellectual property have limited countries’ ability to access vaccines.
Supply is slated to increase next year, but the introduction of booster shots by high- and middle-income countries, and the threat of new variants, such as omicron, create uncertainties. Getting the vaccines is also not enough — countries need financial, human resources, and technical assistance to ensure doses go from tarmacs to people’s arms.
“Vaccine inequity … is probably the most horrific injustice of 2021. I hope and I pray that it can be improved in 2022,” said Dr. Michael Ryan, executive director of the emergencies program at WHO, during a press briefing Wednesday.
The scene was set for inequity early in the rollouts when higher-income countries hoarded vaccines. This stacked the cards against COVAX, the global COVID-19 vaccine procurement mechanism that aimed to provide equitable access to doses.
It faced financial constraints and challenges in securing supplies, with a lack of commitment from manufacturers and countries engaging in vaccine nationalism, Aurélia Nguyen, managing director of COVAX, wrote to Devex.
It also faced export restrictions. Early on, COVAX relied heavily on AstraZeneca doses produced by the Serum Institute of India. But those supplies quickly dried up when India, dealing with a deadly second wave of COVID-19, imposed vaccine export restrictions that lasted for eight months, leaving many countries, which relied on COVAX, with limited to no access to doses.
WHO and its partners called on countries that already vaccinated high-risk groups, such as health care workers and the elderly, to donate doses as a stopgap measure. And a handful of higher-income countries responded with pledged doses. As a result, in July, African nations received more doses from COVAX than the months of April to June combined.
But it came at the wrong time after many lives were already lost, Dr. Phionah Atuhebwe, new vaccines introduction officer at WHO Africa, told Devex.
“At a point where we were going through the third wave in Africa and had completely no doses, the richer countries were rushing to vaccinate even their teenagers, when health care workers in Africa were working in COVID treatment centers, unvaccinated. They knew it. We were in the news. We were making all of these noises. We were literally begging,” she said.
“Let me be as explicit as possible: Leaving people in poor countries unvaccinated will also cost the lives of people in the richest countries.”
— Winnie Byanyima, executive director, UNAIDSBut even with an increase in donated doses delivered, countries are still behind on their pledged doses. Of the over 1.5 billion doses pledged to COVAX through next year, only 378 million doses were delivered as of Dec. 21. That’s part of COVAX’s total deliveries to date of about 806 million doses, which is still 300 million doses short of the 1.1 billion doses it expected to deliver by the end of this year when it announced its revised supply forecast in September.
COVAX has been pummeled with criticism for key decisions made along the way. Nguyen said in planning for future pandemics, contingency financing and a geographically distributed manufacturing base for vaccines, especially in emerging markets, should be a priority. But as supply becomes relatively stable, it will also be important to ensure countries get the support they need to grow their capacities to absorb and deliver doses, she said.
Now, even with adequate levels of supply, many countries are struggling to roll out vaccines.
"People in big city centers, big towns have really accessed these vaccines. But then people in rural areas, where a health facility is a couple of kilometers away, are not able to access these vaccines," said Elizabeth Ntonjira, global communications director at Amref Health Africa.
A key hurdle is the donation of vaccines with short shelf lives. COVAX has struggled with receiving detailed information from vaccine manufacturers and donor governments about vaccine deliveries, making it difficult for countries to plan rollouts.
"Even when you have a nice, smoothly running program — the moment you get short shelf life vaccines, everything is thrown into tatters and you have to rush and quickly deploy these vaccines throughout the country,” Ntonjira said.
High-income countries donating doses near expiry, while opposing proposals to waive intellectual property on COVID-19 vaccine production is like “offering crumbs off the table while banning hungry people from using the recipe to bake their own bread,” said Byanyima, citing similarities to the AIDS epidemic. It took a decade, and the death of 12 million Africans before antiretroviral medicines became more accessible in lower-income countries, she said.
“This profit-first, people-second, strategy has given us a world in which just 3% of people in low-income countries are fully vaccinated: The ideal breeding ground for new virus variants,” said the UNAIDS chief.
“Let me be as explicit as possible: Leaving people in poor countries unvaccinated will also cost the lives of people in the richest countries,” she added.
It’s been a year of missed targets. Many countries failed to meet WHO’s goal to vaccinate 10% of populations by September and at least 35 countries have yet to reach this target as of Dec. 21. And at the current pace, WHO estimates the African continent won't reach an average of 40% of populations fully vaccinated until May 2022.
Forty-eight countries are not on track to meet WHO target to vaccinate 70% of their population by the end of June 2022. In fact, the African continent isn’t expected to vaccinate an average of 70% of its population until August 2024.
Several experts predict supply constraints will start to ease next year. Airfinity, a global health intelligence and analytics company, forecasts production of 8.6 billion doses during the first half of 2022, reaching a total of 19.8 billion doses by the end of June, at current rates of production. But if half of that production shifts to producing a vaccine targeted toward omicron, the total vaccine production forecast could drop to 16.4 billion doses.
Australia, India, Japan, and the United States are reportedly on track to produce at least one billion doses of COVID-19 vaccines by the end of 2022. The bulk of high-income countries’ pledged dose donations is also planned for next year. Other vaccines, including those produced by Novavax and Clover Biopharmaceuticals, are expected to become available. Nguyen said COVAX and partners must work with countries to prepare them for introducing these new vaccines.
"In theory, there are enough doses for everyone. It is a case of prioritizing supply to Africa and of course, supporting African countries to accelerate their vaccine programs," Atuhebwe said.
Supplies, and support to deliver doses are also needed in conflict-affected countries and displaced populations within countries. A few organizations have already applied for doses via COVAX’s Humanitarian Buffer, but majority of vaccine makers’ reluctance to waive legal indemnity requirements — meaning governments or humanitarian organizations receiving the vaccines for distribution to assume liability for any injury claims by those who received the shot — has posed challenges for vaccine distribution via the buffer.
So far only Johnson & Johnson, and Chinese vaccine manufacturers Sinopharm, Sinovac, and Clover have agreed to waive the indemnification requirements for humanitarian agencies delivering the vaccines to these vulnerable populations. The first deliveries via the buffer took place just last month to reach displaced populations in Iran, including Afghan asylum-seekers and migrants, and another batch is slated for migrants and refugees in Thailand. Both deliveries are expected to vaccinate almost 800,000 people.
But these supplies could face constraints as a number of countries accelerate their booster programs. Over 461 million booster shots have been administered as of Dec. 22, more than the total vaccines administered in Africa. Each day, about 20% of all administered doses globally are boosters or additional doses, which WHO defines as a vaccine that “may be needed as part of an extended primary series for target populations where the immune response rate following the standard primary series is deemed insufficient.”
This is despite WHO’s vaccine advisory group saying there’s no evidence yet suggesting the need for a booster dose for the broader population — except for individuals who received inactivated vaccines as primary shots, and immunocompromised individuals. Gavi, the Vaccine Alliance CEO Dr. Seth Berkley said in an AP interview that he’s beginning to see donor countries “not wanting to donate their doses as fast as they might have” amid fears over the impact of omicron. Tedros forecasts that there will only be adequate supplies to broadly administer booster shots “later in 2022.”
For some parts of the world, such as many countries on the African continent, there are adequate supplies of vaccines right now, but “what it looks like now is not exactly what it would look like a few months down the road,” Atuhebwe said.
"I know that we will always get the leftovers," she added. "If the shoes changed, if we changed places, I know Africa would do more for the Western world than they did for us."
