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Global inequality in vaccination against COVID-19 is more than a moral issue

Months before the first COVID-19 vaccine was approved, rich nations struggled to get hundreds of millions of advance doses for their citizens. By the end of 2020, Canada had purchased 338 million doses, enough to inoculate its population four times. The UK was hooked enough to cover a population three times its size. The United States has reserved more than 1.2 billion doses and has already vaccinated about 14 percent of its residents.

It’s a drastically different story for less wealthy nations. More than 200 have not yet administered a single dose. Only 55 doses were administered among the 29 lowest-income countries, all in Guinea. Only a few countries in sub-Saharan Africa have initiated systematic immunization programs.

“The world is on the brink of catastrophic moral failure and the price of this failure will be paid with the lives and livelihoods of the world’s poorest countries,” Tedros Adhanom Ghebreyesus, director of the World Health Organization, recently said.

COVAX, an international initiative tasked with ensuring more equitable access to COVID-19 vaccines, aims to address this imbalance by obtaining offers that ship free to low-income countries. Despite new promises of support from some of the richest nations, COVAX is slowly starting. His first shipment of 600,000 shots was sent on February 24 to Ghana. COVAX still needs nearly $ 23 billion to meet its goal of vaccinating 20 percent of participating countries by the end of the year.

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Such strong inequalities not only raise moral issues of equity. With the demand for vaccines still far outstripping supply, uneven distribution could also prolong the pandemic, fuel the evolution of new potentially evasive variants, and drag the economies of rich, poor, and vaccinated and unvaccinated nations.

“I think the leaders of rich nations have done a very poor job explaining to their citizens why it is so important that vaccines are distributed around the world and not just within their own nation,” says Gavin Yamey, a health policy expert. world public at Duke University. "No one is safe until we're all safe, because an outbreak anywhere can turn into an outbreak everywhere."

Vaccine inequality could lead to variants that prevent vaccines

Therefore, a new outbreak of coronavirus anywhere can turn into an outbreak everywhere: viruses mutate.

It is normal and occurs by chance when a virus replicates within a host. Most mutations are harmless or harmful to the virus. But every once in a while, a small genetic modification causes the virus to infect guests or dodge their immune response. The more a virus spreads, the more chance a (or more likely a handful) of these settings can have to generate a new, more threatening strain.

This is already happening. In December, scientists detected a new variant, nicknamed B.1.1.7 in the UK. It soon became clear that he had acquired mutations that made him more infectious (SN: 27/01/21). In a few months, that variant went around the world, appearing in more than 70 countries, including the United States.

Another variant first detected in South Africa is also more transmissible and appears to be slightly less affected by existing vaccines (SN: 27/01/21). It has also spread all over the world. Variants detected in California and New York are now also of concern. As widespread viral transmission continues, new variants will emerge.

“It’s not safe right now if we have to continually pursue this virus and develop more vaccines,” says William Moss, executive director of the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health.

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The more the virus reproduces, the more chance it has of evolving around existing vaccines or natural immune responses to older variants, Moss says. Large pockets of unvaccinated people can serve as incubators for new variants. The longer these pockets persist, the greater the chance that the variants will accumulate changes that will make them increasingly resistant to vaccines. Finally, these variants could invade well-vaccinated countries that are believed to be safe.

Hardly vaccinated populations can be especially fertile grounds for vaccine-avoiding variants, says Abraar Karan, an internal medicine physician at Harvard Medical School and Brigham Women’s Hospital in Boston. In a vaccinated individual, mutations that even slightly evade that induced immune response may have a fulcrum. Unless that variant completely eludes vaccines, which is unlikely, its spread will be overwhelmed by a well-vaccinated population. But if most of one region remains completely naive in the face of infection, that new variant could burn rapidly through the largely unvaccinated population, fueling the spread of the changed virus to other regions.

In Israel, where cases have fallen after more than 40 percent of the population received at least one dose of vaccine, the health ministry has reported at least three cases of reinfection by the South African variant in unvaccinated people. That is a very small but indicative sample of the threat posed by unequal vaccination rates globally.

“If we want to stop the spread we have to stop it everywhere, starting with the most vulnerable,” Karan says. "Otherwise, we will see continuous outbreaks and suffering."

In areas where coronavirus transmission increases, restrictions may be imposed on companies to curb the spread. Because international demand is driving the global economy, stops like these will slow the global recovery, experts say.Ian Forsyth / Getty Images

"No economy is an island"

Protecting people from the sick is obviously a major driver of the vaccine rush in rich nations, many of which have been heavily affected by the virus. Vaccines are also seen as a way out of the world’s biggest economic recession since World War II, down about 4.4 percent. But an uneven distribution of vaccines could jeopardize a robust and rapid recovery, experts say.

