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A young man, wearing a face mask, rolls up his short-sleeve shirt to show a bandage covering up a vaccination shot. Shutterstock / Jacob Lund

How do we vaccinate the entire world?

The case for multiple vaccines to help fit a global population.

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Nearly two years into the Covid-19 pandemic that upended life as we know it, experts might be described as “cautiously optimistic” about the outlook going forward — others might put the emphasis more firmly on “caution.” Certainly, we’ve come a long way since the earliest days of the pandemic. The unprecedented global effort to develop Covid-19 vaccines has resulted in several safe and effective vaccines now authorized for use worldwide, with more in development — a medical feat unlike any in our lifetimes. As of mid-February 2022, 10.42 billion doses of Covid-19 vaccines have been administered worldwide.

But while the vaccines’ development and rollout can be counted as wins for public health, it’s increasingly clear that the world can’t afford to slow down its fight. With the rise of variants like Omicron and Delta, the approval of some vaccines for children, and the CDC and other health organizations now recommending booster shots for adults to help maintain immunity and prevent breakthrough infections, the world will continue to require billions of doses of vaccines in the coming years to help halt the spread of this deadly pandemic. Ensuring a steady supply of vaccines and adequate access to them — especially in low-income countries where immunization rates are lagging — will prove a critical next step.

As the Northern Hemisphere heads deeper into cold and flu season, we spoke with scientists, global health experts, and journalists on where we stand in the fight against Covid-19, where we need to focus efforts next, and why, in a connected world, none of us are truly protected until everyone is.

A middle-aged female doctor administers a shot to a young Indian woman wearing a headscarf, sitting outdoors in a village.
In the U.S., more than 70 percent of adults have received at least one dose of a vaccine. But worldwide, it is a different story.
Shutterstock / PhotoBankIndia

The “long middle phase” in fighting Covid-19 in the U.S.

Bob Kocher, MD and Former Special Assistant to President Barack Obama for Health Care and Economic Policy, believes we are now in the “long middle phase” of fighting Covid-19. Where we’ve succeeded, Kocher says, is in “developing remarkably effective vaccines and seemingly very effective new therapeutics.”

In the United States, three Covid-19 vaccines are now authorized for use, with another 10 vaccines in use worldwide, and others undergoing regulatory reviews. All of these vaccines have proven safe and effective at preventing transmission, serious illness and hospitalization, and deaths related to Covid-19. A study by the Yale School of Public Health estimates that between October 2020 and July 2021, Covid-19 vaccinations prevented 1.25 million hospitalizations, and saved 279,000 lives in the United States alone.

The critical protection provided by vaccines is also now available to more Americans than ever, with the recent FDA authorization of vaccines for use in children ages 5 through 11. In November 2021, the CDC began recommending that all Americans over the age of 18 receive a booster shot to improve their protection against Covid-19, which can degrade over time following the initial immunization. Reinforcing this evidence, British scientists recently published data around the safety, side-effects of, and immune response to, seven vaccines when used as a third booster jab. University of Birmingham scientists found all seven vaccines are effective as boosters.

As of early February 2022, over 75 percent of adults in the United States have received at least one dose of a vaccine, and 64 percent of U.S. adults are fully vaccinated. With a concerted public health campaign promoting vaccination and the federal government providing vaccines free of charge to all people living in the United States, regardless of immigration or health insurance status, the U.S. is on its way toward what many public health experts consider a satisfactory level of vaccinations. However, demand for booster shots and immunization for children means that vaccine demand will remain high.

An uneven rollout, with some countries left behind

However, the United States is a small part of the bigger, global picture. With vaccines emerging as a key to ending the darkest days of the pandemic, U.S. leaders have called for a goal of ensuring that 70 percent of the world’s population is vaccinated by the end of 2022. So, how is the world tracking toward that goal? In a word — unevenly.

Worldwide, 61 percent of the population has received at least one dose of a COVID-19 vaccine. But look closer at that number and it’s clear vaccination rates vary widely from country to country because of income variation. While a handful of countries have vaccination rates above the 70 percent global goal, many other nations lag far behind. The disparity is particularly notable in low-income countries, where only 10 percent of people have received at least one dose of a vaccine. Overall, Africa has the lowest vaccination rates as a continent — in countries like Ethiopia and Nigeria, 2 percent of the population is fully vaccinated.

In a connected world, vaccine disparities are a matter of public health as well as conscience. “You can close borders, but viruses will find a way in,” says Anita Manning, a former USA Today Medical Reporter. “As long as there are unvaccinated people to infect, viruses will continue to spread and mutate.” Manning says that health officials, political leaders, and citizens need to take the threat of large populations of unvaccinated people seriously and work to overcome barriers to access, from vaccine shortages to lack of access in the developing world. “Until everyone in the world can be vaccinated, we all are vulnerable.”

