The Scope
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The Scope

Vaccinating the 99%

How do you vaccinate developing nations?

By Aparajita Kaphle

Bhutanese refugee Bhakti Prasad Baral, 83, receives a COVID-19 vaccination at the Beldangi refugee settlement in eastern Nepal. Image courtesy of Santosh Kumar Chaudhary

On April 23rd Biden’s administration announced that more than 50% of adults in the US have received at least one dose of the COVID-19 vaccine. On the same day, Reuters released that India had reported 332,730 new cases, setting a new worldwide record. As a developing nation, India has been poor at responding to the pandemic with overcrowded hospitals and a rising death toll. While news of a functional vaccine signaled the end of the quarantining and six feet apart mandates for those residing in developed nations such as the US, to those in developing nations like India, the pandemic is far from over. As with the effects of the virus, vaccine distribution and accessibility has not been not equitable.

In the US, public health and success seldom went together in the same sentence with regards to COVID-19. In the year since the first case detected on February 29th, 2019, the US reported over 500,000 deaths due to COVID. Mask scarcity, overworked medical staff and dwindling numbers of hospital beds were all exacerbated by lax guidelines on social distancing and prevention measures enacted by individual states. While states such as Vermont, which Anthony Fauci remarked as a “model for the country” were fairly successful, states like California continued to report rising numbers following superspreader events. On December 11th, the FDA confirmed the emergency use of Pfizer-Biotech vaccine, signaling the beginnings of vaccine distribution in the US. Over the next month or so, companies like Moderna as well as Astra-Zeneca gained greater approval by the national governments. By January 5th, Moderna had set in motion plans to have over 500 million vaccines developed and ready for use. Biden’s inauguration on January 20th further signaled a change in COVID policy for the US as former President Trump had repeatedly stoked skepticism of both downplaying the danger of the virus while also overexaggerating the “danger” of the vaccine. Although vaccine rollout was sluggish at the start, the US quickly picked up the pace, administrating over 200 million doses as of May 21. Nonetheless, the US has a long way to go as epidemiologists confirm that effective pandemic response requires early response and containment, which the US had varying levels of success in.

A vaccination site in Germany. Image courtesy of The Economist

Early response and contamination in the US depends heavily on individual states’ governments to effectively enforce policies and manage economic shocks. Developing nations whose governments do not have the infrastructure to enforce quarantining guidelines are thus hit the hardest during pandemics. Tourism and hospitality, which many developing nations rely on, was severely impacted by travel restrictions, thus sending economic shocks throughout the countries. At the early start of the pandemic the shortage of personal protective equipment hurt developing countries disproportionately as there was a lack of affordable masks available to the public as well as health staff. As cases began to rise, many countries were unable to accommodate a large influx of patients into hospitals, and the death toll rose. What’s worse was that detection methods, such as the PCR test, required equipment that was expensive and difficult to come by in certain nations. Researcher at the Institute for Molecular Medicine in Finland, Anil K Giri researched Nepal’s access to detection tools reporting that in the country, “there was only one laboratory equipped to test for coronavirus infection” as of early March. The same is true of other states like Democratic Republic of Congo where weak road systems make it difficult to transport testing kits to and from sites and laboratories. Detection is hindered by both lack of scientific facilities and public infrastructure. This leads to an increased spread of the virus across communities. With increased spread, there is an increased likelihood of new strains emerging. However, fortunately these new strains are still able to be mitigated by the vaccine.

