How will countries which produce a viable vaccine decide on global allocations of their vaccine? Could we be about to witness ‘vaccine nationalism’?

 

The virus once described by some leaders as a hoax, with symptoms of just a few sniffles that would soon magically disappear, has now infected 17 million people across the world and caused 700,000 deaths, probably more by the time you read this. After nearly seven months of death and economic disruption wrought by the pandemic, the world is anxiously awaiting a glimmer of hope for a return to the normal, which partly explains the continued frenzy over vaccine development.

A typical vaccine can take years to get off the ground, as it must be proved to be safe and effective first in animal studies, then in small trials in healthy volunteers, and finally in large trials in representative groups of people, including the elderly, the sick and the young. Vaccine candidates being designed and developed for this pandemic are moving ahead at a pace never seen before, from the lab to human trials in a record-setting 63 days! So perhaps now is the time to pose the questions: “When will we know one is good and safe enough to use, and how will it be distributed?”

In America, where there have been more than 4 million contracting Covid-19 and 150,000 deaths, last Monday 30,000 people in 89 sites around the country were rolling up their sleeves to receive an experimental vaccine. This was the third and final-stage testing of a new vaccine, called mRNA the first of its kind, developed by the US National Institute of Health in partnership with the Boston-based biotech company Moderna. On Wednesday, the company issued the good news that mRNA, a two-dose vaccination, had led to a “robust immune response and protection against Covid-19 in non-human primates” and that it is “working to accelerate the development of its vaccine pipeline”.

At the same time, 5,000 volunteers in Brazil were taking part in clinical trials of another candidate, a single dose vaccine called ChAdOx1, made from a genetically engineered virus, which causes the common cold in chimpanzees. This is being developed by Oxford University’s Jenner Group in collaboration with the biopharmaceutical company AstraZeneca. Remarkably, phases one and two of this clinical trial took place in southern England as early as April, only three months after China released the genetic sequence of the new virus. These trials checked the safety and immune responses in 1,077 healthy volunteers between the ages of 18 and 55, and were reported last week as “hugely promising”, showing that the vaccine created antibodies and T-cells that can fight coronavirus.

Brazil was earlier chosen as an important proving ground for the next phase of this vaccine candidate because of the sheer number of potential candidates, as the virus roars through the country. The Oxford/AstraZeneca team plan to complete the clinical study of ChAdOx1 using 50,000 volunteers in UK, US and South Africa and, assuming the vaccine is effective, will submit it for an initial registration with the UK’s Medicines and Healthcare products Regulatory Agency by the end of the year.

These are just 2 of a list of 25 candidate vaccines in clinical evaluation and 139 in pre-clinical evaluation, listed on the World Health Authority’s website last week, an astonishing number as the world races to find a solution to the catastrophic outbreak.

In normal times, developers are wary of settling on the first vaccine that comes to fruition. After all, one may come along which is far more effective, making their early move redundant and a waste of resources. It’s a delicate balancing act between risk and speed. Scaling up production is hugely expensive and if the wrong candidate is chosen, the cost to a company could be crippling. Obtaining timely approvals for these novel vaccines will also be challenging, even for rich countries with experienced regulators, all of which suggests that the manufacture of Covid-19 vaccines will be limited to a handful of countries.

Although a major issue, scaling up and roll-out judgements are tiny by comparison with decisions soon to be faced by governments. How will countries which produce a viable vaccine decide on global allocations of their vaccine? Could we be about to witness “vaccine nationalism”?

This concern was recognised as early as June this year when the UN Secretary General held an on-line forum. “A vaccine by itself is not enough,” said Antonio Guterres, “we need global solidarity to ensure that every person, everywhere has access”. French President Emmanuel Macron and Chinese President Xi Jinping both agreed that vaccines must be available to all.

But will this actually happen? Will words turn into deeds? Imagine the leader of a country holding 60 million vaccines to protect its desperate 60 million citizens declaring that only half will be vaccinated, as the other 30 million vaccines will be sent to other countries in need. Really? For as long as global supplies of Covid-19 vaccines remain limited, and this could be many months if not years, we are likely to witness vaccine nationalism. Recall that in the early months of the pandemic, in the face of global shortages, China, France, Germany, the European Union and finally the US hoarded supplies of respirators, surgical masks and gloves for their own hospital workers. Overall, more than 70 countries imposed export controls on local supplies of personal protective equipment, ventilators or medicines during the first four months of the pandemic. Notably, this group includes most countries where potential Covid-19 vaccines are being manufactured.

In the US, the Trump administration has devoted nearly $10bn to Operation Warp Speed, a programme designed to deliver hundreds of millions of vaccines by January 2021—but only to Americans. If you want further evidence of “America First”, recall that in early summer the Trump administration bought up virtually all the supplies of Remdesivir, one of the first drugs proven to work against Covid-19, leaving none for the rest of the world for many months.

The one exception has been Adar Poonawalla, the CEO of Serum Institute of India, the world’s largest producer of vaccines. In an interview in July, Poonawalla confirmed that by arrangement with AstraZeneca, the company will be making 1bn doses of the Oxford vaccine, which they are calling Covishield, over the next year for India and other low-and-middle-income-countries. He confirmed that the price will be kept to below Rs 1,000, which compares favourably with $50-$60 per course for the Moderna vaccine.

Serum’s announcement is to be applauded for its philanthropy, but will it actually carry out its promise to provide other countries with Covishield when the virus continues to rampage through India? Will Prime Minister Narendra Modi countenance additional deaths of his countrymen in order to save those of other countries? This is a “prisoner’s dilemma” paradox and there are plenty of sceptics around who say he will put India first.

The world is three or four months away from the arrival of the first proven vaccine, just sufficient time for leaders of vaccine-producing countries to hammer out some form of global equitable distribution. Vaccine nationalism is not just morally and ethically reprehensible, it’s in every country’s health and economic interests to suppress the transmission of a virus that respects no borders and which will be with us for many years to come.

John Dobson is a former British diplomat and worked in UK Prime Minister John Major’s office between 1995 and 1998.