COVID-19 Vaccine Nationalism Limits Africa’s Options
Healthcare workers dons protective equipment

Ibadan, Nigeria – The World Health Organisation (WHO) is advocating for equitable access to effective COVID-19 vaccines but developments surrounding the race to a vaccine suggest this may be extremely difficult. And health policy leaders in Africa and other low and middle-income countries are increasingly worried about their prospects for being pushed to the back of the line queue.   

While it used to be the pharmaceutical companies racing to be the first to have their vaccine candidates approved, the pandemic has also seen countries lobbying to get quick access to the vaccines, even before they become available, with the United States taking the most aggressive lead.

In the US, Operation Warp Speed (OWS) aims to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021. On 30 March 2020, the US Department of Health and Human Services (HHS) announced $456 million funding for Johnson & Johnson’s candidate vaccine, with Phase 1 clinical trials starting in summer. About two weeks later, HHS made up to $483 million in support available for Moderna’s candidate vaccine, which began Phase 1 trials on March 16 and received a fast-track designation from the FDA. Then on May 21, HHS announced up to $1.2 billion in support for AstraZeneca’s candidate vaccine, developed in conjunction with the University of Oxford. 

Under the agreement, at least 300 million doses of the vaccine will be made available for the United States, with the first doses delivered as early as October 2020 and Phase 3 clinical studies beginning this summer with approximately 30,000 volunteers in the United States.

But the US is not the only country that is striving to engage in COVID-19 vaccine nationalism which is an attempt to get as many doses of the vaccine for a country before others. Europe is also 

Late June 2020, Brazil signed a $127 million agreement for local production of AstraZeneca’s experimental vaccine that has shown promise to fight the COVID-19 pandemic. A similar agreement has also been signed by Moderna with Spain’s Rovi.  France, Germany, Italy and Netherlands are also setting up an “Inclusive Vaccine Alliance” through which they will jointly negotiate with COVID-19 vaccine developers and potential producers. For its 27-member states, the European Union is seeking a mandate to negotiate with the companies for advance contracts and reservations for doses of candidate vaccines.

African Countries’ Limited Choices
Shabir Madhi, Principal Investigator of the South African arm of Oxford University’s COVID-19 vaccine trial

With countries in Africa and other low and middle income countries unable to outbid the economic powerhouses, efforts on COVID-19 vaccine development is not on the same level as that of other parts of the world and the possibility of Africa not getting the vaccine as soon as possible is a major concern to the WHO and African leaders – although this is not new.

“Too often, African countries end up at the back of the queue for new technologies, including vaccines. These life-saving products must be available to everyone, not only those who can afford to pay,” said Dr Matshidiso Moeti, WHO Regional Director for Africa, speaking at a press event Thursday on vaccines for Africa, sponsored by the Geneva-based World Economic Forum. 

Currently, there are a total of 152 vaccines in development, and about 20 are in clinical trials. Out of those, only one is currently recruiting volunteers in Africa. 

Prof Shabir Madhi of South Africa’s Wits University is the Principal Investigator of Oxford COVID-19 Vaccine Trial in South Africa. Officially referred to as the South African Ox1Cov-19 Vaccine VIDA-Trial, it aims to involve 2000 volunteers aged 18–65 years, including individuals living with HIV. Clinical trials for the same vaccine are also ongoing in the United Kingdom and Brazil involving thousands of participants.

African Countries Should Support More Clinical Trials Despite Sensitivities

Madhi noted that one of the ways that African countries can accelerate the availability of COVID-19 vaccines for their citizens is for them to actively participate in clinical trials.

“In the past, it usually takes from 5 to 20 years for already approved vaccines to become available in Africa because of the non-existence of local data from clinical trials. We can reduce that by participating in clinical trials,” he told a press conference on Thursday.

According to Gavi, the Vaccine Alliance,  vaccine trials in Africa are a “sensitive and potentially controversial issue”, because of instances of Western researchers conducting unethical trials in African countries, and scientists undertaking medical experiments on people of African origin in the USA.

In April 2020, efforts geared towards encouraging African countries to participate in COVID-19 clinical trials stalled with the emergence of a video in which two French scientists made racist remarks in referring to Africa as the testing ground for new vaccines. Realising this could erode public trust in the science community, the video prompted a direct rebuke from Dr Tedros Adhanom Ghebreyesus, Director-General of the WHO.

Continent has a Long Record of Successful Clinical Trial Research 

Although Africa only accounts for about 2% of the world’s clinical trials, vaccine trials are not new in Africa. Prof. Pontiano Kaleebu, Director MRC/UVRI and LSHTM Uganda Research Unit told the press conference that while French scientists’ gaffe raised concerns about Africans being used as guinea pigs for clinical trials, the continent has been participating in various vaccine trials including trials for HIV and Ebola vaccines.

“There is no advantage in using Africans as guinea pigs and in my experience, we have not seen anyone going below international ethical standards,” he added.

Pontiano Kaleebu

The African Union is also striving to get more African countries involved in COVID-19 vaccine activities. It has endorsed the need for Africa to develop a framework to actively engage in the development and access to COVID-19 vaccines. 

“Success in developing and providing access to a safe vaccine requires an innovative and collaborative approach, with significant local manufacturing in Africa. We need to support the contribution of African scientists and healthcare professionals. We need to act with urgency,” said AU’s Chairperson, President Cyril Ramaphosa of South Africa.

