A Covid-19 Vaccine Will Need Equitable, Global Distribution

A Covid-19 Vaccine Will Need Equitable, Global Distribution

by Rebecca Weintraub , Prashant Yadav and Seth Berkley - April 02, 2020

With the development of potential vaccines for Covid-19 progressing quickly, we need to invest now in infrastructure for distributing a vaccine globally on an equitable basis as soon as it is proven safe and effective.

Vaccines serve two related but distinct functions. They protect the vaccinated persons against the infection, and they reduce transmission, protecting those not vaccinated by reducing the number of people who can transmit disease, drastically reducing spread - a concept known as herd immunity. Equitable vaccine distribution is essential to achieving herd immunity.

Time is of the essence. The development of candidates for Covid-19 vaccines is progressing faster than that for any other pathogen in history. According to the World Health Organization (WHO), there are already two clinical trials underway and more than 50 vaccine candidates in clinical evaluation. Multilateral institutions funded by multiple governments, pharmaceutical companies, and philanthropists are all pouring hundreds of millions into the vaccine development effort, which has helped hasten discovery. We also have vital alliances such as the Coalition for Epidemic Preparedness Innovations (CEPI), which was set up in the aftermath of the Ebola crisis and is dedicated to financing and coordinating the development of vaccines and ensuring fair global access.

Our opportunity is unprecedented. The previous vaccine-development record was set during the Zika virus outbreak in 2015, when it took seven months to develop a viable candidate for testing, though the outbreak had died down before a vaccine could be sent to clinical trial. By contrast, mRNA-1273, the first vaccine candidate to combat Covid-19, entered clinical trials 64 days after the virus’s genome was sequenced and less than four months after the first known cases were recorded in China. A viral vector-based vaccine using Adeno-5 has also entered clinical trials in China. With the resources of governments, the science behind the vaccines is progressing rapidly, and assuming positive clinical trial results, a vaccine could be ready for deployment in 18 to 24 months.

Alongside the expedited discovery process, we need to plan for equally expedited distribution and delivery. Therefore, those involved in investing and building delivery systems must work as quickly as those in the field of discovery to pave the way ahead and learn from prior vaccine delivery experiences.

In general, higher-income countries have higher vaccination rates for routine vaccines than lower-income countries, and coverage disparities within countries cleave along economic lines. That’s unfortunate. We couldn’t agree more with Bill Gates, who wrote, “During a pandemic, vaccines and antivirals can’t simply be sold to the highest bidder. They should be available and affordable for people who are at the heart of the outbreak and in greatest need. Not only is such distribution the right thing to do, it’s also the right strategy for short-circuiting transmission and preventing future pandemics.”

Gavi, the Vaccine Alliance, has been working since 2000 to address vaccine equity and helps vaccinate nearly half of the world’s children. Over the last two decades it has supported 496 vaccine programs in the 73 poorest countries and helped supply them with 600 million vaccine doses every year. While Gavi’s main focus is children, it has helped provide vaccines for people of all ages for epidemic-causing diseases such as yellow fever and meningitis. Based on those experiences, we believe there should be five investment priorities for vaccinating people around the world against Covid-19.

Financing the purchase of vaccines. Many governments of low-income countries may not be able to pay the costs of deploying a new Covid-19 vaccine. They may, however, be able to pay in smaller installments over time. While Gavi can provide some limited financing from its current resources, it’s not enough to address this need; substantial resources are needed immediately. One way to provide this financing is a bond structure backed by OECD countries that would allow the money to be raised in capital markets. The OECD countries would make a legally binding commitment to pay investors in the bonds over time. This would be similar to what Gavi has done using IFFIm.

Strengthening and protecting the health care workforce. Pandemics like Covid-19 can overwhelm health systems and put their workforces at risk. Indeed, Covid-19’s impact on frontline health workers is distressing. Some 1,700 health workers in Italy are known to have already been affected, decimating an overstretched health care workforce. There are similar stories from Spain, and the same worrisome situation seems to be developing in New York City and other places in the United States. Not only will this impede the treatment of patients inflicted with Covid-19, it will also affect the program to administer the eventual vaccine. This could be an especially big problem in low- to middle-income countries, where the depletion of health care workers’ ranks could also weaken existing programs to vaccinate people against other diseases. Investment in personal protective equipment and testing capacity is needed to protect the global frontline workforce.

Identifying residents of developing countries. Around 1 billion people in the world - predominantly residents of developing countries - lack formal identities; many are mobile. This presents a massive challenge for governments trying to reach a critical mass of dispersed people: Without reliable IDs, it’s difficult to know who has received vaccines. Furthermore, the initial Covid-19 vaccine supply will be limited, so it will be essential to verify each dose reaches a real patient. Corruption, leakage, and even accidental duplication waste precious supply and are deadly.

To address this problem, biometric digital IDs can be a game changer. For example, Simprints has deployed biometric IDs on health and humanitarian projects across 12 countries, which have increased health care visits and quality while preventing fraud. It is now partnering with Japanese telecom giant NEC to develop an affordable, interoperable, biometric solution for vaccines that can identify patients even in rural and offline settings. Using robust digital tools can help governments overcome identification barriers to ensure that everyone receives a Covid-19 vaccine.

Leveraging data to predict behavior. We need to understand risk of transmission at the hyperlocal level and the likelihood of adherence for specific geographies and sub-populations. In settings with limited individual-level health data, we will need to leverage available sources. For example artificial intelligence company Macro-Eyes uses satellite imagery, digital conversations, and publicly available data to predict with 76% accuracy which child will drop out of routine immunization programs.

Establishing reliable supply chains. Managing vaccine supply chains in developing countries is challenging. We need simple data-capture systems like that provided by Logistimo to understand the stock and flow of vaccines in the supply chain.

In addition, most vaccines need to be kept between two and eight degrees Celsius. However, in many low- and middle-income countries, electricity sources are unreliable. New technologies can help. Solar direct drive refrigerators, as well as efficient new ice-lined refrigerator technology, has revolutionized the cold chain in developing countries. Gavi has invested heavily in this area and has delivered more than 60,000 new pieces of cold-chain equipment in the last two years.

If the eventual Covid-19 vaccine is not thermostable, we must leverage innovations to ensure the vaccine remains potent all the way to the patient. For example, low-cost wireless remote temperature-monitoring solutions like those offered by Nexleaf Analytics have enabled multiple Gavi-supported countries to track vaccine temperatures in real time.

To achieve all the things we have described, global coordination will be required. At least for the first eight to 12 months after the Covid-19 vaccine becomes available, it is likely that there will be only a limited supply to meet global demand. Consequently, there needs to be a global agreement on allocating stocks to countries around the world. If that doesn’t happen, the result will be political tensions like those we are currently experiencing over the allocation of personal protective equipment, ventilators, and test kits.

Although the poorest countries have in place systems that have been well honed over 20 years through the Vaccine Alliance, middle-income countries ineligible for Gavi’s assistance do not.  We need to decide how to support them - whether to extend Gavi assistance to them or provide other mechanisms.

The time to prepare for globally distributing a Covid-19 vaccine in a way that is effective and equitable is now. It will have a long-term payoff by helping to prevent future pandemics, which scientists predict will be more common as the earth’s climate warms.

Rebecca Weintraub, MD, is a member of the faculties of Harvard Medical School and Ariadne Labs and is managing director of the Draper Richards Kaplan Foundation.

Prashant Yadav is an affiliate professor at INSEAD and a fellow at the Center for Global Development.

Seth Berkley, MD, is CEO of Gavi, the Vaccine Alliance.