One-quarter of the world may not get a Covid-19 vaccine until 2022, experts warn

As wealthy governments race to lock in supplies of Covid-19 vaccines, nearly a quarter of the world’s population — mostly in low and middle-income countries — will not have access to a shot until 2022, according to a new analysis.

As of mid-November, high income countries, including the European Union bloc, reserved 51% of nearly 7.5 billion doses of different Covid-19 vaccines, although these countries comprise just 14% of the world’s population. Meanwhile, only six of the 13 manufacturers working on Covid-19 vaccine candidates have reached agreements to sell their shots to low and middle-income countries.

The analysis, which was published in the BMJ, noted that access “varies markedly” across these countries. For instance, the U.S. reserved 800 million doses, but accounted for one-fifth of all Covid-19 cases globally. By contrast, Japan, Australia, and Canada reserved more than one billion doses, though these three countries combined did not account for even 1% of all current cases.

Looked at another way, the projected vaccine courses per capita by country show Canada, followed by Australia, the U.K., Japan, the European Union, and U.S., have reserved at least one vaccine course per person. Canada has reserved 9.5 doses, or well over four courses, per person. By contrast, low- to middle-income countries, such as Brazil and Indonesia, reserved less than one course for every two people.

Meanwhile, only high and upper-middle-income countries have been able to procure mRNA vaccines—notably from the Pfizer (PFE) and BioNTech (BNTX) partnership, as well as Moderna (MRNA). The Pfizer/BioNTech vaccine has secured emergency use in the U.S. and other countries. But both it and the Moderna vaccine require cold chain distribution and storage, which means they not be readily available in countries with limited infrastructure.

“High-income countries have sought to secure future supplies of Covid-19 vaccines, but have left much of the rest of the world with uncertain access. Those hopes are today focused on a handful of lead vaccine candidates, some of which might yet falter or fail,” wrote the authors.

However, some contracts have not been disclosed or are heavily redacted, making it difficult to pinpoint supply priorities. The authors argued that greater transparency is needed about manufacturer agreements as well as underlying R&D costs, public sector financing and pricing arrangements in order to achieve more equitable access.

“Such limited transparency will fuel concerns about vaccine nationalism, and planning and accountability for ensuring broader access to Covid-19 vaccines could be seriously encumbered,” the authors warned.

The situation is compounded by the different priorities for allocation in each country and region, according to another analysis in the same issue of The BMJ. For instance, if vaccines are preferentially allocated to priority workers to help maintain societal functions, the global target population is 258.3 million people.

The analyses arrive amid increasing concern over access to affordable Covid-19 vaccines now that distribution of the Pfizer/BioNTech (BNTX) vaccine — the first to win regulatory authorization in the U.S. —  has started. As anticipation builds that still more vaccines will become available over the next several months, there is a growing push by some governments and consumer groups for greater access.

For instance, 100 advocacy groups, academics, and health experts from around the world urged the chief executives at 15 vaccine makers in the U.S., Europe, China and Russia to commit some of their output to low and middle-income countries. They also asked the companies to disclose trial results, various costs, prices, advance purchase commitments, and resources received from public and charitable sources.

One reason for such missives is that an ambitious program organized by the World Health Organization called COVAX, which hopes to provide vaccines to 92 low and middle-income countries, has not met all its goals. As of last month, $2 billion was pledged by the European Commission, the Bill & Melinda Gates Foundation, and others. But another $5 billion is still needed to finance the targeted 2 billion doses by the end of 2021.

As the study authors noted, by pooling resources and candidate vaccines, COVAX can provide access to a diversified pool of potential vaccines and economies of scale. But there is concern some countries may “double dip,” or purchase supplies through both COVAX and individual agreements. COVAX, by the way, is jointly run with the Gavi Vaccine Alliance and the Coalition for Epidemic Preparedness Innovations. So far, about 80 countries have committed to purchasing vaccines.

To date, the number of confirmed purchases of Covid-19 vaccines worldwide totaled 7.4 billion doses, according to the Duke Global Health Innovation Center. Of those, high-income countries purchased 3.9 billion doses, upper-middle-income countries secured 1 billion doses and lower-middle-income countries contracted for 1.8 billion doses. Low-income countries bought non. COVAX secured 700 million doses.

“Countries – not Covax – are purchasing nearly all the output that is being produced and is projected to be produced into 2021. Countries pay more per dose on their own than were they to procure collectively via Covax, but purchasing directly secures a space toward the front of the queue,” wrote Kenneth Shadlen a professor of international  development at the London School of Economics, who studies pharmaceutical pricing, patents and access, in a recent blog.

The anxiety over access is something of a moving target, though.

Earlier this week, the Canadian government committed to provide $380 million to various global initiatives designed to provide equitable access to Covid-19 diagnostics, therapies, and vaccines. Canada has reportedly been in talks to donate excess vaccine doses as well, but no commitment or details have been made public.

“As the uncertainty diminishes over which vaccines will succeed and which will not, Canada’s commitment to ensuring an effective global response will be tested,” Anthony So, one of the study authors and a professor at the Johns Hopkins Bloomberg School of Public Health, wrote us.

“How and at what point will it share effective Covid-19 vaccines it has procured with those faring worse in the pandemic or in greater need of receiving even the first round of doses? The same question may face a number of other high-income countries that have entered into bilateral agreements with vaccine manufacturers: scale-up at home or share abroad.

“Investing and coordinating globally through COVAX can help address this challenge, but the U.S. and Russia have declined to participate,” he continued. “So Canada’s commitment to developing a mechanism for equitably reallocating vaccine doses — through COVAX, by exchange or donation — sets an important first step for the global community to follow.”