‘Shocking imbalance’ of COVID-19 vaccine distribution underscores inequity
In one 24-hour period in April, the United States pledged to send raw materials for making COVID-19 vaccines to India and to release 60 million doses of the AstraZeneca vaccine to other countries in need.
The pledges came as COVID-19 cases were declining in the U.S. and rising in other parts of the world, including India, whose escalating outbreak had wider implications.
“India is one of the largest producers of generic medicines and antiretroviral therapy, and so what this large surge will do for the global economy is going to be very concerning,” Krutika Kuppalli, MD, assistant professor of medicine in the division of infectious diseases at the Medical University of South Carolina, told Infectious Disease News. “We really need to make sure that collectively, as a world, we’re safe, because what happens in one part of the world really affects the rest of the world.”
The U.S. has one of the highest COVID-19 vaccination rates of any country. Vaccine access and vaccination rates also are high in other high- or upper-income countries, but the same cannot be said for many low-income and low-resource countries.
“Most countries do not have anywhere near enough vaccines to cover all health workers or all at-risk groups, never mind the rest of their populations,” WHO Director General Tedros Adhanom Ghebreyesus, PhD, MSc, said in a press briefing. “There remains a shocking imbalance in the global distribution of vaccines.”
Infectious Disease News spoke with experts about the issues surrounding vaccine equity and vaccine nationalism and their impact on the pandemic.
As of April 25, more than 1 billion doses of COVID-19 vaccine had been administered globally, according to Our World in Data, a research group affiliated with the University of Oxford. More than 230 million of those doses were administered in the U.S., where almost half of the population had received at least one dose as of April 26, according to the CDC.
Just over 1% of the doses were administered in Africa, which has reported more than 4.5 million COVID-19 cases and 120,000 deaths since February 2020. Vaccines only just began to arrive in Africa following a second wave that peaked at much higher numbers than Africa’s first surge and plateaued around early April at approximately 70,000 cases per week, according to Jean Nachega, MD, PhD, MPH, associate professor of epidemiology, infectious diseases and microbiology at University of Pittsburgh Graduate School of Public Health and professor extraordinary of medicine at Stellenbosch University in Cape Town, and Alimuddin Zumla, MD, PhD, FRCP, professor of infectious diseases and international health at University College London.
In a perspective published in The New England Journal of Medicine, Nachega, Zumla and colleagues said concerns about access to COVID-19 vaccines in Africa resemble concerns regarding access to ART for HIV in the mid-1990s and early 2000s, when it was more accessible in high-income countries than in African countries — “a disparity that resulted in many preventable deaths in these high-burden settings,” they wrote.
“The world’s rich countries have over 1 billion doses of COVID-19 vaccines, whilst the rest of the world has only been able to secure limited doses — leaving billions of people with little hope of receiving a vaccine this year,” Nachega and Zumla told Infectious Disease News.
African countries are trying to overcome the shortfall by sourcing doses through the COVID-19 Vaccines Global Access (COVAX) initiative led by WHO. They are primarily using the Oxford-AstraZeneca and Pfizer-BioNTech vaccines, along with limited doses of a Chinese vaccine, Nachega and Zumla said.
According to Zumla, WHO advised African nations to use the AstraZeneca vaccine, which is cheap and makes up most doses supplied through the COVAX program. Nachega said the Johnson & Johnson vaccine also could be advantageous because it requires only one dose and does not need to be stored at ultra-cold temperatures.
Both vaccines have been investigated for their association with rare blood clotting events. Zumla explained that a few African nations put the rollout of the AstraZeneca vaccine on hold as a precaution but have since decided to reinitiate it. The Johnson & Johnson shot also continues to be recommended by the Africa CDC. South Africa delayed the start of its vaccination program using the AstraZeneca shot, but for a different reason — concern it may not be effective against the variant that emerged there.
The proliferation of variants is another reason to address global vaccine inequity, according to Tom Kenyon, MD, MPH, chief health officer at the international health care nonprofit Project HOPE and former director of the CDC’s Center for Global Health.