New African CDC Consortium Aims to Develop Vaccine

The African CDC has also launched its Consortium for COVID-19 Vaccine Clinical Trial (CONCVACT) through which it seeks to mobilise academics, researchers and the private sector “to work together and use all available platforms for the development of COVID-19 vaccine”.

The consortium aims to secure more than 10 late stage vaccine clinical trials as early as possible on the continent by bringing together global vaccine developers and funders, as well as African organizations that facilitate clinical trials. 

“The goal is to ensure that sufficient data is generated on the safety and efficacy of the most promising vaccine candidates for the African population so they can be confidently rolled out in Africa once vaccines are approved,” Africa CDC stated.

Other challenges – Vaccine Production Capacity and Coverage 

While the global vaccination target is 90% coverage, Africa has averaged at 76% according to Moeti who described the bottlenecks of Africa’s immunisation efforts as a possible limitation in ensuring many Africans are able to get vaccinated against COVID-19 as soon as the vaccine becomes available. But there is another problem, that of mass production.

Advocates of equitable access to COVID-19 vaccine are asking the pharmaceutical companies with the promising vaccine candidates not to hold on to intellectual properties, but to share such to facilitate mass production of the vaccine in various parts of the world.

In Africa, Moeti noted that vaccine production capabilities are available in several African countries including Senegal (which is already producing the yellow fever vaccine), South Africa, Egypt, Tunisia, Ethiopia, Morocco and Algeria. But Madhi added there is no facility in Africa that has the capability to mass produce gene-based vaccines and such vaccines are the ones that are declared effective, Africa may have to rely on producers elsewhere for the vaccine.

Study volunteer receives inoculation at Redemption Hospital in Monrovia on the opening day in Liberia of PREVAC, a Phase 2 Ebola vaccine trial in West Africa.
China to the Rescue?

While the United States, Europe and several other regions are choosing to prioritise getting COVID-19 vaccines for their citizens ahead of the rest of the world, China has promised to supply any COVID-19 vaccine to Africa first, and at no cost.

China is leading the COVID-19 vaccine race with more vaccine candidates in the late clinical trial phase than any other country. Out of the three vaccines that are in Phase III trials, two are from China – Sinovac Biotech and China National Pharmaceutical Group (Sinopharm).

In June 2020, China’s president, Xi Jinping, told African leaders that participated in the Extraordinary China-Africa Summit On Solidarity Against COVID-19 that the continent will get China-developed COVID-19 vaccine for free. According to him, a China-developed vaccine will serve as a global public good. He added that African countries will be the first to benefit from the Chinese vaccine.

Expanding Vaccine Production Globally Could Avoid Competition
Vaccines have been tested on the continent before. But scaling up production in Africa could help avoid competition

Microsoft’s co-founder and co-chair of the Bill & Melinda Gates Foundation, Bill Gates believes that the only way to avoid countries competing for vials of the COVID-19 vaccine and leaving developing countries behind, will be to expand vaccine production capacity globally.

“There’s a plan to have multiple factories in Asia, multiple factories in the Americas, multiple factories in Europe, and if we can make over 1 to 2 billion doses a year, then the allocation problem is not super-acute,” Gates said. 

But there will be an impossible problem if the maximum annual production capacity is only 100 million doses a year.

Gates and Gavi CEO Seth Berkley put the cost of immunizing the world at tens of billions of dollars, said in an interview last month.

“The costs of some COVID-19 vaccines could end up ranging from about $4 a dose to potentially $15 a dose. While effort will involve making financial commitments to several vaccine programs, it’s worth it,” Gates said.

But with developed countries offering pharmaceutical companies huge sums of money to secure millions of doses of their COVID-19 vaccine candidates, Doctors Without Borders recently warned that there’s no guarantee that pharmaceutical companies will charge affordable prices.

“Everyone seems to agree that we can’t apply business-as-usual principles here, where the highest bidders get to protect their people from this disease first, while the rest of the world is left behind. Governments must ensure any future COVID-19 vaccines are sold at cost and universally accessible to all across the world,” said said Kate Elder, Senior Vaccines Policy Advisor for Doctors Without Borders’s Access Campaign.

Despite their limited capacity to outbid rich countries, Madhi advises African governments not to expect the vaccines to be given for free. Instead, he said they should engage the manufacturers and be actively involved in initiatives to dialogue and ensure that Africans are not totally sidelined or excluded.

Africa’s options are however limited. While the developed countries have the dual option of paying for millions of doses for their citizens or locally producing the vaccines after securing authorization and guideline from the manufacturers, Africa’s highly limited and largely unused vaccine production capacity make the continent to be largely unable to compete with the developed countries who are positioned as the first in line to procure doses for their citizens.

“Expecting African companies that have not produced vaccines in the past 25 years to now start producing COVID-19 vaccine over a 25-week period is overly optimistic. So we need to be guided regarding what to expect in terms of manufacturing on the African continent. It’s still a long path ahead to get to the few vaccines that will be available. In the meantime, the focus can’t be around vaccines, the focus remains trying to slow the rate of transmission of the virus,” Madhi said.

Image Credits: Twitter: @WHOAFRO, NIAID, Twitter: @WHOAFRO.