As with the effects of the virus, vaccine distribution and accessibility has not been not equitable

Given this dire situation, it is easy to turn to the successful invention of the COVID-19 vaccine as a turning point. While this may be true in developed nations, developing countries now find themselves facing a new struggle: how to access and distribute the vaccines. Recognizing the need for a worldwide vaccination effort, COVAX, a partnership between the World Health Organization (WHO) and The Vaccine Alliance (GAVI) developed the Access to COVID-19 Tools (ACT) Accelerator in late April 2020 which “brings together governments, scientists, businesses, civil society, and philanthropists and global health organizations’’ to effectively address the pandemic in all nations, but especially developing nations. COVAX is determined to supply vaccines for the state to be able to vaccinate up to 20% of its population. Since their formation, COVAX has sent millions of doses to countries like Ghana, Chad, and Nepal. However, COVAX has been criticized for its lack of transparency to pharmaceutical companies, complicating the development and production of vaccines. In one report, the Coalition for Epidemic Preparedness Innovations or (CEPI), a partner in COVAX, had given one million dollars to Moderna without confirming their involvement with COVAX. The million dollars was essential to Moderna’s development, however due to lack of commitment from Moderna, the company faces little contractual obligation to donate doses to COVAX. Ultimately, Moderna worked with COVAX and has donated millions of vaccines, but this process could’ve been streamlined from the start rather than logistical problems which prevented early distribution.

Image courtesy of Ian Hutchinson

Following the end of the “first wave” of COVID-19 cases, the Indian government laxed their restrictions on social distancing and encouraged religious festivities to occur. This, coupled with India’s dense population, has led to COVID-19 cases increasing dramatically. In a country of over a billion people, public health efforts are unable to adequately meet the needs of the country. The end of the first wave saw the government prematurely lax regulations on public gatherings, thus detrimentally affecting the magnitude of the second wave. The Serum Institute of India (SII), which has been tasked with producing the vaccines for COVAX distribution, is faced with several challenges as they continue to struggle to produce vaccines not only for India but also for other developing nations reliant on COVAX distribution. On March 25th, 2021, the COVAX Facility released a statement to participating countries that “deliveries of doses from the Serum Institute of India (SII) will be delayed in March and April”. In addition to distribution issues, the state has struggled in establishing a vaccination record program, leading to some waiting beyond the necessary 3 weeks for the second dose.

Additionally, there has been increased criticism berating developed nations for stockpiling vaccines and preventing adequate access from developing countries. Elected WHO Director-General Dr Tedros Adhanom Ghebreyesus told BBC News that developed nations’ depletion of the global vaccine supply detrimentally harms developing nations. Furthermore, while some states and countries lack effective scientific infrastructure, prevailing opinions on global health reveal that stockpiling and lack of access to materials are often the driving factor of vaccine inequity. Saad Omer, director of the Yale Institute for Global Health, said in an interview that, “lack of access to reagents is huge in vaccine distribution conversations.” Reagents are the “ingredients” used to make vaccines and oftentimes it is these reagents not the vaccines themselves that states lack access to.

“Rich nations vaccinate one person every second while the majority of the poorest nations are yet to give a single dose”

As vaccination rates increase in many developed countries, developing countries are struggling as only 3% of the developing world is vaccinated. In fact, according to a March 2021 report by the UNAID, “Rich nations vaccinate one person every second while the majority of the poorest nations are yet to give a single dose.” Work must be undertaken by developed nations such as the US to increase access to reagents and increase vaccine distribution. While the US expects normal to be right around the corner, the story is very different for developing countries as it appears that this issue will persist well into 2022.

Developing nations have tried to target pharmaceutical companies in an effort to increase vaccine access. Under the existing pharmaceutical monopolies, the prices set by pharmaceutical companies are often unattainable for developing nations without adequate aid or subsidies. In temporarily stepping over monopolies, prices will be more accessible to developing nations. Unfortunately, this proposal, which was brought up at the World Trade Organization by over 100 developing countries, has been blocked by developed nations such as the US and UK in support of pharmaceutical industries. However, we have seen the global health landscape and vaccine production change drastically as a result of the pandemic. Therefore, if developed states wish to get serious about adequately addressing the pandemic, they must take action to address the pandemic in developing nations. By providing reagents, aid, and subsidies, developed nations can assist developing nations recover.


Saad B. Omer — Director, Yale Institute for Global Health; Associate Dean (Global Health Research), Yale School of Medicine; Professor of Medicine (Infectious Diseases), Yale School of Medicine; Susan Dwight Bliss Professor of Epidemiology of Microbial Diseases, Yale School of Public Health



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