Joachim and Tilman Rüppel present the current data situation on the global distribution of access to COVID-19 vaccines in order to draw important conclusions. A presentation of the results is available for download
Access to COVID-19 Vaccines - Evolving Patterns of Worldwide Distribution
Joachim and Tilman Rüppel
In the heated debate about the global outbreak of the novel coronavirus, let us state the most important facts first: The current status until mid-February 2021 of the statistically confirmed COVID-19 cases shows us that worldwide nearly 110 million people have been infected and over 2.4 million humans have died due to an infection (https://coronavirus.jhu.edu/map.html). Most probably, however, the real death toll is considerably higher given that measured excess mortality in a number of countries is several times vaster than confirmed and reported fatalities. Hence, COVID-19 is the deadliest infectious disease in the world right now. Moreover, the tragic reality is that the pandemic is far from over and that we will see even higher cumulative cases and mortality in the months to come.
Owing to scientific progress and international cooperation in the health sector and beyond, we as the human community possess an increasing arsenal of tools in the fight against SARS-CoV-2 and its mutant variants. One of the most important and promising ones are vaccines. As it stands, several effective and safe vaccines against the virus have been developed and are being produced. At the same time, the global need for those vaccines is immense and the necessity to develop more vaccines as well as to adapt the existing vaccines to the mutated variants is pressing. Still, one of the most important questions at the present is how – as a human community – can we distribute the existing vaccine doses most effectively and equitably in the struggle to save lives and simultaneously ramp up manufacturing capacities in order to produce and deliver more and more vaccine doses in the required quality as quickly as possible.
The argument for an equitable distribution of COVID-19 vaccines on a global scale is clear: Ethically and morally, protecting the most vulnerable people in addition to workers in health and social care settings is paramount. Since members of the first group are most susceptible of suffering severe disease progressions and death, while those belonging to the second group are in close contact with the vulnerable persons and are exposed to an elevated risk of contracting the virus. Furthermore, the enormous losses to the world’s national economies go into the trillions of US-dollars, keep increasing and are far greater than the billions of US-dollars needed for the development, production and distribution of vaccines worldwide. Also, recently published research studies show that because of the interconnectedness of the world’s national economies, even industrialized nations will keep suffering heavy economic losses as long as the economies in low- and middle-income countries cannot recover due to the COVID-19 pandemic. But first and foremost, ensuring that the world population, and in particular priority groups, are vaccinated as fast as possible is the only reasonable thing to do because otherwise we all as human beings encounter an unforeseeable risk that circulating viruses develop mutated variants against which vaccines are less effective. Problematically, recently detected virus variants – especially variant B.1.351 first discovered in South Africa – already prove less sensitive to the immunity induced by vaccines developed and authorized for use so far.
While the case for a globally equitable distribution of vaccines against SARS-CoV-2 is evident, we face several serious shortcomings and crucial questions in this endeavor. In order to provide a contribution in answering some of these questions, we created various diagrams depicting the worldwide COVID-19 vaccine coverage through advanced market commitments in terms of the proportion between the number of secured courses of vaccination according to required doses and the population size. We also put the global COVID-19 vaccine coverage in perspective regarding the cumulative death toll of countries in relation to their population sizes as well as the income status of the world’s nation states. The findings indicate that to a significant extent COVID-19 vaccine coverage is not congruent with the respective threat when using cumulated mortality rates as a critical indicator. Although the countries with death rates above the worldwide average of close to 310 per million people enjoy higher coverage rates than the remaining nations with lower mortality, in a worrying number of cases high risk still coincides with anticipated supply shortages. When excluding China, India and Russia due to the lack of data on local production for domestic needs, 84% of the roughly 1.85 billion people living in countries with above-average mortality would obtain immunizations with one of the approved vaccines (Pfizer/BioNTech, Moderna, AstraZeneca/Oxford), whereas the overall coverage for the approximately 3 billion persons found in nations with below-average death rates would amount to around 30%. However, in the present situation, 700 million individuals live in those countries with higher risk, where less than half of the people would be able to access these vaccines. Applying a wider definition of coverage that also considers vaccines with positive trial data (Gamaleya Research Institute, Johnson & Johnson/Janssen, Novavax) would result in a surplus ratio of roughly 137% in the first country group and a still insufficient coverage rate of 57% in the second category. This points to the urgent need to adjust worldwide allocation giving priority to countries and populations facing the highest risks, while taking all necessary measures to expand manufacturing capacity and enhance delivery channels in order to reach the totality of the world population.
On the other side, it is obvious that economic capacity is a decisive factor for COVID-19 vaccine coverage under the current circumstances. Taken together the countries belonging to the high-income category, where GDP per capita exceeds 12.500 US$, reach a coverage rate of 120% using the stricter definition and 200% calculating with the wider range of vaccines, whereas the respective population-weighted average ratios in the lower income groups hover around a fifth and a third, respectively. Contrary to historical pandemics, most notably the massive threat to global health and human development posed by HIV and AIDS, the available data also demonstrate that on average higher income levels are associated with more severe rates of cumulated COVID-19-related mortality.