If prolonged outbreaks, blockages, disease and deaths continue to occur in countries with less access to vaccines, all economies will suffer, says Selva Demiralp, an economist at Istanbul’s Koç University. "No economy is an island," he says, "and no economy will fully recover unless others recover."

Extreme vaccine inequality could cost the world economy more than $ 9 trillion by 2021, about half of which would come from rich nations, Demiralp and colleagues reported on Jan. 25 in an article published by the National Bureau of Economic Research. In that scenario, rich nations largely vaccinate their populations in the middle of the year, but leave out the poorest nations.

Everyone gets success thanks to the interconnection of the global economy. The production process for building a Volkswagen or an iPhone, for example, spans continents. Interruptions to a link in that supply chain, for example, steelmaking in Turkey, are proliferating. Today’s market is also global: declining demand for goods in countries with coronavirus restrictions will affect the end result of companies based in rich nations. “As infections increase in a country, both supply and demand may decrease,” Demiralp says.

She and her colleagues estimated these virus-induced supply and demand fluctuations by combining a statistical model of how the coronavirus spreads with large amounts of economic data in 35 sectors in 65 countries. By adjusting the pace and extent of vaccination, the team estimated the total costs for each country under different scenarios. The $ 9 trillion figure represents extreme inequality. But the less extreme gaps are still very expensive.

If rich countries vaccinate their entire population in four months, while lower-income countries vaccinate half their population by the end of 2021, the world’s gross domestic product this year will fall by 1.8 to 3.8 trillion. dollars, and rich countries will lose about half, the team calculated.

Those costs could be avoided with a much smaller investment, in the order of tens to hundreds of billions of dollars, in the distribution of vaccines worldwide. “You don’t do anything,” Demiralp says. "It's not an act of charity. It's economic rationality."

At night the playing field

COVAX is trying to match the vaccine playing field, but so far it has had limited success. There are many obstacles, from getting low doses to ensuring that countries have the infrastructure to handle them. This could mean equipping some countries with more ultracold refrigerators to store vaccines (SN: 20/11/20) to renew mass vaccination programs designed for children to work for adults as well. “Equitable distribution will take much more than protecting vaccines,” says Angela Shen, a public health expert at the Philadelphia Children’s Hospital Vaccine Education Center.

Three global public health powers lead the international initiative: the Global Alliance for Vaccines and Immunization, the World Health Organization, and the Coalition for Epidemic Preparedness Innovations. COVAX uses funds from governments and charities to buy doses from pharmaceutical companies and distribute them free of charge to lower-income countries.

For starters, COVAX plans to distribute 330 million doses to lower-income countries in the first half of the year, enough to vaccinate, on average, 3.3 percent of each population. Meanwhile, in June, many rich nations will be well on their way to vaccinating most of their populations.

That said, COVAX says it has reserved 2.278 billion doses so far, enough to vaccinate 20 percent of the populations of 92 low-income countries by the end of the year. Really meeting that goal is subject to raising $ 37 billion, and COVAX isn’t even halfway there. On February 19, several countries, including the United States and Germany, pledged an additional $ 4.3 billion to the effort. Still, COVAX has nearly $ 23 billion.

“Money is not the only challenge we face,” Ghebreyesus of the WHO said in a Feb. 22 news release. Agreements between rich nations and pharmaceutical companies threaten to fatten the global supply of vaccines, reducing COVAX access. "If there are no vaccines to buy, the money doesn't matter."

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People who get vaccinated, in any country, are something to celebrate, says Yamey of Duke University, "but it should upset us to know that low-risk people are going to be vaccinated in rich countries long before high-risk countries poor. " A more equitable implementation, Yamey says, would give priority to health workers and vulnerable people in all countries. "Unfortunately, I don't see this happening in any scenario."

Even if COVAX achieves its goal this year, these countries will be far from reaching herd immunity, the threshold at which there are enough people immune to a pathogen to curb its spread (SN: 24/03/20). Estimates to achieve that herd immunity range from 60 to 90 percent of the population.

“Many low-income nations will not have widespread vaccination until 2023 or 2024, because they can’t get the doses,” Yamey says. "This inequality is due to the hoarding of doses by rich nations and that approach, first me alone, goes against their long-term interests."

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