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Access to and equitable distribution of COVID-19 vaccine

in low-income countries
Krishna Prasad Acharya1 ✉, Tirth Raj Ghimire 2✉
and Supram Hosuru Subramanya 3

npj Vaccines (2021)6:54 ; https://doi.org/10.1038/s41541-021-00323-6

The ongoing Coronavirus Disease 2019 (COVID-19) pandemic jobs, a loss of trade, and has dwindled the already weak national
caused by SARS-CoV-2 still poses significant health challenges economies in the LICs. In this situation, equitable access to a
globally. The Harvard group’s models predict that a resurgence of suitable and effective vaccine, especially for the front-line workers,
SARS-CoV-2 could occur as late as 2024 after a period of apparent is critical for mitigating and maintaining public health systems and
elimination, if the duration of immunity is intermediate and if other economic growth. That is why the demand for COVID-19 vaccines
corona viruses induce intermediate cross-immunity1. Among more has been soaring, although supply has been limited. Many
than 60 vaccine candidates in clinical trials, currently, only the underlying causes of vaccine inequity exist in the LICs, which we
Pfizer-BioNTech, Moderna COVID-19, and Johnson & Johnson now discuss in turn.
COVID-19 vaccines have received Emergency Use Authorization First, many LICs have low socio-economic status with low levels of
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(EUA) for active immunization to prevent COVID-19 from the US education, income, and occupation. These factors may directly affect
Food and Drug Administration (FDA)2–4. The Oxford-AstraZeneca the vaccine-purchasing and accepting processes of their people.
COVID-19 vaccine has additionally received approval in the Second, the geographical landscape of many LICs poses a significant
European countries, India, Argentina, Mexico, Brazil, Pakistan, Nepal, challenge to vaccine distribution. Many high altitudinal landscapes
and others5. For emergency use, other vaccines like Sputnik V, within Hindu-Kush Himalayan regions, such as Nepal, Bhutan,
BBIBP-CorV, CoronaVac, Ad5-nCoV, EpiVacCorona, and BBV152 have Pakistan, and Afghanistan, make it very difficult for the vaccine
been approved in many countries in the world6. The approval of the campaigners and staff to distribute vaccines. The difficult situation
vaccines has created some degree of confidence, and many might be worsened in the desert and remote areas engulfed in war,
countries have begun administering them. However, the accessi- instability, and conflict. In this context, more than 160 million people
bility of the vaccines to low-income countries (LICs) may be have been estimated to be at risk of inaccessibility of the COVID-19
hindered, and thus, many concerned authorities have been vaccine in Yemen, Syria, South Sudan, and Ethiopia11.
questioned. It is because most of the vaccines have been reported Third, people from urban slums and marginalized and migratory
to be reserved by wealthy nations6,7. These issues are extensively populations have poor access to immunization facilities. Vaccine
reviewed by the Lancet Commission on COVID-19 Vaccines and distribution is challenging in urban and peri-urban slums that are
Therapeutics Task Force Members8. overgrowing in developing countries. Fourth, most of the available
As of February 19, 2021, about 90 countries had access to at
COVID-19 vaccines need to be transported and stored at refrigerat-
least one COVID-19 vaccine. Gibraltar and Israel had more than 78
ing to freezing temperatures, for example, the Oxford-AstraZeneca
cumulative COVID-19 vaccination doses administered per 100
COVID-19 vaccine at 2–8 °C and the Pfizer vaccine at −70 °C,
people in this context. Compared to this, Cambodia, Pakistan,
Mauritius, Albania, Ecuador, Guyana, and Bolivia had less than 0.1 although new stability data submitted by the companies to the US
doses administered6. Until this period, ten countries that account regulator show that the latter vaccine can be stored at temperatures
for 60% of the global gross domestic product had administered of −15 to −25 °C for up to 2 weeks12. Even to protect their quality,
75% of all COVID-19 vaccines9. Dr. Tedros Adhanom Ghebreyesus, care is still needed after transferring these vaccines to the
the WHO Director-General, and Henrietta Fore, UNICEF Executive refrigerator or following thawing. Strict regulations for temperature
Director, have pointed out that there are 130 countries, with a total are critical for the maintenance of efficacy, potency, and stability of
population of 2.5 billion, that are yet to administer a single dose10. vaccines. These are significant challenges in LICs due to a shortage
It is a pity that expert health workers are dying in sub-Saharan of cold chain infrastructures and a lack of advanced technology to
Africa9, indicating an international moral failure in these regions monitor the cold chain for storage, distribution, and transportation
although six hundred thousand doses of the AstraZeneca-Oxford of vaccines, especially in the rural regions13–15. It could result in low
vaccine, produced by the Serum Institute of India have recently immunization coverage in these areas and, subsequently, the
reached in Ghana. In summary, most countries in Africa and a few probable endemicity of COVID-19 infections.
in Asia and South America are in the risk groups for vaccine Fifth, levels of vaccine hesitancy, fear, and confusion have been
inaccessibility. Antonio Guterres, the Chief of the United Nations raised in many countries because of the range of data from efficacy
(UN), has stated that progress on COVID-19 vaccinations has been trials for the same product. For example, the Sinovac, a Chinese
wildly uneven and unfair (https://twitter.com/antonioguterres). company, showed 50–91% efficacy16,17. Also, there is the apparent
Scientists believe that this uneven pattern of inoculations could doubt whether the vaccines that have been designed and
also lead to virus mutations and new vaccine-resistant variants. developed by the researchers following one year of the experiment
The COVID-19 pandemic has resulted in the deaths and severe will work against new variants of the virus. In this context, it is not
illness of many people and the disruption of normal lives, a loss of easy for a developing nation to decide to spend a considerable

