As many high-income countries are relaxing restrictions for the summer months, low- and middle-income countries (LMICs) are witnessing rises in cases, deaths, and overwhelmed hospitals. 

Countries in Europe and the United States are increasingly allowing in travellers, ending mask mandates, and allowing large gatherings including football matches and concerts. 

At the same time, the third wave is intensifying in several countries, with critical oxygen shortages rising in sub-Saharan Africa, Southeast Asia, and parts of Latin America. Some 19 countries are about to run out of oxygen.

“We face a two-track pandemic,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, at the ACT-Accelerator Facilitation Council Briefing on Tuesday. “The countries that are now opening up their societies are those that have largely controlled the supply of life-saving personal protective equipment [PPE], tests, oxygen, and especially vaccines.”

“Meanwhile, countries without access to sufficient supplies are facing waves of hospitalizations and deaths,” Tedros said. 

“While some parts of the world go on to enjoy summer vacation in near normality, others brace themselves for overwhelmed hospitals and economies on the brink of collapse,” said Dag-Inge Ulstein, Norway’s Minister of International Development and Co-chair of the ACT-Accelerator Facilitation Council. 

Pandemic is in a ‘Very Dangerous Phase’

After weeks of decline, global COVID-19 cases are now on the rise in five of the six WHO regions. The African region is currently experiencing a fast-surging third wave that could pose a far greater threat to the continent than the second wave. 

“We shouldn’t be in this position 18 months into a global pandemic where all of us are exhausted and with more than 183 million confirmed cases and 3.9 million deaths,” said Maria Van Kerkhove, WHO COVID-19 Technical Lead. 

Over 20 countries globally have an exponential growth in cases and “almost vertical transmission,” said Van Kerkhove. 

This is largely being driven by the Delta variant, first identified in India and classified as a “variant of concern” by WHO in mid-May. It is considered 40-60% more transmissible than the Alpha variant, identified in the United Kingdom. 

More than 96 countries have reported the Delta variant and it is expected to become the dominant virus in the coming months. 

The pandemic “remains in a very dangerous phase,” with the continual emergence of variants, inequitable vaccinations, and overburdened health systems, said Tedros. 

“Most of the world remains susceptible to infection,” due in part to the uneven rollout of vaccines globally and the inconsistent implementation of public health and social measures around the world, said Van Kerkhove. 

“Urgent action is required, not only to redress inequitable access to health care and to vaccines, but to ensure that countries have the capacity to translate vaccines into vaccination, diagnostics into effective surveillance, and therapeutics into treatment,” said Van Kerkhove. 

The WHO identified priority actions for member states, namely to: enhance national, regional, and global surveillance, testing, clinical care, and access to oxygen and therapeutics; maintain focus on public health and social measures to suppress transmission; scale up the research, production of and equitable distribution of vaccines, diagnostics, and therapeutics; and strengthen the capacity and resilience of health systems.

Inequities are Decreasing, But Stark Disparities Remain

While a global milestone of administering three billion doses has been reached, only 0.3% of those have gone to low-income countries. Of the 2.6 billion COVID tests performed globally, less than 4% have been administered in Africa, which accounts for 17% of the world’s population.

While vaccine deployment is improving everywhere in the world, there are still stark disparities between the regions in terms of coverage.

No low-income countries have achieved more than 20% vaccination coverage nationally, compared to 80% of high-income countries.

Some 68 WHO member states have reached 20% coverage, the majority from the European region. The African region and Southeast Asian region have the lowest share of countries with coverage over 20%. 

Vaccine inequity is gradually decreasing, but high-income countries have still administered 63 times more doses per inhabitant than low-income countries. Of the 194 WHO member states, 189 have started vaccinating. 

“These persistent inequalities are translating into countless preventable deaths while the world has the tools to stop this,” said Mmamoloko Kubayi, Acting Minister of Health of South Africa and Co-chair of the ACT-Accelerator Facilitation Council.

“We need to mobilise resources to fund medical oxygen storage and infrastructure, pay for emergency supplies, and finance the transportation of equipment and other tools needed,” said Kubayi. 

