Vaccine equity

Vaccine equity means ensuring that everyone in the world has equal access to vaccines.[1][2] The importance of vaccine equity has been emphasized by researchers and public health experts during the COVID-19 pandemic[3] but is relevant to other illnesses and vaccines as well. Historically, world-wide immunization campaigns have led to the eradication of smallpox and significantly reduced polio, measles, tuberculosis, diphtheria, whooping cough, and tetanus.[4]

There are important reasons to establish mechanisms for global vaccine equity.[4] Multiple factors support the development and spread of pandemics, not least the ability of people to travel long distances and widely transmit viruses.[5] A virus that remains in circulation somewhere in the world is likely to spread and recur in other areas. The more widespread a virus is, and the larger and more varied the population it affects, the more likely it is to evolve more transmissible, more virulent,[4] and more vaccine resistant variants.[1] Vaccine equity can be essential to stop both the spread and the evolution of a disease. Ensuring that all populations receive access to vaccines is a pragmatic means towards achieving global public health. Failing to do so increases the likelihood of further waves of a disease.[4][6]

Infectious diseases are disproportionately likely to affect those in low and middle-income neighborhoods and countries (LMICs), making vaccine equity an issue for local and national public health and for foreign policy. Ethically and morally, access for all to essential medicines such as vaccines is fundamentally related to the human right to health, which is well founded in international law.[4][6][7][8] Economically, vaccine inequity damages the global economy: supply chains cross borders, and even areas with very high vaccination rates depend on areas with lower vaccination rates for goods and services.[9]

Achieving vaccine equity requires addressing inequalities and roadblocks in the production, trade, and health care delivery of vaccines.[10] Challenges include scaling-up of technology transfer and production, costs of production, safety profiles of vaccines, and anti vaccine disinformation and aggression.[11]

Patterns of vaccine inequality

The wealthy generally have better access to vaccines than the poor, both between and within countries.[12] Within countries, there may be lower rates of vaccination in racial and ethnic minority groups, in rural areas, in older adults, and among those living with disabilities or chronic conditions, in rural communities. Some countries have programs to redress this inequality.[13] Political, economic, social, and diplomatic factors can limit vaccine availability in some countries.[12]

Factors

Achieving control of a disease (such as COVID-19) requires not only developing and licensing vaccines but also producing them at scale, pricing them so that they are globally affordable, allocating them to be available where and when they are needed, and deploying them to local communities. An effective global approach to achieving vaccine equity must address challenges in these four dimensions: vaccine production, allocation, affordability, and deployment.[2][14]

Doctors Without Borders (MSF) lists five major obstacles to vaccine equity, taking into account that many of those to be vaccinated are children:[15]

  • Vaccine prices; new vaccines are on-patent and expensive (affordability)
  • Getting vaccines to children; this is expensive and gets even more difficult in conflict zones and natural disasters (affordability, deployment)
  • Five clinic visits in the first year of life is often too many; for people in remote areas with many children, it can be much more costly and difficult to get to a clinic. (deployment)
  • Keeping vaccines cold; see cold chain. (deployment)
  • Age-out; children who don't get vaccinated on-schedule often have to pay for their shots. Disruption from natural disasters or conflict can mean that entire generations go unprotected.(affordability, deployment)

Vaccine development

Developing a new drug and gaining regulatory approval for it is a long and expensive process that can involve a variety of stakeholders. The time to develop a new drug can be 10 to 15 years or longer.[16] The average cost of developing at least one successful epidemic infectious disease vaccine from preclinical to the launch phase, taking into account the cost of failed attempts, has been estimated at from 18.1 million to 1 billion USD.[17][18]

As of 2021, the United States was the country launching the highest number of new drugs, and the country with the largest expenditure overall on pharmaceutical discovery, approximately 40% of the research done globally.[19] The United States is also the country with the highest profits for pharmaceutical companies,[20][21] and the highest drug costs for patients.[22][23][24]

Emerging and reemerging viruses substantially affect people in low and middle income countries (LMICs),[25] a pattern that is likely to increase due to climate change.[26][27][28] Pharmaceutical companies have few financial incentives to develop treatments for neglected tropical diseases in poor countries.[24]

International organizations such as the World Health Organization, Unicef and the Developing Countries Vaccine Manufacturers Network support development of treatments for diseases such as West Nile virus, dengue fever; Chikungunya, Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), Ebola, enterovirus D68 and Zika virus.[16][17]

