Brand inequity in access to COVID-19 vaccines

Abstract

In anticipation of a safe and effective COVID-19 vaccine being available in 2021, COVAX was launched as a mechanism to ensure equitable supply of and access to COVID-19 vaccines to all countries in the world.1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar Despite the initial commitment and global enthusiasm, there has been global inequity in access to vaccine doses in low- and middle-income countries (LMICs). Many high-income countries (HICs) and wealthy economies signed bilateral agreements with vaccine manufacturers to ensure doses were available to their citizens.2Brown G. The world is making billions of Covid vaccine doses, so why is Africa not getting them?.The Guardian. 2021; (published online Aug 16) (accessed Nov 10, 2021)https://www.theguardian.com/commentisfree/2021/aug/16/world-billions-covid-vaccine-doses-africa-unprotectedGoogle Scholar This has resulted in health workers and at-risk populations in LMICs largely being unvaccinated, with approximately <5% of eligible population in LICs being vaccinated.3More Than 7.32 Billion Shots Given: Covid-19 Vaccine Tracker. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/ (accessed Nov 10, 2021).Google Scholar Complex reasons are driving inequities in vaccine supply and access including purchasing power, intellectual property for vaccine development, exports bans on vaccine ingredients, cold-chain and distribution logistics and have been discussed elsewhere.4Wouters OJ Shadlen KC Salcher-Konrad M et al.Challenges in ensuring global access to COVID-19 vaccines: production, affordability, allocation, and deployment.The Lancet. 2021; 397: 1023-1034Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar,5Hoen E.t. Vaccine knowledge needs to be a global public good: Remarks to the World Trade Organization-World Health Organization High-Level Dialogue.Med. Law Policy. 2021; (published online July 22) (accessed Nov 10, 2021)https://medicineslawandpolicy.org/2021/07/vaccine-knowledge-needs-to-be-a-global-public-good-remarks-to-the-world-trade-organization-high-level-dialogue/Google Scholar Implementation of COVID-19 vaccination programs led to divergent vaccination policies,6Forman R Jit M Mossialos E. Divergent vaccination policies could fuel mistrust and hesitancy.The Lancet. 2021; 397: 2333Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar following reports of vaccine-related thrombosis with thrombocytopenia syndrome (TTS), temporally associated with the first dose of the AstraZeneca vaccine.7MacIntyre CR Veness B Berger D Hamad N Bari N. Thrombosis with Thrombocytopenia Syndrome (TTS) following AstraZeneca ChAdOx1 nCoV-19 (AZD1222) COVID-19 vaccination – A risk–benefit analysis for people < 60 years in Australia.Vaccine. 2021; 39: 4784-4787Crossref PubMed Scopus (15) Google Scholar Many HICs acted on clinical guidance and modified their vaccine policies based on the local COVID-19 epidemiology and risks vs benefits of vaccination with AstraZeneca compared with infection with SARS-CoV-2. Due to an association between age and TTS, many countries either introduced age-based cut offs in settings with low incidence of COVID-19 (for example Australia) or discontinued the use of AstraZeneca (for example Denmark) on the basis that the risk of blood clotting from the vaccine itself was greater than that from natural SARS-CoV-2 infection.6Forman R Jit M Mossialos E. Divergent vaccination policies could fuel mistrust and hesitancy.The Lancet. 2021; 397: 2333Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar Many of these vaccine recommendations from regulator and advisory bodies were guided by the scientific evidence to prevent vaccine-related severe health outcomes in their own population. Policy recommendations are often based on the precautionary principle in public health,8Isaacs D. The precautionary principle, the AstraZeneca COVID-19 vaccine and mixed messaging.J Paediatr Child Health. 2021; 57: 472-473Crossref PubMed Scopus (4) Google Scholar but these divergent policies, if not well communicated can have unintended consequences like increase in vaccine scepticism and reduced vaccine uptake.6Forman R Jit M Mossialos E. Divergent vaccination policies could fuel mistrust and hesitancy.The Lancet. 