Recent announcements from pharmaceutical companies Pfizer/BioNTech, Moderna and AstraZeneca suggest that there will soon be safe, effective vaccines to help tackle Covid-19.

In the global race to secure access to vaccines, there are fears that developing countries may miss out.

This Insight explores the challenges to secure enough vaccines for the world’s poorest and most vulnerable people.

Covid-19 challenges in developing countries

Some developing countries have features making them more vulnerable to Covid-19. Their health-systems may be under-developed and funded, with high prevalence of diseases such as malaria, HIV/AIDS, and tuberculosis add additional burdens.

Research has shown that malnourished children have poor immune systems and are more vulnerable to disease. Existing routine immunisation programmes have been disrupted by the pandemic, putting children in some developing countries at further risk.

The economic impact of Covid-19 is also projected to increase the numbers of those living in extreme poverty globally.

Access for internally displaced people and refugees

Certain vulnerable groups are less likely to gain access to vaccines. Alain Alsalhani, a vaccine pharmacist who works with Médecins Sans Frontières, told The Guardian that in Syria many internally displaced people might not receive vaccines, if “they end up in areas not controlled by the government, or they might be considered to be anti-government or pro-revolution.”

Plans will be needed to vaccinate the large numbers of people living in refugee camps. This includes 197,000 refugees living in the Kakuma camp and Kalobeyei Integrated Settlement in North-west Kenya, and over 850,000 Rohingya refugees in 34 refugee camps around Cox’s Bazar in Bangladesh.

Logistical problems

Poor transport infrastructure and a lack of adequate refrigeration facilities may also hamper the distribution of vaccines.

The AstraZeneca Oxford vaccine can be stored for at least six months at normal fridge temperature, while the Pfizer vaccine needs to be stored at -70°C before use (though the company says it has plans on how to make that possible) .

Moderna says its vaccine is stable at regular freezer temperature (-20°C) for up to six months, and after thawing it can last in the refrigerator for 30 days. This suggests the Oxford vaccine could be better suited for distribution in developing countries. Vaccines requiring sub-zero storage, like the Ebola vaccine, have been distributed in sub-Saharan Africa before, but not on the scale required for the Covid-19 rollout.

Costs and pharmaceutical company profits

Costs will also be a major consideration for access. The Oxford vaccine will be priced at maximum of $3 per dose for Lower and Middle Income Countries (LMICs) and $4-$5 elsewhere.

Pfizer has agreed a cost with the US Administration of $19.50 a dose. It says this could become a benchmark for developing nations. Moderna is charging $32 to $37 a dose for smaller deals and less for larger orders.

Oxford University and its partner AstraZeneca, pledged to not profit from the programme “during the pandemic”, but for low and middle income countries this pledge will be “for perpetuity.” Their programme has received funding from both the UK and US Governments.

However, funding from the US Administration did not come with strings attached regarding profits, so companies have taken different approaches. Johnson & Johnson and Moderna both received US funds, Johnson & Johnson has also said it will not profit from its vaccine, while Moderna’s President told the US Congress in July that “we will not sell it at cost.” Pfizer/BioNTech did not take US funds and is not selling at cost.

Imperial College London, which is pursuing its own vaccine, has formed a new social enterprise VacEquity Global Health (VGH) with support from the life science investor Morningside Ventures. For the UK and low-income countries abroad, Imperial and VGH have announced they will waive royalties and charge only “modest cost-plus prices” to sustain the enterprise’s work.

Aid support initiatives

International institutions and aid donors are trying to ensure better vaccine access for the developing world. Gavi, the vaccine alliance, is running the largest such initiative.

Gavi’s COVAX Advance Market Commitment (AMC) aims to secure doses of Covid-19 vaccines for 92 LMICs at the same time as wealthier nations. It aims to deliver two billion doses of vaccines to all participating countries including the 92 LMIC economies, by the end of 2021. This initial drive will provide doses for an average of 20% of each country’s population, focusing on health care workers and the most vulnerable groups.

Gavi says the initiative requires US$2 billion by the end of 2020, in order to reserve one billion doses. To date, $1.7 billion has been raised of which $958 million came from the UK, Canada, Germany, Italy and Sweden. At least US$ 5 billion is said to be needed in 2021 to procure further doses.

In August it was announced that the Serum Institute of India (SII – the world’s largest vaccine manufacturer by volume), Gavi and the Bill & Melinda Gates Foundation, will accelerate the manufacture and delivery of up to 100 million doses of Covid-19 vaccines for LMICs as part of the COVAX AMC.

In October, the World Bank announced $12 billion of funding for developing countries to finance the purchase and distribution of Covid-19 vaccines, tests, and treatments for their citizens.

Access to vaccines in developing countries

Despite such initiatives, it’s not certain that developing countries will be able to access enough doses for their populations.

Duke University analysis shows that high income countries have signed enough purchasing agreements to vaccinate their entire populations, and some will be able to do so many times over. It suggests billions of people in the developing world will be left waiting till 2024 to receive vaccinations, even with the COVAX initiative.

India and South Africa proposed a World Trade Organization (WTO) exemption for Covid-19 drugs and vaccines from patent and intellectual property protections, saying these may hinder the timely provision of affordable medical products. The WTO could not come to an agreement on this issue, but agreed to look at it in further detail.

Further Reading

About the author: John Curtis is a researcher at the House of Commons Library, specialising in international affairs and development.

Photo by National Cancer Institute on Unsplash

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