In fact, cumulative mortality related to COVID-19 constitutes a rather imperfect indicator of the risk to experience an explosive spread of coronavirus with life-threatening consequences considering the highly dynamic nature of outbreaks on a national or local level. Furthermore, in several well documented cases the root causes of devastating epidemics did not lie in structural conditions, such as resource constraints, unfavorable living conditions or the unprecedented force of the pandemic in its initial phase, but were closely related to the misuse of economic, political and ideological power. The desperate epidemiological situation seen in the respective countries at present was to a high degree inflicted by irresponsible governments and the selfish interest of influential sectors of national societies. Under a humanitarian and human rights perspective, however, combating avoidable deaths represents the fundamental and undisputable principle of action in the field of health and human development, besides the fact that generally those who suffer the most are not primarily responsible for the disaster. Therefore, mortality risk is of foremost importance for priority-setting and planning the distribution of vaccines and other life-saving technologies in a situation of scarcity. In consequence, cumulative death rates can serve as a proxy indicator for future mortality risks and should be taken into account as a central criterion for decisions regarding worldwide allocation, especially in this phase when the international community neither can rely on a prolonged use of other effective means to prevent the impact of the pandemic nor can it realistically expect that outbreaks lead to herd immunity in any significant population. Anyhow, these immediate considerations should not distract us from the fundamental fact that overcoming the shortage through enacting all necessary measures to enhance vaccine production and supply remains our overarching concern and, in the absence of an effective treatment option, represents the only feasible way to achieve a sustainable control of the threat posed by the pandemic.
Examining the structural and political failures with respect to pandemic preparedness and looking at the resulting fierce debates and hectic actions to secure vaccine supplies as fast as possible, we see that entering in supply contracts with vaccine manufacturers does not necessarily translate into fast delivery. In the rat race for procuring vaccines the most self-centered actors, frequently driven by the disastrous consequences of their own unwillingness or incapability to contain the pandemic within their countries, enjoy an advantage when it comes to hoarding the vital but scarce products. As long as the world community does not manage to resolve the fundamental issue of vaccine production, a number of countries with secured advance purchase contracts inevitably will be passed by others, but unlike the most disadvantaged nations, they got an advantageous place in the queue. Secrecy around the respective agreements is obstructing a clear view of the conditions involved, which probably impede a distribution system that would prove to be more just, wiser and, finally, better for all. The lack of international cooperation and basic transparency reduces our chances for overcoming the pandemic and coping with its enormous consequences.
Which consequences can we draw from these findings?
First, nation states need to adhere to global allocation framework’s like the one designed by the COVAX initiative. Meaning that in a very first step of worldwide vaccine coverage every personnel working on the frontline in the global fight against the novel coronavirus must receive immunization. Second, vulnerable groups have to be prioritized in all of the world’s countries before vaccinating individuals for whom severe COVID-19 disease progressions are much less likely. In order to achieve this goal in the fastest way possible, wealthy nation states that have already secured the vast share of the global COVID-19 vaccine supplies should donate surplus vaccine doses to COVAX since these doses are not needed to immunize vulnerable groups and workers in health and social care settings. Moreover, they should stop the bidding war between each other to procure as many vaccine doses as possible as long as the respective purchase contracts are vastly surpassing the production capacities and are blocking access of other populations with more pressing needs. Instead, adhering to COVAX’s global procurement mechanism and equitable allocation framework is the fastest way out of this pandemic.
Significantly, the world community must ramp up production capacities as quickly and broadly as in any way possible. Relying on a handful of pharmaceutical corporations and rare bilateral licensing agreements between pharmaceutical firms is insufficient in the eye of the perfect storm formed by the COVID-19 pandemic and the accelerating spread of mutant variants. We desperately need more vaccine manufacturers form all sectors, both public and private, on an international scale that possess the legal means, the scientific know-how as well as the technological abilities to produce COVID-19 vaccines in the required quality that ensures safety and effectiveness. As long as the COVID-19 technology access pool (C-TAP), which was founded due to this specific purpose last year, is ineffective because pharmaceutical companies deny to share their intellectual property rights and scientific know-how with this vital mechanism in the world’s fight against COVID-19, too many potential vaccine manufacturers are prevented from producing COVID-19 vaccines. Therefore, it is urgently required to politically strengthen C-TAP and ensure that pharmaceutical companies do everything they can in order to forego intellectual property rights and share scientific know-how. Simultaneously, the so-called TRIPS waiver submitted by India, South Africa and other countries within the framework of the World Trade Organization (WTO) should be supported since through waiving exclusive intellectual property rights for a limited time period, this approach possesses the potential to considerably increase the worldwide production volume of COVID-19 vaccines, therapeutics, diagnostic tools and protective equipment and thus counter the severe shortages of these medical products.
Essentially, more financial resources must be invested in the global fight against the COVID-19 pandemic. That is why we finally need full funding of the COVAX initiative to support its main target to acquire and deliver 2 billion vaccination doses until the end of 2021 in order to immunize the most vulnerable individuals in addition to frontline workers in health and social care settings in all of the world’s nations. However, COVAX is just one out of four pillars of the so-called Access to COVID-19 Tools Accelerator (ACT-A) – an initiative created by the international community in order to develop, produce, deliver and apply vaccines, diagnostic tools and therapeutics against COVID-19 as well as strengthen healthcare systems in their fight against the pandemic. Dramatically, the ACT-A’s pillars comprising therapeutics, diagnostic tools and health system strengthening are vastly underfunded and lack even more of their required financial resources than the COVAX initiative does. Since we can only win the fight against SARS-CoV-2, if we apply all the tools in our possession in the global struggle against the pandemic, it is of utmost importance that ACT-A receives its full funding now.
Additionally, governments of nation states should seriously consider how manufacturing capacities of COVID-19 vaccines can be scaled up much more quickly than at the current insufficient pace by directly investing into production facilities. This can occur with the assistance of increased investments in private companies in addition to the already invested billions of US-Dollars as well as through the initiation of publicly funded and managed manufacturing facilities.
Lastly, countries lacking the necessary logistical infrastructure and healthcare systems to roll out sizable vaccination campaigns have to receive more support in order to improve their abilities to vaccinate their populations by increasing their healthcare workforce, expanding their infrastructure and strengthening their health systems at large. While multilateral organizations like UNICEF, GAVI and the Global Fund are already tasked with providing such support, more has to be done to assist these international organizations.