2021; 397: 2333Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar,9Solís Arce JS Warren SS Meriggi NF et al.COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries.Nat Med. 2021; 27: 1385-1394Crossref PubMed Scopus (229) Google Scholar Amongst the Pacific Island Countries and Areas (PICs), as of 8 November 2021, most countries except Fiji and Papua New Guinea had zero local cases of COVID-19 (Table 1). Many PICs (Fiji, Kiribati, Pitcairn Islands, Samoa, Solomon Islands, Tonga, Tuvalu, and Vanuatu) have relied on the AstraZeneca vaccines for persons aged ≥18 years. Despite low COVID-19 incidence, these countries were unable to apply age-based recommendations for AstraZeneca because other vaccine types were unavailable. The best option for them was to vaccinate their populations with the vaccine available.Table 1COVID—19 cases and vaccination status in Pacific Island Countries and Areas, 5 November 2021.Pacific Island Countries and AreasVaccine brand in usePopulation*source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021.Median age^United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1 Retreived from::https://population.un.org/wpp/Download/Standard/Population/" [Online Resource] note: countries or areas provided in this data set included only those with 90,000 inhabitants or more in 2019.Total reported confirmed COVID19 cases 01 April 2021⁎⁎source: Secretariat of the Pacific Community, Pacific Data Hub - "Stat Data Explorer". Published online at stats.pacificdata.org Retrieved from: 'https://stats.pacificdata.org/?tm=covid&pg=0′ [Online Resource] Data extracted 11 November 2021.Total reported confirmed COVID19 cases 08 November 2021⁎⁎source: Secretariat of the Pacific Community, Pacific Data Hub - "Stat Data Explorer". Published online at stats.pacificdata.org Retrieved from: 'https://stats.pacificdata.org/?tm=covid&pg=0′ [Online Resource] Data extracted 11 November 2021.Total cases per 1000 population as on 08 November 2021⁎⁎source: Secretariat of the Pacific Community, Pacific Data Hub - "Stat Data Explorer". Published online at stats.pacificdata.org Retrieved from: 'https://stats.pacificdata.org/?tm=covid&pg=0′ [Online Resource] Data extracted 11 November 2021.Percentage population fully vaccinated (all ages)⁎⁎source: Secretariat of the Pacific Community, Pacific Data Hub - "Stat Data Explorer". Published online at stats.pacificdata.org Retrieved from: 'https://stats.pacificdata.org/?tm=covid&pg=0′ [Online Resource] Data extracted 11 November 2021.American Samoa1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar.Moderna, Johnson&Johnson, Pfizer/BioNTech55197050.156.3AustraliaModerna, Oxford/AstraZeneca, Pfizer/BioNTech2578821737.929333*source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021.1828707.0967.4*source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021.Cook IslandsPfizer/BioNTech17564000.066.8Federated States of Micronesia1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar.Moderna, Johnson&Johnson, Pfizer/BioNTech11502124.4000.035.9FijiOxford/AstraZeneca Moderna2Brown G. The world is making billions of Covid vaccine doses, so why is Africa not getting them?.The Guardian. 2021; (published online Aug 16) (accessed Nov 10, 2021)https://www.theguardian.com/commentisfree/2021/aug/16/world-billions-covid-vaccine-doses-africa-unprotectedGoogle Scholar.89644427.9675229858.363.2French PolynesiaJohnson&Johnson, Pfizer/BioNTech28090433.61863346755166.452.4Guam1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar.Moderna, Johnson&Johnson, Pfizer/BioNTech16878331.4781018688110.772.2KiribatiOxford/AstraZeneca, Sinopharm/Beijin11944623000.09.4Marshall Islands1US-Affiliated Pacific Islands (USAPI)..Moderna, Johnson&Johnson, Pfizer/BioNTech59194440.135.1NauruOxford/AstraZeneca10834000.066.9New CaledoniaPfizer/BioNTech28549133.61211148640.256.9New ZealandPfizer/BioNTech512260037.92501*source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021.77761.564.8*source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021.NiuePfizer/BioNTech1618000.071.1Northern Mariana Islands1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar.Moderna, Johnson&Johnson, Pfizer/BioNTech575571593606.360.8Palau1.Moderna, Johnson&Johnson, Pfizer/BioNTech18092080.486.9Papua New GuineaOxford/AstraZeneca, Sinopharm/Beijin894702722.46475314793.51.2Pitcairn