COVID-19 vaccinations

COVID-19 and vaccine equity — outlook for 2022

In prior posts, I have written extensively on the issue of vaccine equity. In my view with the large ramp up of global production and increased production in multiple country locations, the key to equitable distribution going forward lies in improved fulfillment of contractual commitments, increased donations, and greatly increased efforts at improving the ability of low income and lower middle-income countries (as categorized by the World Bank) to handle increased vaccine supplies and other goods.

The U.S., EU and others have stepped up donations and made large commitments for donations in 2022. India, which was supposed to be a major source of vaccines for COVAX in 2021, has in recent months started to export vaccines again.

While the flow of vaccines and other medical goods has been significantly behind goal to low income and lower middle income countries in 2021, in recent months, the challenge has been helping those countries get people vaccinated with the increased supplies that are becoming available.

The WHO has issued emergency use authorization for more vaccines. The multilateral organizations — World Bank, IMF, WTO and WHO — have been working hard to coordinate developments among the organizations. There is agreement on working to achieve 70% vaccination of populations around the world by July 2022.

Data on global vaccinations compiled by Bloomberg as of December 30, 2021 (a.m.) reflect more than 9.11 billion vaccine doses having been administered globally to date — 118 shots for every 100 people worldwide. See Bloomberg, More than 9.11 Billion Shots Given: Covid-19 Tracker, updated December 30, 2021 at 6:37 AM EST, However, vaccination rates vary enormously with very low rates in many low income and some lower middle income countries. So 70% global vaccination targets should be achievable if challenges in 2022 remain similar to those faced in 2021 recognizing the many advances.

However, the omicron variant is sweeping the world with large increases in infections, though the early analysis suggests infections are resulting in less severe cases. In the United States, new infections were close to 500,000 on December 29 alone – an incredible increase in cases in the last several weeks. The same is happening in many European countries (for example, France recorded its first 200,000 infection day this week).

The new variant and the renewed restrictions being imposed by many countries complicate the picture for 2022. With larger numbers of infections, governments are evaluating how to keep economies functioning and what restrictions the public will accept after the long period of disruption during the last two years.

Early studies indicate that boosters can significantly improve the effectiveness of existing MRNA vaccines against the new variant. Of course, boosters for people will reduce the volume of vaccines that can be shipped to countries with low levels of vaccination.

Some countries are imposing vaccine mandates and limiting activities of those who refuse to get vaccinated. The hit to the global economy from renewed restrictions particularly for hard hit sectors like travel and entertainment is unknown at present.

As increasing numbers of people are quarantined after being infected or being in contact with such individuals, governments, hospitals and companies struggle to cover operating needs. Will this cause supply chain problems for vaccines and other medical goods and supplies?

So how well vaccine equity will develop in 2022 will depend on a number of unknowns: will the omicron variant result in production setbacks in the coming months, reducing the volume of vaccines that get produced? Will a number of the existing vaccines prove to be ineffective against the omicron variant? If so, how quickly can other vaccines be ramped up including all needed inputs? What implications are there for medical infrastructure in the countries with low current vaccination rates if different vaccines are needed than those presently available and readily usable in the countries?

The heads of the World Bank, IMF, World Trade Organization and World Health Organization released a joint statement on December 17, 2021. See WTO Press Release, International organizations discuss how to improve access to COVID vaccines, countermeasures, 22 December 2021, The joint statement identifies what the four organizations perceive as doable actions to improve vaccine equity.

Seventh Meeting of the Multilateral Leaders Task Force, December 17, 2021:
“’From Vaccines to Vaccinations’
“Joint Statement

“The heads of the International Monetary Fund, World Bank Group, World Health Organization, and World Trade Organization held high-level consultations with Gavi and UNICEF on December 17, 2021 aimed at increasing the use of COVID-19 vaccines and other critical medical countermeasures in low-income (LIC) and lower middle-income (LMIC) countries and supporting countries to be better prepared, resourced, and ready to roll out vaccines.

“We agreed on the urgency to accelerate vaccinations in LICs, where under 5% of the population is fully vaccinated, as well as in LMICs, where around 30% of the population is fully vaccinated. We agreed to work with countries to support and strengthen their national vaccination goals consistent with the global target to vaccinate 70% of the populations in all countries by mid-2022. The emergence of the Omicron variant underscores the vital need for fair and broad access to vaccines as well as testing, sequencing, and treatments to end the pandemic.

“Addressing vaccine inequity, particularly in LICs, requires increasing the supplies of vaccines to COVAX and AVAT, encouraging LICs and LMICs to purchase additional vaccine doses, and enhancing country readiness to deploy vaccines. Furthermore, to facilitate trade flows to support the manufacturing and distribution of vaccines and other COVID tools, export restrictions must be rolled back and trade-facilitating measures must be put in place. Fully funding the ACT-A Accelerator’s Financing Framework would play an important role in narrowing these gaps and reaching the global target.