“Our only way out [of the pandemic] is to support countries in the equitable distribution of PPE, tests, treatments, and vaccines,” said Tedros.

“This pandemic is testing our ability to save lives, but also our ability to save the architecture of international cooperation that we spent so many decades building,” added Ulstein. 

Constraints on COVAX Vaccination Progress 

COVAX has shipped 95.9 million doses to 135 countries, including 69 low- and middle-income countries. Some 40 countries began their vaccination campaigns because of COVAX.

“We should have been at a much higher level of distribution by now, perhaps between 300- and 400 million doses, but because of the constraints…we have yet to touch 100 million,” said Soumya Swaminathan, WHO Chief Scientist. 

COVAX is currently facing supply shortages primarily due to delays in clinical trials, regulatory approvals, the validation of new manufacturing sites, supply chain bottlenecks, and export controls. 

“In recognition of these risks that we are facing, we’re very much focused on having a diversified portfolio of vaccines…in terms of resilience across different manufacturing sites across the globe and having a very actively managed portfolio,” said Aurelia Nguyen, Managing Director of the COVAX Facility. 

WHO officials expect to have a “very strong increase” in vaccines available to COVAX in the fourth quarter of 2021 with additional vaccines getting WHO emergency use listing (EUL) and scale ups in vaccine manufacturing. 

The hope is also that exports of the AstraZeneca vaccine from the Serum Institute of India (SII), a major source of doses for the COVAX Facility, will resume in late 2021. 

Supplies from the SII manufacturing site were redirected to address the domestic surge in cases and deaths in April, causing delays in COVAX deliveries to low- and middle-income countries. 

Boosting the availability of vaccines immediately will require dose sharing from countries with a surplus of vaccines. Several countries have committed over 530 million doses to COVAX, with the commencement of deliveries from France, New Zealand, and the US. 

Four new manufacturers have signed up with COVAX – Moderna, Novavax, Johnson & Johnson, and Clover, a Chinese biotech firm – committing 1.5 billion doses. 

As a result of the new deal and ongoing negotiations, COVAX expects “substantial volumes” of vaccines through 2021 and early 2022, said Nguyen.

“We are forecasted to have approximately 1.9 billion doses available for delivery by the end of 2021 and of this, the advanced market commitment participants, the 92 lower-income economies, are expected to receive 1.5 billion doses of that,” said Nguyen.

Appeal for Funding for the ACT-Accelerator

As of the end of June, US$17.7 billion was raised for the Access to COVID-19 Tools (ACT) Accelerator – an initiative to speed up the development, production, and access to tests, treatments, and vaccines – but a considerable gap in funding remains, said officials at the Facilitation Council meeting. 

ACT-A has a funding gap of US$16.8 billion, two-thirds of which is needed for the supply diagnostics and PPE. The rest is intended for R&D and manufacturing, the health systems connector pillar of ACT-A, and the supply of therapeutics and oxygen. 

Some 60% of the total supply need for diagnostics and therapeutics is in LMICs. 

Particularly in the context of the current surge in cases, “there is an urgency to ensure that the ACT-Accelerator’s financing needs are met,” said Michaela Pfeiffer, WHO Technical Officer of ACT-A Hub. 

As the world approaches the “sobering juncture” of four million lives lost from COVID-19, funding commitments to ACT-A are critical, said Ulstein.

WHO officials called on the Group of 20 (G-20), an intergovernmental forum for economic collaboration, to not delay financial commitments to the Accelerator. 

“Our appeal for countries to finance ACT-A is not new, but it is ever more relevant,” said Ulstein. 

In addition to financing, countries were also called upon to share vaccines, as at least 250 million doses will be needed to reach 10% vaccine coverage in all countries by September. 

The pharmaceutical industry and manufacturers have a role to play in scaling up production and facilitating technology transfer to improve the global vaccine manufacturing capacity. 

“We need manufacturers to help by sharing know-how and accelerating technology transfer,” said Tedros. 

“The stakes are high and the challenges before us are vast, but not insurmountable,” said Ulstein. “A clear message has been sent that the solutions exist, it is only that we need to have the political will to realize them and ensure that everyone everywhere has access to life saving measures.”

Image Credits: WHO.