A young Black doctor administers a shot to a young Asian man in a vaccine clinic.
In a connected world, vaccine disparities are a matter of public health as well as conscience.
Shutterstock / Prostock-studio

Addressing the inequities

So, what steps should we take next to ensure adequate vaccination rates worldwide? With an estimated 11 billion doses needed to fully vaccinate 70 percent of the world against Covid-19, global demand for vaccines may outstrip supply for some time. Therefore, Saad B. Omer, Director of the Yale Institute for Global Health says, “we need to expand the portfolio of vaccines available.” It’s a sentiment echoed by the global health partnership Gavi, the Vaccine Alliance, which advocates a multi-vaccine approach to meet the massive need for vaccine doses globally, and because different vaccines are optimized for different environments.

For example, the World Health Organization (WHO) notes that the currently available vaccines have very different cold-chain handling requirements. Some require a so-called “ultra-cold chain” — that is, to remain effective, the vaccines must maintain a strict and stable -70°C temperature throughout their entire supply chain. According to the WHO, maintaining such conditions “may be challenging for many countries and would require additional training and logistics to ensure sustained vaccine quality.”

New variants — and new vaccines

The CDC reports that the vaccines currently used in the U.S. are effective against both the early forms of SARS-CoV-2 (the virus which causes Covid-19), and the Delta variant, which is twice as contagious as earlier strains. But less is known about the recently discovered Omicron variant, which scientists are in the early phases of studying. While the CDC recommends existing measures like vaccines, masks, and testing as important interventions to help prevent its spread, it notes that Omicron’s emergence underlines the need for more uptake of vaccines and boosters.

Helping to meet the continued need for more doses and boosters, a new vaccine is currently under investigation in the U.S. and has received authorization in countries around the world — the Novavax vaccine. The Novavax shot is now authorized for emergency use in the European Union, Australia, New Zealand, Canada, Singapore, and Great Britain, as well as with the World Health Organization (WHO). In partnership with the Serum Institute of India, the vaccine has been authorized in India, Indonesia, and the Philippines, and in partnership with SK bioscience, it is authorized in South Korea. There are also additional filings under review in multiple markets worldwide. The WHO’s grant of emergency use listing opens the door for vaccine distribution to low- and middle-income countries through the COVAX Facility.

Like other vaccines, the Novavax shot was tested in large clinical trials where it demonstrated efficacy and safety in preventing infection, serious illness, and hospitalization related to Covid-19 along. It underwent testing when the virus had already begun to mutate. “We conducted two randomized placebo-controlled trials — the gold standard of evidence,” says Gregory M. Glenn, MD and Novavax President of Research and Development.

A more collaborative fight ahead

Several of the experts noted the need for a robust collaboration in vaccine research, manufacturing, and distribution ahead. Omer believes wealthy nations must act in concert with pharmaceutical companies and multilateral initiatives like the COVAX Facility (short for Covid-19 Vaccines Global Access), an initiative working to ensure worldwide access to Covid-19 vaccines, to greatly increase direct donations of vaccines to low-income countries. Omer also says U.S. investment in increased domestic vaccine production, and pharmaceutical companies working closely with foreign manufacturers to scale up production, will be critical for success. Manning noted the role groups like Doctors Without Borders and other NGOs will have to play to provide, deliver, and administer vaccines around the world, “while also keeping up the pressure for global equity.”

Bob Kocher highlighted the importance of “investing in the last mile” to deliver vaccines to those in low-income countries or rural areas. “We will need to train people to give vaccinations, create mobile data systems to register patients, and find funding to pay to set up convenient vaccination locations everywhere, and marketing to let people know when, where, and how to get a shot.”

The war against Covid-19 is being waged on many fronts — as it must be, given the stakes in the pandemic that’s claimed over 5 million lives so far. While the world is still far from an ideal vaccination rate, there are reasons to be hopeful. Pharmaceutical companies are working to create new potentially life-saving vaccines that help address variants, ramp up production for existing ones, and continue to study their efficacy against novel strains. Organizations and initiatives like COVAX, which is co-led by CEPI, Gavi, WHO and UNICEF, are working with governments and private sector pharmaceutical companies worldwide to ensure a more equitable global distribution going forward. It’s a development that’s long overdue — and one that must be a priority both in terms of our conscience and our safety in a world where none of us are safe until the entire world is safe.

“It’s a huge privilege that we in the U.S. have had early and consistent access to vaccines,” Omer says. “Nobody should feel guilty for that — but the only way to pay back that privilege is to pay it forward. Our next step must be vociferous advocacy for everyone else to get the vaccine, too.”

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