Priorities for the COVID-19 pandemic at the start of 2021: statement of the Lancet COVID-19 Commission

Abstract

The Lancet COVID-19 Commission calls for three urgent actions in the COVID-19 response (our broader overview is available on our website). First, all regions with high rates of new COVID-19 cases, including the USA and the European Union (EU), should intensify measures to minimise community transmission alongside rapid deployment of COVID-19 vaccines. Second, governments should urgently and fully fund WHO and the Access to COVID-19 Tools (ACT) Accelerator,1WHOWhat is the ACT-Accelerator.https://www.who.int/initiatives/act-accelerator/aboutDate: 2020Date accessed: February 9, 2021Google Scholar including COVAX. Third, the G20 countries should empower the International Monetary Fund (IMF) and multilateral development banks to increase the scale of financing and debt relief. Success on all three priorities—containment of transmission, rapid vaccination, and emergency finance—will require improved global cooperation. The high rates of community transmission (>100 new COVID-19 cases per million per day)2Ritchie H Ortiz-Ospina E Beltekian D et al.Statistics and research: coronavirus pandemic (COVID-19). Our World in Data.https://ourworldindata.org/coronavirusDate: 2021Date accessed: February 9, 2021Google Scholar in the USA, Europe, South Africa, and other countries show the emergence of new variants of SARS-CoV-2, such as lineage B.1.1.7 in the UK,3Davies NG Barnard RC Jarvis CI et al.Estimated transmissibility and severity of novel SARS-CoV-2 variant of concern 202012/01 in England.medRxiv. 2020; (published online Dec 26.) (preprint).https://doi.org/10.1101/2020.12.24.20248822Google Scholar, 4Volz E Mishra S Chand M et al.Transmission of SARS-CoV-2 lineage B.1.1.7 in England: insights from linking epidemiological and genetic data.medRxiv. 2021; (published online Jan 4.) (preprint).https://doi.org/10.1101/2020.12.30.20249034PubMed Google Scholar, 5Mahase E Covid-19: what have we learnt about the new variant in the UK?.BMJ. 2020; 371m4944Crossref PubMed Scopus (64) Google Scholar, 6WHOSARS-CoV-2 variant—United Kingdom of Great Britain and Northern Ireland.Disease Outbreak News. Dec 21, 2020; https://www.who.int/csr/don/21-december-2020-sars-cov2-variant-united-kingdom/en/Date accessed: February 9, 2021Google Scholar, 7Chand M Hopkins S Dabrera G et al.Investigation of novel SARS-CoV-2 variant. Variant of Concern 202012/01. Technical briefing document on novel SARS-CoV-2 variant. Public Health England.https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-20201201Date: January, 2021Date accessed: February 9, 2021Google Scholar 501Y.V2 in South Africa,8Tegally H Wilkinson E Giovanetti M et al.Emergence and rapid spread of a new severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) lineage with multiple spike mutations in South Africa.medRxiv. 2020; (published online Dec 22.) (preprint).https://www.medrxiv.org/content/10.1101/2020.12.21.20248640v1Google Scholar and additional variants emerging in California, USA,9County of Santa Clara Emergency Operations CenterCOVID-19 variant first found in other countries and states now seen more frequently in California.https://www.sccgov.org/sites/covid19/Pages/press-release-01-17-2021-COVID-19-variant-more-frequent-in-CA.aspxDate: Jan 17, 2021Date accessed: February 9, 2021Google Scholar, 10Zhang W Davis BD Chen SS Martinez JMS Plummer JT Vail E Emergence of a novel SARS-CoV-2 strain in Southern California, USA.medRxiv. 2021; (published online Jan 20.) (preprint).https://doi.org/10.1101/2021.01.18.21249786Google Scholar and in Brazil.11PAHOWHOOccurrence of variants of SARS-CoV-2 in the Americas. Pan American Health Organization, Washington, DC2021Google Scholar, 12Franceschi VB Caldana GD de Menezes Mayer A et al.Genomic epidemiology of SARS-CoV-2 in Esteio, Rio Grande do Sul, Brazil.medRxiv. 2021; (published online Jan 26.) (preprint).https://doi.org/10.1101/2021.01.21.21249906Google Scholar New lineages are increasing transmission of infection and raising risks in regions that have been less affected by COVID-19, including in sub-Saharan Africa.13Mwai P Coronavirus: Africa infections have risen sharply in worst-affected countries. BBC, Jan 25 2021https://www.bbc.co.uk/news/world-africa-53181555Date accessed: February 9, 2021Google Scholar, 14Callaway E Mallapaty S Novavax offers first evidence that COVID vaccines protect people against variants.Nature. 