THE covid-19 pandemic has entered a dangerous new phase, with new variants spreading widely and overwhelming healthcare systems in some countries, such as India. Vaccines promise to bring an end to the pandemic, but with supplies still severely limited, many believe we need to think more wisely about how best to use the doses we have.

“Our vaccinations should go to those that are most vulnerable, in most urgent need and where they can make the most difference,” says Krishna Udayakumar at Duke University in North Carolina.

That isn’t what is happening. High-income countries have bought the vast majority of vaccine doses made so far, and the small amount being distributed by the global scheme set up by the World Health Organization (WHO) and others, known as COVAX, are initially being allocated per head of population.

“COVAX is purely based on pro-rata distribution models, which is a very good place to start, but can’t be the only consideration,” says Udayakumar.

What’s more, not only are those high-income countries not sharing the vaccines they have bought with other countries equitably, many are sitting on stockpiles that won’t get used immediately and which those countries might not need at all.

“We don’t want these doses sitting in these countries for even a day,” says Jenny Ottenhoff at ONE, an international charity campaigning to eradicate poverty and preventable diseases. “There’s way too many people around the world that need to be vaccinated.”

The US alone has more vaccine doses sitting unused than have been distributed via COVAX. According to Unicef, COVAX will deliver its 65 millionth dose this week (see “How is COVAX distributing vaccines?“). “We have around 60 million doses sitting in refrigerators at the state level. The federal has more,” says Ali Mokdad at the University of Washington in Seattle. Udayakumar estimates that the US may have 70 million doses unused. “This is, in my opinion, criminal,” says Mokdad. “We should start sharing. There are people dying out there.”

Globally, around 9 per cent of the world’s 8 billion people have had at least one vaccine dose, which many regard as an amazing achievement in just six months.

“9%of the world’s 8 billion people have had one dose of vaccine”

But there are huge differences between countries. A few, including Israel and the UK, have given more than half their populations at least one dose of a covid-19 vaccine. Some others, including the US and Chile, are approaching half. However, no country in Africa has given a vaccine to more than 2 per cent of its population.

Brazil and India – both battling devastating outbreaks – have given at least one dose to 15 and 10 per cent of their populations respectively. Both are slightly above the world average, meaning they have vaccinated more people than if all doses had been globally distributed on a per head of population basis. This is because both are manufacturing vaccines locally, and Brazil also began buying extra doses this year.

The Serum Institute of India was meant to be the main supplier of vaccines to COVAX, but as the country’s infection rate soared, the Indian government temporarily suspended vaccine exports, leaving COVAX short.

COVAX has yet to distribute enough doses to get close to its initial aim of 3 per cent vaccination in all countries. Meanwhile, Israel, the UK, the US and to a lesser extent countries in the EU are well on their way to vaccinating their entire populations.

The aim of high-income countries, even if not openly stated, is to use vaccination to eliminate the coronavirus within their borders, says Antoine Flahault at the Institute of Global Health in Geneva. That is, to try to pass the herd immunity threshold and stop the virus spreading.

Reducing mortality

By contrast, the focus of COVAX is on preventing deaths and severe cases. “Countries should focus initially on reducing mortality and protecting the health system,” states the document on fair allocation by COVAX drawn up by the WHO in September.

If high-income countries gave away vaccine doses once they have vaccinated the most vulnerable groups, instead of keeping enough and more for their entire populations, many deaths could be avoided, suggests a model created last year by Alessandro Vespignani at Northeastern University in Boston and his colleagues. It concluded that global deaths would be halved in a cooperative scenario compared with richer countries keeping most vaccines to themselves. The team is updating the model and plans to publish these findings shortly.

But high-income countries aren’t sharing in this way. In fact, some, including the UK, are now ordering additional booster shots, which will prevent other countries receiving more first doses.

“100,000 vaccine doses donated to COVAX by France”

Is there a better way of using the few doses that COVAX has? One option, for instance, would be distributing doses according to the proportion of vulnerable people in a country and the current threat level. That is what COVAX plans to do once 20 per cent of people in all countries have been vaccinated.

But we are still far from this point, and changing the plan now would be difficult as countries that signed up to COVAX did so on the agreement that doses would be allocated per head of population.

What’s more, according to a source who didn’t want to be named, the single biggest issue with equitable distribution isn’t getting vaccines to countries but what happens after they arrive.

The WHO has set out priorities for who should be vaccinated first when supplies are limited, which are similar to those used by high-income countries in their roll-outs. If doses for fewer than 10 per cent of a population are available, healthcare workers at high risk and older people should be prioritised. If there are enough doses for up to 20 per cent of a population, the next in line should be people at risk because of other health problems and groups who are especially vulnerable, such as refugees or other people who are homeless.

“The US alone has more vaccine doses sitting unused than have been distributed via COVAX”

Many low-income countries, however, don’t have the infrastructure to contact older and more vulnerable people, or to get them to vaccination centres. A high proportion of people are digitally illiterate, so can’t enrol via websites. As a result, jabs are being given to whoever can get to mass vaccination centres rather than to those who are supposed to get them.

“70 million vaccine doses may be sitting unused in the US”

India has changed its plan of vaccinating front-line workers and those over the age of 45 and is now vaccinating everyone over 18, with up to half of doses being supplied via the private sector. This could work if it had enough supplies, says Udayakumar, but in practice could lead to more inequity. “To open up eligibility to 900 million people when there are 70 to 80 million doses a month of capacity creates an even worse mismatch between demand and supply,” he says. “There’s a path for people who can afford vaccines to get it more quickly as opposed to those who might benefit most.”

