Immunity war: Who gets to receive COVID-19 vaccines first?

Rich countries have already secured quite a large portion of COVID-19 vaccine supplies while access for the rest of the world remains indefinite, according to a study.

“High-income countries have reserved just over half of these vaccine doses from 13 leading vaccine manufacturers,” the researchers said. “Low- and middle-income countries have the remainder despite these countries comprising more than 85 percent of the world’s population.”

In addition, even if all vaccine manufacturers were to succeed in reaching their full production capacity, at least one-fifth of the world’s population would not get vaccinated until 2022.

This cross-sectional analysis obtained data from the World’ Health Organization’s (WHO) draft landscape of COVID-19 candidate vaccines, along with company disclosures to the US Securities and Exchange Commission, company and foundation press releases, government press releases, and media reports.

The researchers then assessed premarket purchase commitments for these vaccines and price per course, vaccine platform, stage of research and development, as well as procurement agent and recipient country.

Several countries have made premarket purchase commitments as of 15 November 2020, which totaled 7.48 billion doses, or 3.76 billion courses, of COVID-19 vaccines from 13 manufacturers. Fifty-one percent of these doses have been reserved to high-income countries, representing 14 percent of the world’s population. [BMJ 2020;371:m4750]

The US, which accounts for a fifth of all COVID-19 cases globally (11.02 million cases as of study period), has secured 800 million doses. Japan, Canada, and Australia have collectively reserved more than 1 billion doses even if they account for <1 percent of current global COVID-19 cases (0.45 million cases).

“Several analyses have highlighted the number of vaccine doses reserved by high income countries as a sign of vaccine nationalism,” the researchers said. [https://globalhealth.duke.edu/news/will-low-income-countries-be-left-behind-when-covid-19-vaccines-arrive; https://yubanet.com/world/most-of-pfizers-vaccine-already-promised-to-richest-campaigners-warn/; https://www.oxfam.org/en/press-releases/small-group-rich-nations-have-bought-more-half-future-supply-leading-covid-19]

Should all vaccine candidates be produced successfully, the total projected manufacturing capacity would be 5.96 billion courses by the end of 2021. Of these vaccine courses, 2.34 billion (40 percent) might be delivered to low- and middle-income countries, but this could still be less if rich countries exercised their scale-up options.

Of note, a tenfold variation was reported in the prices of vaccines, from $6.00 per course to as much as $74 per course.

“With broad country participation apart from the US and Russia, the COVAX Facility—the vaccines pillar of the WHO’s Access to COVID-19 Tools (ACT) Accelerator—has secured at least 500 million doses, or 250 million courses, and financing for half of the targeted 2 billion doses by the end of 2021 in efforts to support globally coordinated access to COVID-19 vaccines,” the researchers noted.

On the other hand, the possibility that the first COVID-19 vaccine to reach the market might not be the most effective could lead to a situation in which competing vaccines differed considerably in effectiveness in various country settings.

Second-generation vaccine could be more effective, but the challenges remain, including scale-up facilities locked into existing vaccine production, switching costs, vaccine hesitancy due to adverse reactions for the first-generation vaccines, and potential barriers to intellectual property rights as patent thickets emerge, according to the researchers.

As such, it would be crucial for the expansion of global and country-level coordination of trials among vaccine candidates, the emergence of second-generation vaccines that outdo those first to market, and the ability to switch facilities from less effective vaccines to more optimal ones.

“Greater transparency is needed about manufacturer agreements as well as the underlying costs of research and development, public sector financing for COVID-19 vaccine candidates, and pricing arrangements,” the researchers said. “Pooled procurement, coordinated production, and head-to-head trials of COVID-19 vaccines will require global collective action.”