2021; 590: 17Crossref PubMed Scopus (67) Google Scholar, 15European Centre for Disease Prevention and ControlRisk related to spread of new SARS-CoV-2 variants of concern in the EU/EEA.https://www.ecdc.europa.eu/en/publications-data/covid-19-risk-assessment-spread-new-sars-cov-2-variants-eueeaDate: Dec 29, 2020Date accessed: February 9, 2021Google Scholar Additionally, acquired immunity from earlier COVID-19 infections might be less protective against reinfection with some of the new SARS-CoV-2 variants.16US Centers for Disease Control and PreventionEmerging SARS-CoV-2 variants.https://www.cdc.gov/coronavirus/2019-ncov/more/science-and-research/scientific-brief-emerging-variants.htmlDate: Jan 15, 2021Date accessed: January 20, 2021Google Scholar Mutant lineages might also reduce the efficacy of COVID-19 vaccines and require adapted vaccines or boosters.17Callaway E Could new COVID variants undermine vaccines? Labs scramble to find out.Nature. 2021; 589: 177-178Crossref PubMed Scopus (55) Google Scholar, 18Callaway E Fast-spreading COVID variant can elude immune responses.Nature. 2021; 589: 50-51Crossref Scopus (68) Google Scholar The numbers of new COVID-19 cases in east Asia and the Pacific (<10 new cases per million per day in most countries) have been consistently below those of Northern America and Europe. The lower numbers of COVID-19 cases in these countries result from the successful implementation of comprehensive containment measures: border restrictions and other limits on movement; behavioural changes including widespread use of face masks and physical distancing; active surveillance by public health systems, including mass testing, backward tracing (to identify the sources of outbreaks), and forward tracing (to identify the contacts of new cases); and the quarantine of all suspected cases and the use of facility-based isolation of confirmed cases of COVID-19. The USA and the EU failed to implement such comprehensive measures, and there was generally excessive decentralisation of containment efforts across the 50 US states and 27 EU members in 2020. Lack of centralised coordination undermined control of COVID-19, not least because of interstate travel in the USA and intercountry travel in the EU.19Studdert DM Hall MA Mello MM Partitioning the curve—interstate travel restrictions during the Covid-19 pandemic.N Engl J Med. 2020; 383: e83Crossref PubMed Scopus (13) Google Scholar Both the USA and EU need to step up more top–down coordination in 2021. Stronger health systems that incorporate universal health coverage and community-based health workers are vital in the response to COVID-19. At least half of the world's population lacks access to essential health services.20McNeill K Jacobs C Half of the world's population lack access to essential health services—are we doing enough? World Economic Forum.https://www.weforum.org/agenda/2019/09/half-of-the-world-s-population-lack-access-to-essential-health-services-are-we-doing-enough/Date: Sept 20, 2019Date accessed: February 9, 2021Google Scholar Strengthening community-based and gender-responsive health systems will be essential to implement inclusive and comprehensive COVID-19 immunisation campaigns. The global roll-out of COVID-19 vaccines to date is neither inclusive nor adequately planned. COVAX has targeted immunisation coverage of at least 20% of the population in each participating country by the end of 2021,21WHOCOVAX Announces additional deals to access promising COVID-19 vaccine candidates: plans global rollout starting Q1 2021.https://www.who.int/news/item/18-12-2020-covax-announces-additional-deals-to-access-promising-covid-19-vaccine-candidates-plans-global-rollout-starting-q1-2021Date: Dec 18, 2020Date accessed: February 9, 2021Google Scholar and has contracted for 2 billion doses of COVID-19 vaccines. Yet the timely supply of vaccines to COVAX is in question, as high-income countries (HICs) step to the front of the queue for limited supplies of COVID-19 vaccines. As of Feb 9, 2021, 148·08 million COVID-19 vaccine doses had been delivered, of which 115·67 million were delivered in the USA (43·21 million), China (40·52 million), the EU (18·36 million), and the UK (13·58).22Ritchie H Ortiz-Ospina E Beltekian D et al.Coronavirus (COVID-19) vaccinations. Our World in Data.https://ourworldindata.org/covid-vaccinationsDate: 2021Date accessed: February 11, 2021Google Scholar Other countries in Africa, Latin America and the Caribbean, and Asia (not including China) have received very few vaccine