“As long as the SARS-CoV-2 continues to spread and mutate, it will breach borders and continue to have an impact globally,” Nachega and Zumla said. “Affluent countries should not monopolize the [use] of vaccines and instead should make sure they are distributed equally globally.”
‘The U.S. can step up’
In another perspective published in The New England Journal of Medicine, Ingrid Theresa Katz, MD, MHS, associate professor of medicine at Harvard Medical School and associate faculty director of the Harvard Global Health Institute in Boston, and colleagues argued that global vaccine inequity will make it very difficult to end the current pandemic and prepare for the next one.
Early purchases by the U.S. and other high-resource countries “have fed a widespread assumption that each country will be solely responsible for its own population,” they wrote.
“I would say that, at the highest level, this moment is a call to action to invest in public health globally. What we are seeing now is a byproduct of the long-term neglect of global health and public health,” Katz told Infectious Disease News.
“Global vaccine distribution is critical — not only as a matter of equity but also a matter of morality,” she said “We are all neighbors on this planet, and viruses do not respect borders. We need to be thinking much more coherently and cohesively about a global health strategy — now and in the future.”
In January, the U.S. ordered an additional 200 million doses of COVID-19 vaccine from Pfizer-BioNTech and Moderna — 100 million of each — and has contracts with the various vaccine manufacturers totaling around 800 million doses, according to a count by Kaiser Health News — more than enough to vaccinate the entire population.
During a presentation at this year’s Conference on Retroviruses and Opportunistic Infections, Gregg Gonsalves, PhD, co-director of the Global Health Justice Partnership and assistant professor of epidemiology at Yale School of Public Health, argued that the Biden administration should use the Defense Production Act to scale up production of vaccines for other countries, not just the U.S.
“Biden is saying he wants to get most Americans vaccinated by the summer, but I want to hear his goal of what he’s thinking about the rest of the globe,” Gonsalves said. “President George W. Bush made a commitment to people all around the world living with HIV, almost 20 years ago, which nobody thought would ever be possible, and he helped to make it a reality” by creating the President’s Emergency Plan for AIDS Relief. “The U.S. can step up once again and be a leader in the fight against another infectious disease.”
Kenyon said the U.S. would be “very shortsighted” in thinking that vaccinating only Americans is going to be sufficient.
“COVID-19 is a very dangerous disease spread through respiratory droplets and cannot be adequately controlled locally if it remains unchecked globally,” he said. “It’s dangerous for any country or community to behave as though it’s in the clear if the science, numbers and facts say the opposite. It is not only our human imperative to make vaccines accessible to all countries faster and in sufficient quantities, but it is also in our public health interest to further minimize the emergence of variants that could render vaccines, diagnostics and therapeutics less effective.”
The U.S. has made progress in vaccinating its own people, especially after Biden moved up the deadline to make all U.S. adults eligible by almost 2 weeks to April 19, Kenyon said.
“Yet, with vaccination coverage in the U.S. at 40%, we still have a way to go to reach some level of herd immunity,” he said, noting that some high-risk populations remain particularly underserved.
“The people hit hardest by the pandemic — and the shadow pandemics it has caused — are also less likely to be vaccinated and should be at the center of this massive global effort, not left out of it,” Kenyon said. “Women, Black, Latinx and Indigenous people of color in the U.S. and those from impoverished communities globally must be equals in health care access.”
To improve vaccine access for underserved communities and those disproportionately affected by COVID-19 in the U.S., the Health Resources and Services Administration (HRSA) and CDC launched a program to directly allocate vaccines to around 1,500 HRSA-supported health centers serving these populations.
COVAX and other efforts
According to a report in BMJ, high-income nations representing 14% of the world’s population possessed up to 53% of the global supply of COVID-19 vaccines as of December — including 100% of the Moderna supply and 96% of the Pfizer-BioNTech supply — whereas 67 low-income countries had made no purchases of their own and were wholly reliant on COVAX.
“At the current rate, it is likely that only 10% of people in the majority of low-income countries will be vaccinated in 2021, which increases the risk that dangerous variants will develop,” Kenyon said.
