2021: Year of the shot in the Arm
For the next couple of years, the world’s most vied for commodity will not be a metal, currency, or even time; it will arrive in delicate glass vials – each with no more than 10 to 20 drops. Often, shipping it will require not only a fragile warning, but packs of dry ice and, perhaps, even security. Upon arriving at its destination, it will be delivered as a shot in the arm, each injection carrying not just a vaccine, but also an eventual way out of a pandemic that has devastated the world.
As of December 31, there are three coronavirus vaccines approved in the world after due scientific process. Made by Pfizer-BioNTech, Moderna and Oxford-AstraZeneca, each drug has largely passed rigorous scrutiny to check for their safety and efficacy. At the time of this writing, a handful of countries have begun administering them to their citizens, setting the pace for what is likely to dominate 2021 – a year that will be measured not by how much of the past we leave behind, but how much of it we can go back to.
The experiences in the US, the UK, and several European countries over 2020 have demonstrated that the factory-to-syringe process can throw up several challenges, and that even the most resourceful of nations can struggle with a process that can be as labyrinthine as it needs to be precise. This process involves identifying the people who need to be inoculated against the virus most urgently, ensuring that each dose is maintained at the right temperature, and requiring close follow-up to monitor for adverse reactions and then -- three or four weeks later -- bringing back vaccine recipients for a booster.
The urgency of it is hastened by the threat of a new variant of the virus that threatens to accelerate the pandemic even further.
In 2021, vaccine makers and their production partners have projected that they will be able to make 20 billion doses cumulatively, according to the Unicef’s Covid-19 Vaccine Market Dashboard. The number, however, is unlikely to remain at this level. Some have recently made subtractions. AstraZeneca and its partners have, for instance, pared back end-of-December projections from 400 million to a little over 100 million. At the same time, analysts expect a big bump in production later in 2021.
“In the first six months, there is definitely going to be a situation where there is shortage globally; nobody can help that. We will see that easing off by August-September because you will have other vaccine manufacturers also being able to supply… Eventually everyone is going to get it; of course some countries will have to wait a little longer,” Adar Poonawalla, the CEO of Serum Institute of India, said on Tuesday. SII is manufacturing the Oxford-AstraZeneca vaccine and has contracts for several others that are further down the pipeline.
According to science analytics company Airfinity, the three approved candidates together have a declared production capacity of around 4.8 billion doses by the end of 2021. The other candidates for which a large number of doses are expected this year are being developed by Novavax, Johnson & Johnson/Janssen and Sanofi/GSK. Together, they have plans to produce about 4.1 billion doses, but they are yet to complete large-scale trials that the approved vaccines have.
NOT JUST ABOUT DOSES
But production-line bottlenecks are still further downstream. Airfinity’s assessments also point to a possible shortage of vials and syringes that could slow down packaging and delivery, even if the inoculations are made in ample volumes. At present, roughly nine billion syringes and vials are produced annually across the world, the company’s latest assessments showed.
In 2021, syringe production is expected to be expanded to a little over 12 billion, and vials to around 15.5 billion – but these numbers are still short of the expected vaccine production. Most vaccine makers are now switching to larger vials that can hold 5-10 doses to overcome part of the shortage.
These problems are overtaken still by the strict temperature demands of some of these vaccines, particularly the mRNA shots developed by Moderna and Prizer-BioNTech that need to be kept frozen. The latter needs temperatures of -70 degrees C – colder than most typical cold-storage infrastructure capacities. Public health officials estimate that ultimately, up to 15% of the stocks may be lost to wastage.
THE BILLION-PEOPLE QUESTION
Shipping vials to destinations, however, is likely to pale in comparison to the challenge of profiling and managing millions of recipients, some of whom may need a dose sooner than others. The challenge is particularly acute in countries with large populations and geographic areas such as India.
According to the Indian government’s tentative priority list, around 300 million people have been placed first in line for vaccinations. Comprising health care workers, frontline essential service workers such as police and firefighters, and people above the age of 50 (as well as those younger people with comorbid conditions), these are groups deemed most at risk of an infection or severe disease. The government hopes these groups will get a vaccine by July – meaning that should the rollout begin in January, India will need to vaccinate roughly upwards of 1.5 million people every day.