doses or none at all.22Ritchie H Ortiz-Ospina E Beltekian D et al.Coronavirus (COVID-19) vaccinations. Our World in Data.https://ourworldindata.org/covid-vaccinationsDate: 2021Date accessed: February 11, 2021Google Scholar This unequal access to COVID-19 vaccines is partly due to the difficulty of managing the ultracold supply chain needed for the two mRNA vaccines, but it is also due to the vaccine supply deals negotiated by HICs directly with the vaccine producers, rather than through COVAX. If COVAX is provided with more guaranteed funding, it could incentivise expanded production and delivery of COVID-19 vaccine doses for low-income and middle-income countries (LMICs) and assure COVAX's place in the vaccine queue. To achieve meaningful results in 2021, COVAX should have guaranteed funds in 2021 of US$20–40 billion, which it would turn into firm agreements on expanded vaccine production. Moreover, members of the Developing Countries Vaccine Manufacturers Network should be engaged with the efforts of COVAX to produce low-cost vaccines at scale. India and South Africa have called for an urgent waiver of the World Trade Organization (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) on intellectual property related to COVID-19 prevention, containment, or treatment.23Council for Trade-Related Aspects of Intellectual Property RightsWaiver from certain provisions of the TRIPS Agreement for the prevention, containment and treatment of Covid-19. Communication from India and South Africa. World Trade Organization, Oct 2, 2020https://docs.wto.org/dol2fe/Pages/SS/directdoc.aspx?filename=q:/IP/C/W669.pdf&Open=TrueDate accessed: February 9, 2021Google Scholar The Lancet COVID-19 Commission supports the emergency waiver of TRIPS in all circumstances that would facilitate the rapid scale-up of production and distribution of life-saving COVID-19 vaccines and therapeutics, noting that it is in the interest not only of LMICs but also of the entire world to suppress the pandemic as rapidly as possible.24Eurasia GroupEnding the Covid-19 pandemic: the need for a global approach. Eurasia Group, New York2020Google Scholar During the COVID-19 pandemic, the revenues of governments have plummeted at a time when higher government spending is urgently needed.25International Monetary FundWorld economic outlook, October 2020: a long and difficult ascent.https://www.imf.org/en/Publications/WEO/Issues/2020/09/30/world-economic-outlook-october-2020Date: October, 2020Date accessed: February 9, 2021Google Scholar As a result, the need for emergency deficit financing is unprecedented. HICs are able to finance large deficits by borrowing in the capital markets together with open-market operations by the central banks that partly monetise the new debt. If LMICs run deficits and open-market operations equivalent as a share of gross domestic product to those in the USA and Europe, most LMICs would incur steeply rising interest rates, depreciating currencies, and high inflation. Thus, while HICs are running huge budget deficits,26Battersby B Lam WR Ture E Tracking the $9 trillion global fiscal support to fight COVID-19. IMF Blog, May 20, 2020https://blogs.imf.org/2020/05/20/tracking-the-9-trillion-global-fiscal-support-to-fight-covid-19/Date accessed: February 9, 2021Google Scholar the poorest countries are reducing investment spending to make room for urgent social spending.27Gurara D Fabrizio S Wiegand J COVID-19: without help, low-income developing countries risk a lost decade. IMF Blog, Aug 27, 2020https://blogs.imf.org/2020/08/27/covid-19-without-help-low-income-developing-countries-risk-a-lost-decade/Date accessed: February 9, 2021Google Scholar Even worse, many of the poorest countries cannot cover the costs of urgent social needs. The IMF and multilateral development banks (the World Bank and regional development banks) were created for such emergencies. In 2020, the IMF lent about $105·5 billion of emergency financing to 85 countries.28International Monetary FundDebt Service Relief from the Catastrophe Containment and Relief Trust (CCRT).https://www.imf.org/en/Topics/imf-and-covid19/COVID-Lending-Tracker#ftnDate: 2020Date accessed: February 10, 2021Google Scholar We welcome the possibility of a new allocation of Special Drawing Rights (SDRs), the reserve currency of the IMF. As the IMF supplements the international reserves of IMF member states, a new SDR allocation would be particularly important for countries that face balance of payment shortfalls in