What will it take to improve access to vaccines?

The struggle to get vaccines and treatments to those in need reached a new fever pitch during the COVID-19 pandemic. Even as the urgency of the pandemic fades, that struggle remains unresolved, which is why public health experts and governments are once more grappling with access issues with renewed urgency.

The stakes are high for everyone caught up in an outbreak or epidemic of an infectious disease that demands new vaccines or treatments. But the stakes are especially high for low- and middle-income countries, as COVID-19 made clear. Many of these countries suffered through months-long delays in access to vaccines through the peak of the COVID-19 pandemic — such that by the time they were readily available, demand for them had vanished.

In late February, public health institutions large and small gathered alongside civil society groups and governments in Johannesburg, South Africa, to start hashing out the shape of “an equitable and sustainable medical countermeasures platform” for the next pandemic.

What that means in practice will depend on how the next pandemic develops. But should another truly massive vaccination drive become necessary — for a novel influenza, say — today’s plans could help determine how successfully and widely those vaccines are delivered. In Johannesburg the focus was on financing and procurement of vaccines, diagnostics, and therapeutics as much as fostering rapid research and development.

“Vaccines aren’t like other commodities. They’re public goods, and they exist because of very substantial public investment,” says Tom Frieden, chief executive of Resolve to Save Lives and one-time director of the U.S. Centers for Disease Control and Prevention. “Different countries have different ways of controlling drug prices, but vaccines are different. I do think the bigger issue here is a need to reset the rules of the game.”

Frieden says that means resetting vaccine policies. The tools used for financing and gaining access to vaccines and their distribution during COVID-19 was led by large multilateral agencies and global organizations, including the World Health Organization (WHO); Gavi, the Vaccine Alliance; The Global Fund; the Coalition for Epidemic Preparedness Innovations; the World Bank; UNITAID; Wellcome; and FIND, the global alliance for diagnostics.

Together these partnerships were able to deliver a billion vaccines, but only after long delays that starkly illustrated a gap between rich and poor countries. The pace of delivery and the difficulty of obtaining steady financing meant demand in many places had deflated by the time the vaccines arrived, and the amount of vaccine delivered, while significant, fell far short of the original goals.

Given all this, the success of these initiatives in purchasing and delivering vaccines, therapeutics, and diagnostics to low- and middle-income countries is still being evaluated and vigorously debated, and likely will be for some time to come. Part of the discussion is about what should be done differently in the next pandemic. Advocates are lining up behind different approaches: Bill Gates, for example, is touting a WHO initiative called Emergency Medical Teams aimed at bringing together a “global health emergency corps” under a solidly funded network that would run exercises for potential outbreaks, conduct epidemiological surveillance, and support paid community health workers.

But not everyone agrees. Richard Horton, editor-in-chief of The Lancet, has written blisteringly about the need to seek a new path that isn’t reliant on the WHO or other global institutions.

Sir Andrew Pollard, director of the Oxford Vaccine Group and chief investigator of the clinical trials for the Oxford vaccine against SARS-CoV-2, expects equitable access to vaccine technology in a future pandemic will likely be challenged again, at least initially, by limited supply. “The best way to overcome this is to ensure manufacturing capacity and agreed-upon global partnerships on technology sharing are in place, particularly in resource-poor regions,” he says.

Building local production is therefore an important key to vaccine access. But Pollard and Bernhard Braune, global health policy and financing division head at the German Federal Ministry of Economic Cooperation and Development in Berlin, both make the point that it isn’t enough just to build manufacturing plants. “There needs to be a plan for use of those facilities over the years until the next pandemic strikes so that an experienced and skilled workforce is available,” Pollard says.

Across the entire continent of Africa, 99% of vaccines are currently imported. The German government is sending US$550 million to support manufacturing buildup on the continent. BioNTech, the Mainz-based biotech that developed the COVID-19 vaccines with Pfizer, delivered several mobile vaccine production modules to Kigali, Rwanda, just this month. When assembled these will form a hub from which mRNA vaccines can be produced.

This “turnkey” manufacturing facility should be operational in early 2024; active vaccine will be filled into vials and finished via partners in Ghana and South Africa. Other vaccine manufacturing ventures are underway in South Africa and Senegal, with an effort in Cape Town via the biotech Afrigen and its partners at the University of Witwatersrand to develop domestically-owned mRNA-based vaccine production capabilities. The African Union has set its aim on delivering 60% of the continent’s vaccine needs using regional manufacturing by 2040.

A longtime bugbear for vaccine storage and delivery efforts in rugged and remote climates has been the need to keep the vaccines in the deep freeze, or what’s called the cold chain (a frozen supply chain which stretches as far as it needs to from factory to the time of use). At one point in the pandemic the bulk of vaccines to be delivered to low- and middle-income countries was meant to be the AstraZeneca/Oxford formulation, which can be stored at relatively warmer temperatures, similar to that for the widely distributed polio vaccine.

But the specialized cold chain equipment flown in to try and accommodate mRNA vaccines, especially in sub-Saharan African countries, remains there still. So long as it is maintained, it will be another way to improve local vaccine access. Meanwhile, researchers are pursuing mRNA vaccine formulations that can withstand storage at warmer temperatures.

COVID-19 is broadly moving from its acute pandemic stage to becoming endemic, comparable in some ways to endemic influenza. In many parts of the world, that means the response to it will become part of routine vaccination programs or primary health care. In vast regions these routine vaccines are delivered by community health workers, often traveling and reaching out to people in remote places — the so-called “last mile.” This is going to get harder, as the same workers delivering measles and polio vaccines will now be expected to deliver COVID-19 vaccines. Even if COVID-19 response is absorbed into primary health care, Braune says, we still live in a world where people have limited or no access to that, either.

Strengthening these systems for vaccine delivery will have benefits far beyond COVID. In a recent opinion piece in The New York Times, Barney Graham, a professor and senior adviser for global health equity at the Morehouse School of Medicine who helped develop the Moderna COVID-19 vaccine while at the U.S. National Institute of Allergy and Infectious Diseases, wrote: “Having next-generation vaccine technology without adequate systems for implementation and distribution to all people is a waste.” The goal is to develop those systems now before the next pandemic strikes.

Michael Dumiak, based in Berlin, reports on global science, public health, and technology.

Read more:

• Special Report from the Financial Times on communicable diseases
• UNICEF on the key to efficient vaccine delivery
• UNICEF on how to improve primary healthcare to prepare for future pandemics
• Vaccine Preparedness for the Next Influenza Pandemic, National Library of Medicine