Addressing Vaccine Inequity — Covid-19 Vaccines as a Global Public Good

Abstract

T h e ne w e ngl a nd jou r na l o f m e dicine n engl j med 386;12 nejm.org The first peer-reviewed clinical trial evidence that a Covid-19 vaccine provided robust protection against SARS-CoV-2 infection was published in the Journal in December 2020, 1 less than a year after the sequence of the viral genome was reported. This unprecedentedly rapid development of vaccines was a scientific triumph. In the year since, about 62% of the world's population has received at least one dose of a Covid-19 vaccine, and 54% have completed the primary vaccine series. 2 This would appear to be a landmark success in global health mobilization. The truth, of course, is very different. The availability of Covid-19 vaccines differs vastly across the globe (Fig. 1). While several wealthy countries have exceeded 90% vaccine coverage, only about 11% of all people in low-income countries have received at least one dose, and only 25% of our health care colleagues in Africa were fully vaccinated by November, before the omicron wave. 3 Approximately three billion people worldwide have not received a single dose. The gulf in vaccination rates according to national income is overwhelming, despite the fact that a number of the pivotal phase 3 trials that led to vaccine licensing were conducted in part in some less developed countries. Poorer countries with no capacity to manufacture vaccines joined the end of the queue, as countries with manufacturing capacity prioritized local supply and wealthier countries purchased the vaccines. We should not be surprised by vaccine nationalism ; company CEOs and boards have a fiduciary responsibility to maximize their stock price, and politicians are elected to prefer the interests of their voters over populations in other nations, despite cogent arguments to prioritize vaccinations globally for the vulnerable and for health care workers. 4 And a new challenge to the global vaccine supply has emerged: data from multiple in vitro and real-world studies published in the Journal have shown that antibodies to SARS-CoV-2 wane over a matter of months after vaccination, findings that underscore the need for a booster to restore high antibody levels both to reduce infection with new variants and to minimize hospitalization and death. 5 In developed countries, the rapid emergence of the omicron variant has increased the urgency of these booster doses. Israel, a front-runner in providing booster doses, is now testing the efficacy of yet a fourth vaccine dose, and further boosters and redesigned vaccines are likely to be needed over time. These developments guarantee that existing vaccine supplies will be directed to rich countries, further delaying their availability in poor countries. Appeals from the World Health Organization (WHO) to delay booster doses in order to prioritize first doses to the world's three billion un-vaccinated people have gone unheeded in countries that see boosters as the way to open their economies and end unpopular social interventions. There is also the risk that "old vaccines" will be dumped on poorer countries as the rich shift to second-generation redesigned vaccines.