When a safe and effective COVID-19 vaccine emerges, the next challenge will be to allocate doses in an ethical and equitable way. This is no easy task. Manufacturing and scalability issues will be compounded by unprecedented demand. Any ethical framework will need to navigate complex public health guidance, economics, diplomacy and public opinion.
The Covid-19 vaccine allocation plan (known as COVAX) is the chief international vaccine allocation initiative. Co-led by Gavi, the World Health Organization (WHO) and the Coalition for Epidemic Preparedness Innovations (CEPI), the scheme aims to fund vaccines for low- and middle-income countries to ensure global, equitable access. To do this, COVAX will pool funding from subscribing countries around the world into the development of 12 different vaccines and will ensure that participating countries receive early vaccine access when they become available. The idea is that low-income countries will gain access to vaccines, and in return, high-income funders will have a diverse range of vaccine options.
Sixty-four high-income countries and 92 low- and middle-income countries have joined COVAX so far. The initiative aims to make two billion doses available by the end of 2021: one billion at low expense for low- and middle-income countries, and one billion at full cost for high-income countries.
Some world leaders have publicly backed the campaign: ‘Equitable, timely and affordable access to a safe and effective vaccine will be critical to help protect people’s health,’ said Justin Trudeau, in a press release.
Edwin Dikoloti, minister of health and wellness for Botswana said: ‘COVAX and the idea of equal access to a COVID-19 vaccine, is not just a moral imperative, it is the only practical solution to this pandemic.’
There are concerns however that ‘vaccine nationalism’ could weaken the collective aims of COVAX. While Germany, France, Italy, Sweden, Canada and New Zealand have all joined COVAX, the US has opted out, joining Russia and China in going it alone. Instead, the US has signed deals worth more than $6 billion with several vaccine developers under ‘Operation Warp Speed’, which aims to secure vaccines for the entire US population by January 2021. The UK is also yet to join COVAX, sitting on the ‘interested in joining’ list. By mid-August, the UK had independently pre-ordered 340 million vaccine doses, enough for five doses per citizen. Vladimir Putin announced on 13 August that Russia had become the first country to grant regulatory approval to a COVID-19 vaccine, despite Sputnik V not having completed its phase three trial.
Together, the world’s wealthiest countries have publicly announced deals to buy more than two billion doses of pre-clinical vaccines: including 460 million doses from Sanofi/GSK, 330 million doses fromJ&J/Janssen’s, and 230 million from Pfizer/BioNTech. Some sceptics have suggested that COVAX’s modest target of two billion doses by the end of 2021 has incentivised high-income countries to seek out independent deals to meet their population demands with more security.
The scramble for vaccines is not a new phenomenon. The 2009 H1N1 influenza outbreak saw a handful of wealthy countries buy-up the majority of the supply. COVAX aims to avoid a replication, issuing ethical guidance for allocation across countries.
The scheme proposes that ‘target groups’ be prioritised, including: frontline health workers and social care workers; people over 65; and people under 65 with underlying health conditions which put them at higher risk of death from COVID-19. It also suggests that allocations be made in phases: phase one doses would be allocated to all participating countries, beginning with three per cent of the population, followed by proportional allocation until every COVAX country has vaccinated 20 per cent of its population. Phase two would then expand allocation at a rate proportional to a country’s calculated threat and vulnerability to COVID-19. Threat would be calculated based on a country’s Rt rate, and vulnerability would be assessed based on the health system capacity and occupancy of hospital beds. Some doses of vaccine under COVAX’s allocation proposal would be reserved as a ‘humanitarian buffer’.
Scientists have offered additional ethical frameworks to support the COVAX initiative, which they hope will help governments, vaccine producers and health institutions responsibly allocate vaccines. Nineteen global health experts recently proposed a three-phase plan for ethical distribution, termed The Fair Priority Model. Phase one aims to reduce premature deaths around the world, using health metrics such as Standard Expected Years of Life Lost (SEYLL) to identify where vaccines should be prioritised. Phase two then continues to address harm to health, but also aims to reduce economic losses by calculating the absolute size of the poverty gap reduction per dose of vaccine. Phase three aims to reduce community transmission, by prioritising countries with higher Rt values.
It remains to be seen however how the scramble for vaccines will play out. While 156 countries have agreed to COVAX, crucial high-income players remain absent, choosing to prioritise their own populations. Proponents of COVAX suggest that if high-income countries such as the US and the UK stockpile more vaccine doses than the amount needed to keep Rt below one, the threat of COVID-19 could persist across the world for longer than necessary.
‘COVID-19 is an unprecedented global crisis that demands an unprecedented global response,’ said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. ‘Vaccine nationalism will only perpetuate the disease and prolong the global recovery. Working together through the COVAX Facility is not charity, it’s in every country’s own best interests to control the pandemic and accelerate the global economic recovery.’