WHO warned that “COVID-19 cannot be beaten one country at a time” and said that, although the agency recognized that countries are working in the interest of their own people, the best approach globally is to distribute vaccines fairly and equitably.
“The epidemiology shows that no country will be safe from the fallout of the pandemic until all countries are protected,” WHO told Infectious Disease News in a statement. “The fact that numerous countries have had measles outbreaks and even lost their measles elimination status in the recent past, despite having extremely high vaccination rates, shows that national coverage is not enough — it has to be achieved in every community and every family.”
According to Nachega and Zumla, the goal of COVAX is to deliver more than 2 billion doses to people in 190 low- and middle-income countries in less than a year. By March 25, it had delivered more than 16 million vaccine doses to 28 African countries, according to the Africa CDC. On April 9, the Pan American Health Organization said COVAX had delivered 3 million doses to 28 countries in Latin America, with a target to provide enough to vaccinate around 100 million people by the end of the year.
The Biden administration announced in January that the U.S. would finally join COVAX, which followed the approval in December of a U.S. funding package that included $4 billion for Gavi, the Vaccine Alliance, to support lower income countries’ capacity to, among other things, procure vaccines, a Gavi spokesperson said.
“People can stop the continuation of the coronavirus tragedy, but we must put science and lives first,” Kenyon said. “When science is sidelined, we lose our greatest potential to outsmart the virus. As vaccinations ramp up, we must continue to embrace, not ignore, such preventive measures as wearing masks when needed, avoiding large crowds wherever possible, and handwashing. And we must hold on just awhile longer until this pandemic turns the corner.”
- Africa CDC. Coronavirus disease 2019 (COVID-19). https://africacdc.org/covid-19/. Accessed April 27, 2021.
- CDC. COVID data tracker – COVID-19 vaccinations in the United States. https://covid.cdc.gov/covid-data-tracker/#vaccinations. Accessed April 27, 2021.
- Dyer O. BMJ. 2020;doi:10.1136/bmj.m4809.
- Gonsalves G, Hassan F. Vaccine nationalism is killing us: How inequities in research and access to SARS-CoV-2 vaccines will perpetuate the pandemic. Presented at Conference on Retroviruses and Opportunistic Infections; March 6-10, 2021 (virtual meeting).
- HRSA. Ensuring equity in COVID-19 vaccine distribution. https://www.hrsa.gov/coronavirus/health-center-program. Accessed on April 14, 2021.
- Katz IT, et al. N Engl J Med. 2021;doi:10.1056/NEJMp2103614.
- Knight V. Biden’s criticism of Trump team’s vaccine contracts is a stretch. March 8, 2021. Accessed April 27, 2021. https://khn.org/news/article/fact-check-president-joe-biden-criticism-of-trump-administration-vaccine-contracts-and-supply-not-accurate/.
- Nachega JB, et al. N Engl J Med. 2021;doi:10.1056/NEJMp2103313.
- Our World in Data. Coronavirus (COVID-19) vaccinations. https://ourworldindata.org/covid-vaccinations. Accessed April 27, 2021.
- Pfizer. Pfizer and BioNTech to supply the U.S. with 100 million additional doses of COVID-19 vaccine. https://www.pfizer.com/news/press-release/press-release-detail/pfizer-and-biontech-supply-us-100-million-additional-doses. Accessed on April 16, 2021.
- WHO. COVAX. https://www.who.int/initiatives/act-accelerator/covax. Accessed on April 9, 2021.
- For more information:
- Ingrid Theresa Katz, MD, can be reached at firstname.lastname@example.org.
- Tom Kenyon, MD, MPH, can be reached at email@example.com.
- Krutika Kuppalli, MD, can be reached at firstname.lastname@example.org.
- Jean Nachega, MD, PhD, MPH, can be reached at email@example.com.
- Alimuddin Zumla, MD, PhD, can be reached via email at firstname.lastname@example.org.
Click here to read the At Issue, "Will equity issues persist for boosters or variant-specific doses of COVID-19 vaccine?"