“Some LICs and LMICs are facing serious challenges in vaccine deployment. Constraints related to storage, cold chain capacity, and trained vaccinators are exacerbated in some cases by doses arriving with short shelf lives and without adequate lead time and shortages in ancillary supplies (such as syringes, safety boxes, and dilutants), with challenges to plan and finance vaccination campaigns in a timely manner. As in wealthier countries, vaccine hesitancy is also an issue in some LICs and LMICs.

“To address such challenges, we call on governments that have already achieved high coverage to:

“o fulfill their donation pledges as quickly as possible to accelerate near-term deliveries to COVAX;

“o release manufacturers from contracts and options and implement delivery swaps, so they can prioritize supply to COVAX, AVAT, and low-coverage countries.”

We urge governments that have yet to achieve high vaccination coverage to:

“o contract additional doses immediately through AVAT, COVAX, or bilaterally;

“o establish in-country surge capacity to increase the rate of vaccine utilization as supplies increase; and

“o coordinate between health and finance authorities for making increased use of multilateral development banks’ resources that are readily available for both vaccine purchase and deployment.

“We call for better coordination among vaccine manufacturers, dose donating countries, COVAX, AVAT, and other partners to improve visibility on vaccine supply schedules and quality of supply for LICs and LMICs, to support country-level planning and preparedness for turning vaccines into vaccinations. Visibility on schedules along with adequate lead times and shelf lives of vaccines are critical for both equitable distribution as well as for recipient countries and their partners to prepare for in-country deployment. 

“Growing volumes of COVID-19 vaccines are forecast to arrive in LICs and LMICs in the coming months. Close coordination amongst all stakeholders will be crucial to help provide countries with the assistance and necessary resources to increase their capacity to administer those doses. In this regard, we welcome the recent appointment by UNICEF and WHO, in partnership with Gavi, of the Global Lead Coordinator for COVID Vaccine Country Readiness and Delivery, who will play an important key role in strengthening in-country vaccine deployment.”

The actions called for by the four organizations are reasonable and likely doable assuming existing vaccines are what is needed to address the current variants. However, I have raised in the past the desirability of understanding what has permitted some low income and lower middle-income countries to achieve significant vaccinations while some upper middle-income and high income countries are not achieving adequate levels of vaccination.

For example, Rwanda is one of 27 low income countries in the 2022 World Bank grouping. Yet Rwanda has achieved 99.3 vaccinations per 100 people as of data in the December 30 Bloomberg analysis. What actions permitted Rwanda to dramatically exceed the performance of other low income countries?

Similarly, amongst lower middle-income countries, many have achieved good vaccination rates in 2021. For example, Cambodia has achieved 183.9 vaccinations per 100 people, Mongolia 161.9/100 people, Bhutan 155/100 people, Sri Lanka 153.7/100 people, Vietnam 153.6/100 people, El Salvador 148/100 people, Morocco 141.2/100 people, Iran 139.6/100 people, nine other countries more than 100/100 people (Samoa, Nicaragua, Uzbekistan, Tunisia, India, Belize, Cape Verde, Indonesia and the Philippines) and four more who provided more than 80 vaccinations/100 people (Honduras, Timor-Leste, Bolivia and Laos). Why did so many lower middle-income countries achieve such levels of vaccinations versus other countries in the group?

In upper middle-income countries, Gabon has only gotten 27.2 vaccinations/100 people. A number of other countries in this group are similarly well below 80/100 people (a proxy for 40% vaccination of the population) — Namibia at 29.9; Equitorial Guinea at 33.3; Iraq at 36.2; Libya at 40.5; Jamaica at 44; Bosnia and Herzegovina at 47.1; South Africa at 47.5; Bulgaria at 53; and eight others (Armenia, St. Vincent and the Grenadines, St. Lucia, Guatemala, Lebanon, Moldova, Georgia and Grenada). Shouldn’t the international organizations be focused on all countries that are far below vaccination targets? What caused these countries to have such poor vaccination rates?

The Bahamas is the only high income country with a vaccination rate of less than 80/100 people (78.8) but there are other high income countries or islands with low rates of vaccination compared to other high income countries.

If the world is to achieve vaccine equity during 2022, all countries need to participate in achieving acceptable levels of vaccination. If problems differ among countries as to impediments to greater vaccinations, those problems need to be identified and addressed as well.

My compilation of data from the Bloomberg vaccine tracker of December 30 and an identification of which countries are classified in which income group by the World Bank is attached.