Will vaccines reach low-income countries during a global pandemic?

WASHINGTON — If COVID-19, the novel coronavirus, becomes a global pandemic, it will raise new questions about how to rapidly scale up vaccination efforts in low- and middle-income countries, according to the head of Gavi, the Global Vaccine Alliance.

While other disease outbreaks like Ebola have given some sense of what is required to create and deliver new vaccines in low-resource settings, those experiences were relatively limited in comparison to a virus that has already spread to multiple regions, and which threatens wider transmission.

Global health experts now face the potential challenge of having to figure out how to develop and deliver to LMICs a vaccine that is also in broad global demand. That could raise some difficult questions about how to ensure equitable vaccine distribution, according to Seth Berkley, CEO at Gavi.

“The good news [is] we know how to get vaccines out. The alliance is really good at that,” Berkley said Monday at the Center for Strategic and International Studies in Washington, D.C.

According to Berkley, “the scary part” of imagining how a global vaccine scale-up for COVID-19 might happen is that countries that produce the vaccine might prioritize immunization for their own populations before making it available elsewhere.

“Let’s just say this vaccine is now produced in the U.S. Are we going to make it available in other countries before we vaccinate the 350 million people in the U.S.? If it’s in the E.U. it’s going to be the same issue,” Berkley said at the event.

“Let’s say we now produce it in India for developing countries. Well, if India’s got a big epidemic of COVID, are they going to make it available, or are they going to vaccinate their 1.3 billion people?” he added.

The challenge presented by Ebola was that there was no market for the vaccine, so the international community — including pharmaceutical companies such as Merck, which produced the drug — had to figure out how to pay for it. COVID-19, on the other hand, presents a potential situation of “unrestricted demand,” Berkley said.

“The thing we have to think about now that’s different is, how do we produce vaccines specifically for the developing world if this is a truly global epidemic. That’s the conversation that we haven't had before,” Berkley said.

There are still huge unknowns about the COVID-19 virus, which originated in China and has now spread to more than three dozen countries. Mortality rates have varied between countries, and there are still open questions about virus characteristics like transmissibility and seasonality.

“Given all that, the more I learn, the more worried I am about this,” Berkley said, adding that in the “best-case scenario,” responders would be able to limit the spread of the virus long enough to develop “countermeasures,” such as the drug and vaccine development efforts currently underway.

If the number of cases peaks very sharply, then that risks overwhelming health systems, which will need to respond to patients. If that curve can be flattened out, “you have a bigger chance for other interventions to be there, but you also allow the health system to take the brunt over a longer period,” Berkley said.

The concern about vaccine access fits squarely into Gavi’s new strategic plan for 2021-2025 — known as Gavi 5.0 — which emphasizes equity and reaching “zero-dose children” who remain unvaccinated despite years of global progress. Fragile and conflict-affected areas present a particular challenge, with vaccination rates at least 10% to 20% lower than non-fragile areas, Berkley said.

Gavi is looking for new partnerships and a strong replenishment in June this year to drive its agenda forward. The U.S. government has already committed $1.16 billion to Gavi over four years — a commitment that was included in U.S. President Donald Trump’s latest budget request.

Global health leaders point out that many of the investments they have made in building out health infrastructure and systems create the foundation for a better response to outbreaks like COVID-19. Immunization programs provide “contact points” between health workers and patients, and establish supply chains that can be adapted to new threats as they arise.

“A lot of the investments that we have been making in laboratory systems and in referral systems and in information systems are all extraordinarily important now, and that’s where we can continue to put some resources,” Irene Koek, acting assistant administrator of the U.S. Agency for International Development’s global health bureau, said at the event on Monday.

“One of the things that we’re starting to do now is put some resources into — can we beef up the labs, can we make sure there’s good infection prevention control practices in place, is there good information out — even though that information is changing dramatically,” Koek added.