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How Equitable COVID-19 Vaccine Distribution Impacts Global Health

July 02, 2021

How can the distribution of COVID-19 vaccines across the globe be made more equitable? What are the consequences of not meeting that need? On June 16, 2021, Yale’s Department of Internal Medicine hosted an event on Clubhouse that sought to answer those and other questions.

The following experts participated in the panel discussion:

· Kaveh Khoshnood, PhD, MPH, associate professor of epidemiology (microbial diseases)

· Saad Omer, MD, MPH, PHD, director of the Institute for Global Health, and a professor of medicine in infectious diseases at Yale School of Medicine.

· Kristina Talbert-Slagle, PhD, assistant professor of general internal medicine

· Moderator Sheela Shenoi, MD, MPH, assistant professor of medicine (infectious diseases) and associate director of the Office of Global Health.

Below some highlights from the event. The conversation has been edited for brevity.

Sheela Shenoi: Vaccination has had a tremendous impact on addressing Covid-19 in the United States, while many other countries have struggled with vaccine rollout. COVAX, which is the organization that has been leading the global vaccine rollout and trying to make it equitable, was founded on the concept that no one is safe until we're all safe. And so I wanted to talk today about what this means for the world.

My first question: While the U.S. has achieved just about a 50% vaccination rate among adults, why have other countries struggled to roll out COVID-19 vaccines to their citizens? What challenges do these countries face?

Saad Omer: There are several issues. The big one is supply; there just isn't enough vaccine. There's also an issue of demand. The fact that India and Pakistan have opened up vaccination to everyone older than 18 is partially because the demand, even at a really low vaccination level, wasn't consistent. Just like in this country, we did not wait for everyone to get vaccinated in high-risk groups but went to the next group.

SS: What else besides vaccine supply is hindering rollout? Saad alluded to interest or demand. What about infrastructure? What infrastructure is needed to be able to deliver vaccines rapidly?

SO: This is the most ambitious adult immunization program in human history. We haven't done anything like this throughout the world. Also, very few countries, and some very few low- and middle-income countries, actually vaccinate adults on a routine basis. It's fairly unique to countries like the U.S. and other high-income countries where we, for example, have routine influenza vaccination for everyone So keeping that in mind, countries do not have the infrastructure to deliver vaccination to adults or a broad range of age groups. However, that is not the current bottleneck, because the supply is so short. As the supply improves, very quickly, both demand and infrastructure become problematic and countries will have really hard choices. In the face of variants, some of the more consistently successful vaccines have been mRNA vaccines, and they have more high-end storage requirements that you can ensure in a capital hospital, but not necessarily in a district hospital or a peripheral immunization center.

Kristina Talbert-Slagle: As supply increases, the next big challenge will be distributing that supply. And one lesson that I hope will be learned from this pandemic is that we not only need to distribute this vaccine, we not only have to build capacity in countries for developing their own vaccine and distributing it, we also need to invest in infrastructure in order to distribute any vaccine, medicine, and health supplies for the next pandemic.

SS: Thank you for that, Kristina. Completely agree that a much bigger investment in resources training, and capacity is needed. Going back to the supply issue, the Biden administration and the G7 have now promised an additional one billion doses. What do you all think about that? Will that be helpful in terms of the amount of doses and the timeline that they're offering?

SO: Helpful, yes. Sufficient, unfortunately, no. This is a substantive donation and can have an impact on the trajectory of mortality associated with this pandemic. However, it falls short of the current estimates that range from 3 to 5 billion doses in the next year.

We know that you need a lot more vaccine doses for a transmission interruption strategy, but if you deploy your vaccines wisely and in a targeted manner, meaning first to the highest risk groups, especially the elderly and older age groups, then you can have an impact on mortality way before you even interrupt transmission. That's what this country did.

What we are seeing is not just a reduction in infection, but a reduction in mortality. However, India and Pakistan have opened up vaccination to everyone older than 18. That gives you a perception of progress that now everyone is eligible, but the unit probability of a high-risk person to get a vaccine goes down, because everyone else is in the same line now. So in terms of vaccine equity, these billion doses have less bang for their buck if they're not deployed wisely. So the answer, again, is that these doses are significant but may not be sufficient.

KTS: Reducing mortality and severe infection is especially important in places where the health care system is less able to take care of patients who are severely infected. So in places where there are shortages of oxygen, where there aren't as many trained specialists, the key is to try to minimize the number of severe infections that would need the level of care the system is not equipped to provide.