the context of COVID-19 and could be mobilised in innovative ways to increase the financing capacity for COVAX. If an additional SDR allocation of about $650 billion were agreed, the amount available to LMICs would be of significant macroeconomic benefit. The multilateral development banks should similarly be supported to substantially increase long-term financing of infrastructure to ensure that COVID-19 does not derail the Sustainable Development Goals and other development objectives, such as mass electrification with renewable energy and universal access to digital technologies. Now more than ever the multilateral system must be supported to work effectively to deliver know-how and COVID-19 vaccines, therapeutics, and other vital supplies (eg, personal protective equipment and COVID-19 test kits) to all nations. Multilateral cooperation should include technical training and cooperation, active sharing of best practices, and the full deployment of international policy instruments, including emergency multilateral financing, flexibilities under the WTO-TRIPS agreement, and active cooperation in global institutions, including WHO, the ACT Accelerator, and COVAX. This online publication has been corrected. The corrected version first appeared at thelancet.com on March 11, 2021 This online publication has been corrected. The corrected version first appeared at thelancet.com on March 11, 2021 LA reports grants from the Sustainable Development and Solutions Network related to this Comment and grants from the Global Happiness Council, unrelated to this Comment. JA reports personal fees from consulting for companies and organisations across many sectors regarding COVID-19 risk reduction strategies: K-12 schools, universities, child-care centres, homeless shelters, commercial real estate, industry, biotech, finance, entertainment, media organisations, faith-based organisations, courts and prisons, and government and has only accepted consulting fees from for-profit organisations, unrelated to this Comment. KSR is a member of the Executive Group of the International Steering Group of the WHO SOLIDARITY Trial (Therapeutics), Chair of the WHO Guidelines Development Group on Hypertension Treatment, and is a member of the WHO EMRO Commission on the Social Determinants of Health. PD reports a grant from Johnson & Johnson to one of EcoHealth Alliance's scientists to conduct work analysing deforestation and health patterns in southeast Asia and this work is unrelated to this Comment and PD is a member of the WHO team investigating the origins of COVID-19 in China but is acting in his own personal capacity as a volunteer and is considered an independent scientist acting as a temporary expert adviser to WHO for the period of the work and his involvement in the Comment has no relationship to the work conducted for WHO. PH and MEB are developers of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E Ltd, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. VG is an employee of the International Monetary Fund (Director of the Fiscal Affairs Department). All other authors declare no competing interests. The authors' views and opinions in this Comment do not necessarily represent the views, decisions, or policies of the institutions, universities, or health systems with which they are affiliated. Department of ErrorCommissioners of the Lancet COVID-19 Commission, Task Force Chairs and members of the Lancet COVID-19, Commission, Commission Secretariat and Staff of the Lancet COVID-19 Commission. Priorities for the COVID-19 pandemic at the start of 2021: statement of the Lancet COVID-19 Commission. Lancet 2021; 397: 947–50—In this Comment, the role and affiliation for George Laryea-Adjei has been corrected to, UNICEF Regional Director for South Asia, Ghana. This correction has been made to the online version as of March 11, 2021, and the printed version is correct. Full-Text PDF Addendum: competing interests and the origins of SARS-CoV-2In February, 2020, 27 public health experts co-authored a Correspondence in The Lancet (“Statement in support of the scientists, public health professionals, and medical professionals of China combatting COVID-19”),1 supporting health professionals and physicians in China during the early stages of the COVID-19 pandemic. In this letter, the authors declared no competing interests. Some readers have questioned the validity of this disclosure, particularly as it relates to one of the authors, Peter Daszak. Full-Text PDF