Urgent needs of low-income and middle-income countries for COVID-19 vaccines and therapeutics

WHO and partners have learnt from the mis-steps in the response to the 2009 H1N1 influenza pandemic¹ and established the Access to COVID-19 Tools (ACT) Accelerator to promote equitable access to vaccines, therapeutics, and diagnostics.² However, many high-income countries already have bilateral agreements with manufacturers of COVID-19 vaccines.³ The COVAX Facility of the ACT Accelerator has agreements to access 2 billion doses of WHO pre-qualified vaccines during 2021, but this represents only 20% of the vaccine needs of participating countries.⁴ Most low-income and middle-income countries (LMICs) face difficulties in accessing and delivering vaccines and therapeutics for COVID-19 to their populations.⁵ COVAX will require decisive action by Gavi, the Vaccine Alliance, WHO, and the Coalition for Epidemic Preparedness Innovations (CEPI), supported by the countries they serve and with financing for vaccine purchasing, to ensure people worldwide have equitable access to COVID-19 vaccines.6, 7, 8

For 80% of the populations in LMICs that will not benefit from COVAX-provided COVID-19 vaccines, finances for purchase or donations are needed. Government measures in response to COVID-19 and the broader global financial situation have led to increasing fiscal imbalances of heavily indebted countries.⁹ Multinational agencies, financial institutions, and wealthier countries should consider measures that could provide relief to indebted LMICs. The World Bank, the International Monetary Fund, and others need to lead an international initiative to mobilise support for LMICs in need.

Many LMICs do not have an established platform for vaccinating their adult populations.¹⁰ Although it is feasible to deliver COVID-19 vaccines to health-care and other front-line essential workers, in some LMICs it will be difficult to effectively reach and vaccinate with two doses all elderly populations and individuals with co-morbidities, given insufficient mechanisms to identify such groups. Governments and technical leaders will need to use transparent, accountable, and unbiased processes when they make and explain evidence-based vaccine prioritisation decisions, while also building confidence in COVID-19 vaccines and engaging with all the stakeholders.

The ultracold chain requirements of mRNA COVID-19 vaccines are likely to be an insurmountable hurdle in LMICs, outside of major cities. COVID-19 vaccine delivery will require considerable investment of resources, health-care staff, and careful planning to avoid opportunity costs, including a disruption of routine health services and a decline in essential childhood vaccination coverage, which could result in outbreaks of measles and other vaccine-preventable diseases. There were more deaths from measles than Ebola virus disease in 2019 in the aftermath of the Ebola outbreak in the Democratic Republic of the Congo, due to failure to maintain adequate childhood vaccinations.¹¹ The infrastructure for vaccination in many LMICs is already inadequate, as shown by the 19·7 million under-vaccinated infants globally, most of whom are in these countries.¹² Thus, preparation for all aspects of COVID-19 vaccine delivery in LMICs must begin now with the support of international partners.

Strengthening the capacity of LMICs to do clinical trials and promoting LMIC participation in research are also crucial.¹³ More LMICs need to participate in future vaccine trials and in testing the clinical effectiveness of different therapeutic agents to ensure that interventions and implementation are suitable for local contexts.

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Tracking the safety and effectiveness of different COVID-19 vaccines over time in various populations and settings will necessitate improvements in pharmacovigilance.¹⁴ Regulatory authorities in many LMICs need to be strengthened and could benefit from a programme of national and international support, as well as regional cooperation and reliance mechanisms.¹⁵ As part of internationally coordinated actions, COVID-19 technologies should be transferred to LMIC-based manufacturers, accompanied by regulatory guidance. Efforts to boost local manufacturing capacity in LMICs will contribute to equity, global solidarity, and global health security. India and South Africa have called for the suspension of intellectual property rights related to COVID-19 vaccines to improve access for LMICs, a move now supported by many other countries, but opposed by the pharmaceutical industry, which cites the disincentive to innovation.¹⁶

There are further challenges. Governments in LMICs with strong private health sectors, as those in high-income countries, will need to manage the inherent potential for inequity, whereby the rich could access COVID-19 vaccines before individuals with less access to private care who may be at increased risk of severe disease and death, such as older people and those with comorbidities. LMICs affected by war, civil conflict, economic crises, or natural disasters, or with large refugee populations or populations with special needs or vulnerabilities need additional support for vaccines and vaccination under extremely difficult operational conditions.

Re-examining global governance structures, including the UN and its Security Council, is much needed so that the voices and interests of billions of people in LMICs are better represented and recognised. Global support to multilateral institutions is essential to sustain their support to LMICs to facilitate vaccinations globally. The COVID-19 pandemic shows that no nation can stand alone. We are all part of a common humanity that requires us to respect our diverse experiences, cultures, and countries and forge partnerships that better serve the interests of all.