SS: Thank you. So, I appreciate the gravity of the situation obviously, and the substantive offering and donation of vaccines that the Biden administration and the G7 now have offered, but clearly this is insufficient to meet the global demand and need. What are the consequences of not meeting that need? What does that mean for COVID-19 in our world right now?

SO: The infection doesn't wait for the vaccination delivery schedule. It proceeds the way it wants to proceed, and the only thing we can do is vaccinate a high number of people to change the trajectory. So there are a few conceivable scenarios, one being that we will see flare-ups like India, where you have really, really high rates of infection and then mortality. And now there's a flare-up happening in Uganda and in East Africa. And so the outbreak burns through various populations. There are two consequences. One is the likelihood of new variants emerging increases. Right now, our current vaccines are holding up against these newer variants including the Delta variant that initially was identified in India.

If you increase the likelihood of more variants emerging, you will eventually have a chink in your armor, and that's concerning. So it’s in our shared interest to make sure that there's vaccinations in other countries. The other part is the mortality in these places, which can be heartbreaking and substantial, while you’re on the path to becoming an endemic infection. There will still be enough people who are vulnerable for vaccination to be worthwhile into 2022, even if we don't do a good job. But during that period, some populations may enter an endemic phase rather than these exponential outbreak phases, but with a lot of tragedy.

Kaveh Khoshnood: Also, there is a lot of indirect consequence of COVID-19 as well, including a halt in routine vaccination of children for polio or measles in many countries. We've seen an increase in mental health issues, substance abuse, suicides, and interpersonal violence. So it is absolutely urgent to do all we can to bring this pandemic to a stop.

SS: There's definitely data already that's been generated showing the impact of COVID and diverting resources to fight COVID on other sectors of the health system. Tuberculosis, HIV, and malaria have all been affected. Data have shown that we've regressed 10 years already in terms of TB control globally.

SS: In terms of nationalism, some people in the U.S. want to focus on vaccinating our children first and prioritizing that versus helping people in other countries, because they see that as less important than over-vaccinating our own population. What are the facts behind that? Do we delay vaccinating children if we respond globally?

SO: People are generally supportive of the U.S. having an engaged role. The nationalism response was earlier on from the policymakers, more than the population. My perspective on vaccine equity, especially with children versus other populations, is that it is not a zero-sum game. We should think big. We should not be taking away a vaccine if it is warranted in a situation. But remember, the U.S. has the highest number of reported deaths in the world, and so having a cautious approach is not irrational. But it is not, as I said, a zero-sum game; we should be doing 20 times more to get vaccines for everyone.

KTS: I have three kids, two are vaccinated, one isn't. I don't love that, so I get it, but we also have to look at the whole world, the interconnectedness, the suffering that we've seen, the suffering that we know personally.

SS: How do we move forward? How do we make this rollout equitable? What is the appropriate or ethical way to think about this massive rollout? Saad, you alluded to a number of steps that can be taken.

SO: The approach should build on these 500 million doses from the U.S. and the additional doses from the G7 countries for a total of a billion doses, and make sure that there is a technology transfer as part of the solution. It should not be just U.S. manufacturing, although that will have to be a big part of the solution, because of its capacity and reliability.

But we should not forget that in the U.S. we just crossed 600,000 deaths yesterday, and there is a significant chunk of the population that is not taking the vaccine. So we shouldn't assume that other populations would be more "rational" in accepting this vaccine. I've been jumping up and down since March 2020, saying that we should be planning for a vaccine delivery strategy, and we should have been doing that since last year. Also, all initiatives should be coordinated with COVAX. Any country shouldn't be doing its own thing without coordination by COVAX and other entities.

KK: One of the things that worry me the most is vaccinating those who are impacted by humanitarian crises, whether it's war and civil conflict, or natural disasters. Helping them get vaccinated, I think is a very tough task. Many of those individuals are in low-, and middle-income countries with health systems that are often fragile or shattered, and some of the basic infrastructure like transportation and supply chain are hampered by security issues.

iI's not a small population, it's millions of people who've been impacted by various humanitarian crises. That is a group that I think is going to need far more attention. And although there'll be many challenges reaching out to them, it's certainly not impossible. Humanitarian organizations have been vaccinating children who are impacted by conflict.

And I'm not sure we talked about vaccine hesitancy and misinformation, which is not just a U.S. issue, it's a global issue. As vaccines become more available, we want to make sure that people are willing to take them.

Submitted by Jane E. Dee on July 02, 2021