“To be able to effectively reach the target population for the Covid-19 vaccination, India will need to utilise its existing national immunisation network, including the infrastructure (production, storage, transport, delivery facilities) as well as the human resources (vaccinators, supervisors, etc.). However, given the scale of the vaccination effort required for Covid-19, the effort will need to build on existing networks. This needs to be planned for, budgeted, and efforts made to put this in place ahead of a vaccine being available,” said Anant Bhan, a researcher in global health, health policy and bioethics.
When, who and where are some of the most crucial questions in the vaccination arithmetic, with countries likely to follow different strategies, based on what they plan to target most with their inoculation programme. For instance, Israel, a small country with a relatively small population, has prioritised people aged over 60, health care workers, carers, and high-risk people. It also boasts, at present, the world’s fastest vaccination drive, having covered close to 8% of its population. The country’s objective is herd immunity.
The UK, by comparison, is prioritising its oldest population. The country is in the grip of its worst-yet wave of infections and hospitals in many regions have surpassed their surge capacities. Its officials on Wednesday declared that they will focus on getting as many people as possible vaccinated to reduce the load on its health care system, even if that means booster shots are delayed.
NATURE OF THE RACE
Among the top 10 countries with the most doses of vaccines administered by the end of 2020, eight are advanced economies. Early in December, international advocacy groups including Amnesty International, Frontline AIDS, Global Justice Now, and Oxfam, which are part of an alliance calling for a People’s Vaccine, said rich nations representing roughly 14% of the world’s population have bought up 53% of the most promising vaccines so far.
Citing data from eight leading vaccine candidates in Phase 3 trials that have struck substantial deals with countries worldwide, the groups estimated that nine of 10 people are likely to not get a vaccine in 2021.
“When you get into a pandemic, the normal market mechanism will take the scarce resources and only make them available to the richest countries, and the richest people in those countries,” said Bill Gates, the co-chair of the Bill & Melinda Gates Foundation, in an interview to HT in December.
Gates and his organisation assist multilateral arrangements, such as Gavi, the Vaccine Alliance in building Covax, a WHO-led initiative to pool resources to help bring vaccines to lower-middle income countries.
Concerns about the inequities caused by the pandemic being perpetuated in the race to secure a vaccine have led some experts to advocate for more creative solutions. Nobel laureate economist Richard Thaler wrote in the New York Times on December 9 about letting celebrities and wealthy people jump the vaccination queue by bidding for spots at an auction. The bids, he suggested, could be used to “to redistribute money from the rich to the poor”.
Such ideas found support among some bioethics academicians: “My idea is that instead of dollars, [wealthy] people should bid on sending units of vaccines to the Global South,” Peter Singer, a bioethics professor at Princeton, said at a discussion hosted by the NYT on December 24.
These conversations have been taking place since much earlier in the pandemic, when experts began calling on policymakers to heed to principles of equity. “Some wealthy countries will likely end up with substantial amounts of vaccine. Over time, if all goes well, these countries will have to decide how much product they’re going to keep and how much, if any, they’re willing to share,” Johns Hopkins bioethicist Ruth Faden, a member of World Health Organization’s Covid-19 Vaccines Working Group, said during a university interview on July 1.
While it remains to be seen if this will come true, some encouraging signs came in December when Canada – which has secured the most per capita doses – announced it will consider giving away its excess doses.
The discovery of a new variant in the UK, which has grown rapidly in parts of the country and accelerated the outbreak, is quickly becoming a cause for concern. Scientists are racing to uncover more about its biology and what it means for the pandemic, but early indications suggest it is yet more capable of infecting people, and possibly even infecting groups (children) that were largely protected till now.
While the variant does not seem to be making the current vaccine options obsolete, it will likely make the dash for doses more intense. “The emergence of this mutant definitely reinforces the importance of vaccinating as many people as fast as possible with Covid vaccines, and to be vigilant about mask wearing and social distancing,” wrote Shane Crotty, a professor at La Jolla Institute for Immunology.
The start of 2021 and much of its first few months could, thus, revolve around these problems. The conversation will at first be dominated by how well, or badly, countries are able to speed up vaccine delivery. Along with it is likely to run a debate on who should be first in line to get a dose and the complex moral calculus of such decisions.
But what may turn out to be the most watched aspect is how well, and how long, vaccines will really protect us – and whether this will be enough to stay ahead of an evolving pathogen.
(With inputs from Rhythma Kaul)