Effort to address global vaccine shortfalls envisions a more equitable new year | Science

After facing setback after setback this year, the nonprofit formed to make sure COVID-19 vaccines reach the poorest countries of the world may finally live up to its promise in 2022. A 14 December report shows that after scaling back its ambitions, the COVID-19 Vaccines Global Access (COVAX) Facility is close to meeting a revised target of 1.42 billion doses available this year. And today, the effort got a huge boost when the World Health Organization (WHO) gave an emergency use listing to a vaccine that COVAX is counting on for up to 1 billion doses next year.

Despite COVAX’s recent successes and its optimistic new supply forecast, delivering the prized shots to needy countries isn’t the last word in achieving global vaccine equity: Many nations may still struggle to distribute their supplies and, in some cases, overcome vaccine hesitancy. “Supply still needs attention, but we have pivoted to delivery and absorption as the main issues,” says Seth Berkley, CEO of Gavi, the Vaccine Alliance.

Established by WHO, Gavi, UNICEF, and the Coalition for Epidemic Preparedness Innovations (CEPI), COVAX initially set a goal of vaccinating 20% of the population in every country—enough to cover health care workers and the people most at risk of developing severe disease. To accomplish this, COVAX said it needed to have 2 billion doses available by the end of this year. The COVAX forecasting report issued this week shows the effort will fall far short of that, with 1.38 billion doses available by year’s end.

COVAX set out to buy vaccines in bulk and then provide them to 1.8 billion people in 92 low- and middle-income countries at little or no cost. But after COVID-19 vaccines first became available in December 2020, many wealthy countries ordered far more doses than they needed, bumping COVAX—which negotiates steep discounts—to the end of the purchasing line. COVAX also counted on the Serum Institute of India to supply up to 1.1 billion doses, but it backed out of the arrangement in March in order to protect India during its Delta variant surge.

But supply steadily increased as wealthy countries began to donate excess doses and more manufacturers received emergency use listing (EUL) authorization from WHO, a COVAX requirement. Last month, Serum also began to export again. And today, WHO issued an EUL for the Novavax protein-based product made by Serum, the ninth COVID-19 vaccine to receive the designation.

The current COVAX forecast projects it will have made 2.39 billion doses available by March 2022. It has options for a total of more than 6.5 billion doses by the end of next year. “I think we’re at a tipping point of the problem being demand-driven versus supply-driven,” says Nicole Lurie, the U.S. director of CEPI.

For now, the vaccine disparities between rich and poor remain stark. As of 16 December, 56.5% of the people in the world have received at least one of the 8.56 billion doses of COVID-19 vaccines that have been administered, according to Our World in Data. But in low-income countries, that figure drops to 7.5%—and plummets to 0.2% in Burundi, the lowest of the low.

And the large numbers of doses soon to be “available” may not boost those figures quickly. “The supply forecast number is certainly important to track, but it is not the most important measure of how many people are actually getting access to vaccines from COVAX,” says Krishna Udayakumar, who heads the Duke Global Health Innovation Center.

Once manufacturers offer the vials, COVAX must allocate them, based on requests from countries and their ability to “absorb” the shipments. There’s a 4- to 6-week lag between availability and delivery, which means at most, COVAX will deliver a total of 1 billion doses this year. Berkley notes that half of their 92 priority countries now have access to enough doses to cover more than 20% of their population. “Of course, it is not enough and there are still horrible inequalities,” he says.

Delivery isn’t the finish line, Udayakumar stresses. “Delivery for COVAX just means it showed up in an airport, and it takes several weeks if not months beyond that and an enormous amount of effort at the country level to get from airports to arms,” he says.

Udayakumar points to several, more nuanced issues linked to supply that will likely continue to create problems for COVAX. High-income countries that donate vaccines often don’t give recipient countries a timeline for delivery and sometimes provide vials that are near their expiration dates, making it difficult to administer doses in time, he says. And COVAX leadership is diffuse, with four institutions jointly coordinating different aspects and no one person running the effort. “The attempt to vaccinate the world is going to run into more intractable problems than the supply issue,” agrees William Moss, an epidemiologist who heads the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health.

Political instability afflicts countries that have the lowest COVID-19 vaccine coverage, whereas others have yet to express much demand. After leaders dismissed the pandemic for most of the year, Burundi had not even signed the paperwork to join COVAX by mid-November. “There are many settings where COVID is just not the priority,” Moss says, noting that countries often have more concern about other diseases.

Lurie says COVAX recipients have also become increasingly discriminating about the vaccines on offer. “Now with all these different vaccines out there and countries expressing preferences for some vaccines and saying which ones they don’t want, it’s a bigger and bigger challenge,” she says. “We’re seeing countries say more and more ‘We want the same vaccines used in America.’” Vaccine misinformation and the attendant skepticism and hesitancy have also become global challenges, she says.

Berkley says COVAX is now moving away from trying to do a blanket distribution of vaccines to hit the 20% mark and instead focusing on helping the 25 countries that have the lowest coverage. “We are creating bespoke plans for each one to deal with their specific bottlenecks,” he says.

Lurie says COVAX’s shortcomings in its first year largely stem from having to “pass the tin cup in the middle of a pandemic,” and she hopes its struggles lead toward a more effective vaccine equity model for the future. “COVAX was set up in a rush to solve a set of problems the world didn’t realize it had before this pandemic, and it did an awfully good job for a first cut,” she says. “But now having hindsight and experience we have the opportunity to really set up a system that will work, and the question is, is the world going to come together and have the appetite to do that so we never have to go through this again?”