“Doses donated from countries with excess supply will be an important part of the solution”

Another option for boosting coverage with limited supplies would be to delay the second dose of a vaccine, as the UK has done. But this can’t be done with all vaccines. SinoVac, for example, was found to be just 3 per cent effective at preventing infection after a first dose in Chile.

Even with more effective vaccines, a recent study suggests a delay is best done with people under 65, which isn’t the stage of roll-out most countries are at yet. And Mokdad thinks it is a bad idea because delaying the second dose will increase the risk of the virus mutating to evade vaccines.

The shortfall in COVAX supplies means that many people aren’t getting the second dose within the planned window. So this delay is happening whether it is desirable or not.

Another way to use doses more efficiently would be to give only one dose to people who have previously been infected, as studies show this provides substantial protection. This is impractical, though, as it would involve providing antibody tests to detect prior infection.

There have been some positive steps forward. First, the US recently gave its backing to a proposed waiver of intellectual property rights for covid-19 vaccines (see “Would an IP waiver boost supplies?“). Although controversial, such a waiver could result in a boost to vaccine supplies in the long run.

Second, a few countries are starting to share vaccines. France recently became the first to donate doses from its domestic supply, providing an initial 100,000 doses to COVAX that the scheme allocated to Mauritania. Norway and New Zealand are donating doses that they had been allocated and paid for via COVAX back to the scheme. And as New Scientist went to press, President Joe Biden announced that the US will send at least 20 million covid-19 vaccine doses abroad by the end of June.

“Given the limited supply environment in the near term, doses donated from countries with excess supply… will be an important part of the solution for getting rapid, equitable access globally,” said a spokesperson for Gavi, one of the organisations behind COVAX.

Finally, there is growing evidence that several of the vaccines are much more effective than we hoped – so much so that Flahault thinks the international community should start talking about whether we could eradicate the SARS-CoV-2 virus in the same way as smallpox, which was officially eradicated in 1980 through vaccination alone.

“I am in favour of opening discussions at an international level regarding the possibility of eradication,” he says. “I am not entirely sure eradication is achievable for covid but maybe it is.”

However, in the short term, things could get worse before they get better, warns Udayakumar. More dangerous variants are emerging, much of the world has reached pandemic fatigue, there are more and more humanitarian crises and we have yet to produce enough vaccine to meet global needs. “I think it is a very dangerous period of time over the coming months,” he says.

How is COVAX distributing vaccines?

Countries followed two main routes to get hold of vaccines. Some dealt directly with vaccine companies. Others signed up to a global initiative to fairly distribute vaccines, called COVAX. Some are doing both.

Countries that can afford it pay COVAX for the doses they get via the scheme, while others get them free, funded by donations. Broadly, higher-income countries buy vaccines while lower-income countries rely on COVAX.

There are some exceptions. South Korea initially relied on COVAX, choosing to wait its turn. But after public criticism, it started buying vaccines directly.

The initial aim of COVAX is to ensure first 3 per cent, then 20 per cent, of everyone in the world gets vaccinated, a proportion that will cover the most vulnerable. The World Health Organization (WHO) wanted higher-income countries to start sharing doses once they reached the 20 per cent threshold, but this hasn’t happened.

COVAX allocates doses in proportion to each country’s population size. However, most haven’t yet been allocated enough to cover even a tenth of their populations, with just a few, such as Tuvalu – population 12,000 – getting up to 44 per 100 people.

Actual deliveries are even scarcer. As of 10 May, COVAX had shipped just 58 million doses to 122 countries. It had hoped to ship 240 million by the end of May. A halt to vaccine exports by India amid its second wave of infections has contributed significantly to the delay.

Of the 78 countries for which figures are available, Tuvalu is the only one to get all its allocated doses. Only six countries have received enough doses to fully vaccinate 3 per cent of their population.

Higher-income countries aren’t donating funds either. On 3 May, the WHO said the initiative that includes COVAX has a $19 billion shortfall.

Would an IP waiver boost supplies?

“These extraordinary times… call for extraordinary measures,” tweeted US trade representative Katherine Tai, as she threw the country’s backing behind a waiver of intellectual property rights for covid-19 vaccines.

The announcement earlier this month turbocharged an idea pushed by India, South Africa and many campaigners… that lifting IP protections on covid-19 vaccines would boost supplies by allowing the vaccines to be made in greater numbers, in more countries.

There has, however, already been strong opposition to the idea. “IP rights weren’t the practical problem to scaling up global vaccine production,” said the UK Bioindustry Association in a statement. The trade body’s members include Pfizer and AstraZeneca.

The response is unsurprising. A World Health Organization-backed plan to scale up vaccine supplies, the Covid-19 Technology Access Pool (C-TAP), was launched a year ago. Companies were encouraged to waive IP on core products and share knowledge to help other firms produce vaccines. It was roundly snubbed by vaccine manufacturers.

Arguments against a waiver include the suggestion that it wouldn’t disclose enough information for other firms to make the product, that there aren’t enough manufacturing facilities or raw materials, and that quality assurance would be difficult. “It won’t result in manufacturing vaccines faster in the following months,” says Zoltán Kis at Imperial College London. “[But] it might lead to producing more vaccines in a year’s time.”

If a waiver is agreed, the impact looks distant. In the short term, the US government’s stance has made C-TAP, in which manufacturers may have been able to set some of the terms for how they share their IP, look like a much more attractive prospect. Adam Vaughan