Vaccine affordability

Intellectual property law causes problems with the economics of vaccines. IP currently operates by granting pharmaceutical monopolies lasting decades. The economics of monopoly power give the monopolist a strong financial incentive to use value-based pricing and set prices that many, often most, potential customers can't afford (a pricing strategy that charges what the market will bear, unlike traditional cost-plus pricing charges the cost of production plus a markup). Price discrimination attempts to charge each person the maximum they would be willing to pay, and charges every purchaser more than they would be charged in a fully-competitive market. A vaccine monopolist has no incentive to let the rich actually subsidize the poor. Medical-product monopolists may claim that the high prices charged to the rich subsidize the lower prices charged to the poor when in fact both are being charged well over independent estimates of the cost of production (see, for instance, GeneXpert cartridges and pneumococcal vaccine).

Amnesty International, Oxfam International, and Médecins Sans Frontières (MSF; Doctors without Borders) have criticized government support of some vaccine monopolies, on the grounds that the monopolies dramatically increase prices and impair vaccine equity.[29][30][31] During the COVID-19 pandemic, there were calls for COVID-related IP to be suspended, using the TRIPS Waiver. The waiver had support from most countries, but opposition from within the EU (especially Germany), UK, Norway, and Switzerland, among others.[32][31][33]

Cheap vaccines are often not administered due to a lack of infrastructure funding.[34]

Vaccine deployment

Logistical difficulties are an obstacle. Hot climates, remote regions, and low-resource settings need cheap, easy-to-use vaccines.[15][35] Vaccines are often not tested to see if they can survive outside a fridge or be administered in a single shot, as it is not in the financial interests of the manufacturer.[35]

COVID-19
See also: COVID-19 vaccine § Access, and Deployment of COVID-19 vaccines § Equitable access

Existing work that had been developed for other coronaviruses allowed the COVID-19 vaccination development team to have a head start, speeding up development and trials.[36] Specifically, development for the COVID-19 vaccination began in January 2020.[36] On May 15, 2020, Operation Warp Speed was announced as a partnership between the United States Department of Health and Human Services and the Department of Defense.[37] $18 Billion was contracted out to eight different companies to develop COVID-19 vaccinations intended for the US population;[38] major companies included where Moderna, Pfizer, and Johnson & Johnson. These three companies received the earliest emergency use approval from the FDA, therefore being the most common vaccinations in the United States.[39]

Vaccine inequality has been a major concern in the COVID-19 pandemic, with most vaccines being reserved by wealthy countries,[1] including vaccines manufactured in developing countries.[40] Globally, the problem has been distribution; supply is adequate.[41] Not all countries have the ability to produce the vaccine.[42] In low-income countries, vaccination rates long remained almost zero.[43] This has caused sickness and death.[1][44][45][46]

Vaccine inequity during the COVID-19 pandemic showed the disparity between minority groups and countries.[47] Based on income and rural or urban setting, vaccination rates were vastly disproportionate.[48] As of 19 March 2022, 79% of people in high income countries had received one or more doses of a covid-19 vaccine, compared with just 14% of people in low income countries.[2] By April 25, 2022, 15.2% of people in low income countries had received at least one dose, while overall globally 65.1% of the global population had received at least one dose.[48]

Throughout the data of COVID-19 vaccination records, rates have consistently been much lower for lower income groups than that of middle and higher income groups.[47] COVID-19 vaccination rates are higher in urban settings, and lower in rural settings.[47] In an underdeveloped country such as Nigeria, vaccination rates are under 11% nationally. Because of persistent vaccine inequity, many countries continue to not have access to free or affordable COVID-19 vaccinations.[49][47]

Our World in Data provides up to date statistics of COVID-19 vaccine access between nations, socioeconomic groups, and more.[47]

In September 2021, it was estimated that the world would have manufactured enough vaccines to vaccinate everyone on the planet by January 2022. Vaccine hoarding, booster shots, a lack of funding for vaccination infrastructure, and other forms of inequality mean that it is expected that many countries will still have inadequate vaccination.[50]

On August 4, 2021, the United Nations called for a moratorium on booster doses in high-income countries, so that low-income countries can be vaccinated.[9] The World Health Organization repeated these criticisms of booster shots on the 18th, saying "we're planning to hand out extra life-jackets to people who already have life-jackets while we're leaving other people to drown without a single life jacket".[40] UNICEF supported a "Donate doses now" campaign.[51]

On 29 January 2022, Pope Francis denounced the "distortion of reality based on fear" that has ripped across the world during the COVID-19 pandemic. He urged journalists to help those misled by coronavirus-related misinformation and fake news to better understand the scientific facts.[52]

See also

References
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