1
Animal Quarantine Office, Budhanilkantha, Kathmandu, Nepal. 2Animal Research Laboratory, Faculty of Science, Nepal Academy of Science and Technology (NAST), Khumaltar,
Lalitpur, Nepal. 3Manipal College of Medical Sciences, Pokhara, Nepal. ✉email: [email protected]; [email protected]

Published in partnership with the Sealy Institute for Vaccine Sciences

 K.P. Acharya et al.
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amount of money to purchase the old vaccines or wait for other 2. WHO. Draft landscape and tracker of COVID-19 candidate vaccines. https://www.
future products that would work against new variants. who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines
Finally, obtaining intellectual property (IP) of COVID-19 vaccines by (2020).
the developing countries from vaccine developers has not been 3. Joffe, S. Evaluating SARS-CoV-2 vaccines after emergency use authorization or
licensing of initial candidate vaccines. JAMA 325, 221–222 (2020).
entirely successful yet18. Although competitions may exist between
4. New Brunswick. Johnson & Johnson COVID-19 Vaccine Authorized by U.S. FDA For
many pharmaceutical companies, they are welcoming any interested Emergency Use - First Single-Shot Vaccine in Fight Against Global Pandemic. https://
company and country to license their intellectual property for COVID- www.jnj.com/johnson-johnson-covid-19-vaccine-authorized-by-u-s-fda-for-
19 vaccines. It has assured that vaccines should be global public emergency-usefirst-single-shot-vaccine-in-fight-against-global-pandemic (2021).
innovations. Based on this principle, Moderna announced that it 5. The New York Times. India Approves Oxford-AstraZeneca Covid-19 Vaccine and 1
allows open access to the relevant IP for the pandemic period and is Other. https://www.nytimes.com/2021/01/03/world/asia/india-covid-19-vaccine.html
planning to out-license the IP during the post-pandemic period19. (2020).
Notably, unrestricted access to IP of COVID-19 vaccine has been a 6. Hannah, R., Macdonald, B., Giattino, C. & Roser, M. Coronavirus (COVID-19) Vac-
boon for few countries like India, the Republic of Korea, Brazil, cinations—-statistics and research. Ourworldindata https://ourworldindata.org/
covid-vaccinations (2021).
Indonesia, and South Africa, which have already started producing
7. Dyer, O. Covid-19: Many poor countries will see almost no vaccine next year, aid
vaccines. However, LICs cannot easily take advantage of this due to groups warn. BMJ 371, m4809 (2020).
their lack of domestic vaccine manufacturing capacity and thus rely 8. Figueroa, J. P. et al. Urgent needs of low-income and middle-income countries for
on rich countries or their vaccine-developing companies. Most LICs COVID-19 vaccines and therapeutics. Lancet 397, 562–564 (2021).
lack vaccine-producing resources like policy, planning, programs, 9. Kupferschmidt, K. Unprotected African health workers die as rich countries buy
vaccinologists, organized laboratories, industries, Research & Devel- up COVID-19 vaccines. Science https://doi.org/10.1126/science.abh1288 (2021).
opments, and government funding. Thus, even if a license is given to 10. VOA News. WHO, UNICEF Say 130 Countries Yet to Administer Any COVID-19 Vaccine.
these countries, it will not solve vaccine production problems. https://www.voanews.com/covid-19-pandemic/who-unicef-say-130-countries-yet-
Currently, rich countries have been blamed for the underlying administer-any-covid-19-vaccine (2021).
11. Margaret, B. Britain to Push for COVID-19 Cease-fires to Get Vaccine to Conflict Zones.
unequal distribution of COVID-19 vaccines around the globe. That
https://www.voanews.com/covid-19-pandemic/britain-push-covid-19-cease-fires-
may not be entirely true. These countries have contributed their get-vaccine-conflict-zones (2021).
efforts in resources and funding, and partnership with other 12. The Irish Times. Pfizer vaccine no longer needs to be stored at ultra-low tempera-
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countries. For example, the activities of the US toward the COVID- tures. https://www.irishtimes.com/news/health/pfizer-vaccine-no-longer-needs-
19 Vaccine Global Access (COVAX) facility, co-led by the Global to-be-stored-at-ultra-low-temperatures-data-1.4489678 (2021).