IslandsOxford/AstraZeneca67000.070.1SamoaOxford/AstraZeneca, Pfizer/BioNTech2Vaccines for persons aged <18 years..19841021.8110.042.5Solomon IslandsOxford/AstraZeneca, Sinopharm/Beijin68687819.919200.05.2TokelauPfizer/BioNTech1350000.071.7TongaOxford/AstraZeneca, Pfizer/BioNTech2Vaccines for persons aged <18 years..10569722.4010.035.2TuvaluOxford/AstraZeneca11792000.049.9VanuatuOxford/AstraZeneca, Sinopharm/Beijin30715021.1350.011.2Wallis and FutunaModerna1124641845440.451.6 source: Hannah Ritchie, Edouard Mathieu, Lucas Rodés-Guirao, Cameron Appel, Charlie Giattino, Esteban Ortiz-Ospina, Joe Hasell, Bobbie Macdonald, Diana Beltekian and Max Roser (2020) - "Coronavirus Pandemic (COVID-19)". Published online at OurWorldInData.org. Retrieved from: 'https://ourworldindata.org/coronavirus' [Online Resource] Data extracted 26 October 2021. source: Secretariat of the Pacific Community, Pacific Data Hub - "Stat Data Explorer". Published online at stats.pacificdata.org Retrieved from: 'https://stats.pacificdata.org/?tm=covid&pg=0′ [Online Resource] Data extracted 11 November 2021.^ United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1 Retreived from::https://population.un.org/wpp/Download/Standard/Population/" [Online Resource] note: countries or areas provided in this data set included only those with 90,000 inhabitants or more in 2019.1 US-Affiliated Pacific Islands (USAPI).2 Vaccines for persons aged <18 years. Open table in a new tab Over time, these safety signals and relatively lower vaccine effectiveness for AstraZeneca (one of the main vaccines available to countries under COVAX) have led to ‘brand inequity’. When a country decides a certain vaccine is not safe for a sub-population or particular age groups, people living in LMICs may wonder why they are being offered a vaccine deemed unsafe for people of the same age group in their local setting. The assumption that LMICs will be grateful for any vaccine that they receive may underestimate the concern and knowledge individuals have for the protection of themselves and their community. Vaccine safety considerations should be equal for all. Vaccine recommendations are no longer a national conversation. Vaccine information is global in its reach and consequence. People living in LMICs and their governments have limited supply and limited vaccine brand options contributing to vaccine inequity. The PICs are one example, who did not have the choice or options to implement similar policies, and used the AstraZeneca vaccine available through COVAX and other means like bilateral donations.10Hart J Saketa S Russell F. Is there a preferred COVID-19 vaccine for Pacific Island countries?.Pursuit. 2021; (published online April 23) (accessed Dec 8, 2021)https://pursuit.unimelb.edu.au/articles/is-there-a-preferred-covid-19-vaccine-for-pacific-island-countriesGoogle Scholar Few LMICs could secure necessary financing to directly purchase vaccines to implement their preferred vaccination strategy.1,11 The system is inequitable and unjust. COVAX which was established to prevent vaccine inequity, fell short in achieving its aim for solidarity and equity.1Usher AD. A beautiful idea: how COVAX has fallen short.The Lancet. 2021; 397: 2322-2325Summary Full Text Full Text PDF PubMed Scopus (26) Google Scholar There is an urgent need to increase the global vaccine supply and distribution through COVAX. While donating excess doses in the short term would help, longer term solutions around support for waiving intellectual property and, technology and knowledge transfer to increase vaccine production in LMICs should be considered to increase supply.11Jecker NS Atuire CA. What's yours is ours: waiving intellectual property protections for COVID-19 vaccines.J Med Ethics. 2021; 47: 595-598Crossref PubMed Scopus (16) Google Scholar,12Pai M Olatunbosun-Alakija A. Vax the world.Science. 2021; 374 (–1031): 1031Crossref PubMed Scopus (8) Google Scholar COVAX needs a level playing field. Without a rapid upsurge in the production of a greater variety of vaccines and increased supply of vaccine doses into COVAX, vaccine brand inequity is real and will have consequences for controlling the pandemic. MS conceptualised the study, SM curated and analysed the data, MS and SD wrote the original draft. All authors reviewed and edited manuscript.