Vaccine Readiness

Background

What Do We Know about Vaccines for COVID-19?

Ending the COVID-19 pandemic will require a large share of the world to gain optimal immunity to the novel coronavirus SARS-CoV-2, the virus that causes COVID-19. The safest way to achieve this is with a vaccine.¹ Vaccines typically require years of research and testing before administration to target populations, but in 2020, scientists embarked on a race to produce safe and effective COVID-19 vaccines in record time.² To expedite the development and distribution of a vaccine that protects against SARS-CoV-2, unprecedented international alliances were formed and billions of dollars were allocated. Consequently, the development and mass production of multiple safe and effective COVID-19 vaccines progressed faster than expected.³

In January 2020, researchers published the genetic sequence of the virus that causes COVID-19.⁵ Eleven months later, after completing large-scale clinical trials, the Pfizer-BioNTech vaccine was the first to be authorized for emergency use. As of the end of October 2021, there were 269 vaccines in development, 100 in clinical testing, and 25 in use in at least one country.^{5, 6} Only a select few of these candidates will eventually reach the market.

We reviewed the landscape of promising COVID-19 vaccines for use and found that the vaccines fell into different product categories, each of which had advantages and disadvantages. These vaccine platforms included protein subunit, nonreplicating viral vector, DNA-based, RNA-based, replicating viral vector, virus-like particle, inactivated virus, and live-attenuated vaccines.⁷ Furthermore, COVID-19 vaccines that were available varied with respect to price (US$2 to US$37 per dose), number of doses required (one to two), and storage requirements during transport (ranging from −70°C to 2°C to 8°C).^{6, 8}

To protect everyone around the world and to meet the needs of each country’s health system, we will require more than one type of vaccine.⁵ However, the simultaneous rollout of multiple kinds of vaccines does pose unique challenges for health systems around the world.

What Are the Challenges to Rolling Out COVID-19 Vaccines for LMICs?

Access to increased supplies of safe and effective vaccines, regardless of the type, is a critical step toward resuming prepandemic levels of mobility and economic activity around the world. However, though safe and effective COVID-19 vaccines were developed in record time, the novel coronavirus has been moving faster than the global distribution of vaccines.⁹

As of October 31, 2021, 49 percent of the world population has received at least one dose of a COVID-19 vaccine and 6.94 billion doses have been administered globally. However, only 3.1 percent of people in low-income countries have received at least one dose.¹ New variants of concern mean that the risks of infection are increased in all countries for people who are not yet protected by vaccination—disproportionately the world’s poorest and most vulnerable.

Procurement Challenges

Though people in high-income countries constituted just 14 percent of the global population, they represented the majority of those who were fully vaccinated against COVID-19.³ In large part, this was because even before vaccine candidates were approved for use, many high-income countries had purchased enough doses to vaccinate their populations several times over. Furthermore, in an effort to receive doses as quickly as possible, those countries have continued to procure more doses of approved vaccines. Because of global manufacturing constraints, this left fewer vaccines available for LMICs and for equity-focused partnerships like the COVID-19 Vaccines Global Access (COVAX) initiative.¹⁰

Adequate vaccine supply is a critical first step. While equitable-access mechanisms such as COVAX have been established to support vaccine supply in LMICs, modest initial targets have not been met. Vaccine inequity continues to be a challenge both between and within countries. Critical work is needed to ensure that vaccines reach their intended target groups.³

Delivery & Demand Challenges

Even with adequate supply, many factors can complicate vaccine rollouts in LMICs—including limited health and surveillance infrastructure, insufficient cold chain capacity and distribution mechanisms, and an under-resourced health workforce.^{11 ,12} Previous Exemplars in Global Health research has focused on the barriers to achieving high vaccination coverage in LMICs for routine vaccination primarily targeting children against diseases such as diphtheria, pertussis, polio, tetanus, measles, and tuberculosis. This research has emphasized the importance of building strong delivery systems, involving communities to create demand, and investing in human resources and infrastructure to sustain coverage despite changing contexts. Many of these lessons have applied to COVID-19 vaccination campaigns as well; however, targeting adults has come with a unique set of challenges.

Issues with COVID-19 vaccine confidence have been observed in countries across the globe, regardless of income level. Vaccine hesitancy can have many sources, including marginalization and social exclusion; negative experiences at health facilities; misinformation about vaccines, especially when circulated on unregulated social media platforms; and lack of trust in authorities and institutions.¹³ Lower levels of demand for COVID-19 vaccines have also been linked to use of new technologies (e.g., mRNA vaccines), the speed with which they were developed and approved, population histories with medical experimentation, prevalent and readily available misinformation, and false beliefs about COVID-19 itself.¹⁴ Additionally, the number of types of vaccines for COVID-19 has led to confusion, skepticism, and misinformation about which vaccines are better in some contexts.^{15 ,16}

While adequate vaccine supply continues to be the most pressing challenge for LMICs, public confidence and trust in COVID-19 vaccines and those who deliver them to ensure uptake are as important as the vaccines’ safety, efficacy, and affordability.⁸ The growing body of evidence on strategies to address vaccine hesitancy suggests that successful efforts require an understanding of regional, cultural, and economic factors; tailored communication and outreach strategies; trainings for health care professionals on vaccine hesitancy; and politicians and health authorities to refrain from politicizing vaccines.¹³

How Can LMICs Address These Challenges in Rolling Out COVID-19 Vaccines?