Alliance for Vaccines and Immunisation (GAVI), the Coalition for 13. Guignard, A., Praet, N., Jusot, V., Bakker, M. & Baril, L. Introducing new vaccines in
Epidemic Preparedness Innovations (CEPI), and WHO are crucial. low- and middle-income countries: challenges and approaches. Expert Rev. Vac-
Although Trump’s government withdrew from WHO in July 2020, cines 18, 119–131 (2019).
accusing it of being a puppet of China during the COVID-19 14. Songane, M. Challenges for nationwide vaccine delivery in African countries. Int.
J. Heal. Econ. Manag. 18, 197–219 (2018).
pandemic, the Biden Government is currently planning to join
15. KC, A. et al. Increased immunization coverage addresses the equity gap in Nepal.
COVAX and rejoin the WHO. COVAX is working for quick, fair, safe, Bull. World Health Organ. 95, 261–269 (2017).
and global equitable access to COVID-19 vaccines, and thus, it is 16. Reuters. Sinopharm’s COVID-19 vaccine 79% effective, seeks approval in China.
one of the best options for LICs to combat the pandemic. COVAX https://www.reuters.com/article/health-coronavirus-china-vaccine-int-
aims to vaccinate at least 20% of the people in 92 LICs of Africa, idUSKBN2940CA (2021).
Asia, and Latin America by the end of 2021 as a first step20. 17. BBC. Sinovac: Brazil results show Chinese vaccine 50.4% effectivefunction translate.
Although affluent COVAX participants are criticized for stockpiling https://www.bbc.com/news/world-latin-america-55642648 (2021).
vaccines for themselves, COVAX might be proved a boon for the 18. CNBC. Countries look to acquire the IP of vaccine makers to fight pandemic. https://
LICs if such confusion and criticism are removed. www.cnbc.com/2021/01/22/countries-look-to-acquire-the-ip-of-vaccine-makers-
to-fight-pandemic.html (2021).
Lessons on how a developed country can facilitate vaccine equity
19. MODERNA. Statement by Modern on Intellectual Property during the COVID-19
can be learned from the example of the UK. The UK ideally and Pandemic. https://investors.modernatx.com/news-releases/news-release-details/
practically has been ready to work for equitable global access to the statement-moderna-intellectual-property-matters-during-covid-19/ (2020).
COVID-19 vaccine11 by negotiating for temporary cease-fires in 20. WHO. COVAX announces new agreement, plans for first deliveries. https://www.
affected countries and facilitating distributing the vaccines for the who.int/news/item/22-01-2021-covax-announces-new-agreement-plans-for-first-
people in those warzones. In a speech to a virtual G7 meeting, Borris deliveries (2021).
Johnson, the UK Prime Minister, pledged to provide most of the 21. BBC News. Covid vaccines: Boris Johnson pledges surplus to poorer countries at G7.
excess doses of vaccine in the UK to distribute to poor countries21, https://www.bbc.com/news/uk-politics-56117120 (2021).
which is a praiseworthy initiation by the world leader in fight against 22. WHO. 172 countries and multiple candidate vaccines engaged in COVID-19 vaccine
Global Access Facility. WHO. https://www.who.int/news/item/24-08-2020-172-
COVID-19 pandemic. In conclusion, the availability of the vaccine for
countries-and-multiple-candidate-vaccines-engaged-in-covid-19-vaccine-global-
LICs under the COVAX program22 and government efforts will play access-facility (2020).
an essential role in achieving global immunity to stop the
transmission of the virus. But the LICs should also receive support
from high-income countries, private partners, UNICEF, GAVI, WHO, AUTHOR CONTRIBUTIONS
and other global humane organizations to have equitable access to All authors contributed equally.
the COVID-19, so there can be vaccines for all.
COMPETING INTERESTS
Received: 3 February 2021; Accepted: 16 March 2021; The authors declare no competing interests.

ADDITIONAL INFORMATION
REFERENCES Correspondence and requests for materials should be addressed to K.P.A. or T.R.G.
1. Kissler, S. M., Tedijanto, C., Goldstein, E., Grad, Y. H. & Lipsitch, M. Projecting the
transmission dynamics of SARS-CoV-2 through the postpandemic period. Science Reprints and permission information is available at http://www.nature.com/
368, 860–868 (2020). reprints

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