In DepthCOVID-19

Despite obstacles, WHO unveils plan to distribute vaccine

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Science  25 Sep 2020:
Vol. 369, Issue 6511, pp. 1553
DOI: 10.1126/science.369.6511.1553

Science's COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation

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Health care workers like these, in Jakarta, Indonesia, would be first to get a vaccine under a World Health Organization arrangement.


The World Health Organization (WHO) this week announced advances in its effort to ensure the entire world, not just wealthy countries, will benefit from successful COVID-19 vaccines. It reported that 156 countries have joined its plan to buy and distribute the vaccines. It also unveiled a mechanism through which it plans to allocate vaccine doses, aiming “to end the acute phase of the pandemic by the end of 2021.”

“It is a huge success to have the equivalent of 64% of the world's population signed up,” says Alexandra Phelan, a global health specialist at Georgetown University. But China, Russia, and the United States are absent from the list of partners in WHO's plan, known as the COVID-19 Vaccines Global Access (COVAX) Facility. Their absence reflects “the deeply unequal power dynamics in global health,” Phelan says. It poses financial challenges for the plan and raises fears that some high-income countries will hoard early vaccine supplies for their own populations. WHO is also grappling with how to fairly share what, at first, is sure to be an inadequate supply of vaccine.

“As of today, 64 higher income countries, including 29 economies operating as Team Europe, have submitted legally binding commitments to join the COVAX Facility,” Seth Berkley, head of GAVI, the Vaccine Alliance, said at a 21 September press conference. Those countries, which include Canada, Japan, and New Zealand, will pay for their vaccine doses. Another 38 higher income countries are expected to sign on.

“The fact that the U.S. is not part of this conversation at all, as far as I can tell, is incredibly distressing,” says Ashish Jha, dean of Brown University's School of Public Health. Berkley said COVAX hopes to work with every country.

Many questions remain about how much COVAX will achieve. So far, donors have committed just $700 million of the $2 billion COVAX hopes to raise this year to pay for vaccine doses for its 92 participating lower income countries. And it is not clear how the deals many wealthy countries have already made with vaccine manufacturers will impact WHO's plans. The deals, says Alex Harris of the Wellcome Trust, could mean countries “won't need COVAX so much themselves, and therefore might not provide sufficient financing for the non–self-financing countries.”

Such bilateral deals pose a threat to the plan, WHO's Mariângela Simão concedes, but negotiations on many of them were underway when COVAX was being set up.

WHO's “fair allocation mechanism” proposes distributing vaccine purchased by COVAX in two phases. In the first phase, all participating countries would receive vaccine doses proportional to their population: initially, enough vaccine to immunize 3% of their people, with the first doses intended for frontline health care and social care workers. Then, doses would be delivered to all countries until 20% of their population was covered. WHO expects those doses to go to people at highest risk from COVID-19: elderly people and those with comorbidities.

The plan's second phase would favor specific countries, which would receive vaccine based on urgency of need. WHO suggests two criteria for deciding priority: how fast the virus is spreading and whether other pathogens, such as influenza or measles, are spreading at the same time; and how vulnerable a country's health system is, based on metrics such as occupancy of beds in hospitals.

Ezekiel Emanuel, a bioethicist at the University of Pennsylvania, criticizes WHO's approach to the first phase, saying countries with the highest need should top the list from the start. He compares the situation to a doctor facing an overflowing emergency room. “The doctor doesn't go out into the waiting room and say: ‘I'm giving 3 minutes to everybody sitting in the waiting room.’ The doctor says: ‘All right, who's got the most serious illness? … I'm going to attend to you first.’” At the moment, he says, sending vaccine to South Korea, New Zealand, or many African countries with low case rates would not do much to reduce deaths from COVID-19.

But WHO's Bruce Aylward notes that new outbreaks can suddenly pop up: “Remember, we are dealing with a ubiquitous threat (the virus) and ubiquitous vulnerability (highly susceptible high-risk populations)!”

Allocating some vaccine to every participating country may have been necessary politically, Jha says. “I think [WHO is] probably balancing between trying to get enough people protected and trying to create enough of a sense of buy-in that people are going to be willing to chip in.” Emanuel says he understands WHO's position, “but we shouldn't confuse politics with ethics.”

For now, though, politics is crucial. “The real question is: When the first vaccine comes online, who will get those doses?” Harris says. “COVAX now needs to secure deals for their member countries that will work alongside other countries' existing bilateral deals so that all countries get some early vaccine doses, rather than some countries getting all.”

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