Procurement

COVAX seeks to de-risk the vaccine purchasing process for countries by investing in the development, manufacturing, and procurement of a wide portfolio of vaccines. Member countries, including 92 lower-income countries known as Advance Market Commitment or funded countries (which will receive some doses for free), buy in and receive vaccines that make it through the World Health Organization emergency approval process. Crucially, COVAX is supposed to guarantee that the vaccines countries purchase will be shared out at the same time, by population level.¹⁰

COVAX aims to provide around 2 billion doses by the end of 2021. However, it is far from achieving this goal.¹⁰ As of October 2021, just over 400 million doses had been shipped through the COVAX mechanism to 144 countries.⁶

With limited purchasing power, many middle-income countries used other strategies to secure doses as they began to roll off the production lines. Countries with manufacturing capacity, like India and Brazil, could negotiate advance market commitments with leading vaccine candidates. Countries without manufacturing or vaccine development capacity but with the infrastructure to host clinical trials, such as Peru, offered that infrastructure to vaccine manufacturers in exchange for deals to purchase some quantity of the finished product. Still others, such as Russia and China, had robust vaccine development programs and were among the first to put forward vaccine candidates and get local approvals.¹⁰

India continued to play a pivotal role in the manufacturing of COVID-19 vaccines. Though exports were suspended during the surge of cases in India in April 2021, the Serum Institute of India has manufactured most of Oxford University-AstraZeneca’s vaccines (under the Covishield name) for distribution to COVAX and LMICs. Likewise, efforts have been made to ramp up the production of COVID-19 vaccines on the African continent; as of September 2021, 12 COVID-19 vaccine-production facilities in six African countries were opened or in the pipeline.¹⁷

Beyond COVAX, multilateral coalitions, such the initiative led by the African Union and the Africa Centres for Disease Control and Prevention, have attempted to address the gap in supply by developing pooled procurement mechanisms and purchasing hundreds of millions of doses for African countries.¹⁰

Delivery & Demand Strategies

From an initial road map for prioritized use and fair allocation of vaccines to in-country readiness assessments and simulation exercises, the World Health Organization, UNICEF, Gavi, the Vaccine Alliance, and many other partners have worked together to support countries in the introduction and scale-up of COVID-19 vaccines. To guide ministries of health from vaccine procurement to administration, the World Health Organization developed the COVID-19 vaccine introduction readiness assessment tool. The tool was designed to assess program readiness to introduce COVID-19 vaccines, identify gaps and prioritize actions for enhanced readiness, and identify opportunities for financial support through the World Bank’s Health, Nutrition, and Population portfolio.¹⁸

The COVID-19 vaccine introduction readiness assessment tool measures readiness across ten areas and within these core areas, there are 50 qualitative and quantitative indicators.

1. Planning and coordination
2. Budgeting
3. Regulatory pathway
4. Prioritization, targeting, and COVID-19 surveillance
5. Service delivery
6. Training and supervision
7. Monitoring and evaluation
8. Vaccine, cold chain, logistics, and infrastructure
9. Safety surveillance
10. Demand generation and communication

In the context of limited supply, countries have taken a variety of approaches, including delaying the second dose and introducing heterologous vaccine schedules. Many LMICs have deployed a wide range of innovative strategies to effectively deliver vaccines—from the use of drones and digital tools for delivery to task shifting for community health workers and various cold chain innovations.

Vaccine Delivery Framework

Wouters et al. described four dimensions to an effective global immunization strategy against COVID-19: development and production, allocation, affordability, and deployment ⁸ While all of these components were relevant, this research focused on deployment. We explored key lessons from previous vaccination campaigns according to seven domains: planning and coordination, target groups and delivery strategies, logistics and supply, vaccination teams, vaccination monitoring and safety surveillance, community engagement and social mobilization, and vaccine confidence. These domains aligned with the Exemplars in Global Health vaccine delivery framework (see below), which we have used to understand the drivers of routine immunization.

Our Partners

This research was conducted by the UK Public Health Rapid Support Team (UK-PHRST). UK-PHRST is funded by UK aid from the Department of Health and Social Care. It is jointly run by the UK Health Security Agency and the London School of Hygiene & Tropical Medicine.

The views expressed in this publication are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health and Social Care.

The UK-PHRST is made up of scientists, researchers and public health experts who are ready to deploy within 48 hours to help respond to infectious disease outbreaks worldwide. UK-PHRST also supports low- and middle-income countries in investigating and building their own capacity for an improved and rapid national response to outbreaks. The UK-PHRST conducts rigorous research to improve epidemic preparedness and enhance our understanding of how best to tackle threats in the future.