Sept. 27, 2021 -- While Americans debate who should receive boosters of a COVID-19 vaccine and when, many nations have barely begun to vaccinate their citizens, an inequity that is not just a humanitarian crisis, but also likely to extend the pandemic, experts and activists say.

Only 2% of the population in low-income countries have received at least one vaccine dose, compared to 30% in lower-middle-income countries, 54% in upper-middle-income countries, and nearly two-thirds in high-income countries, according to the Kaiser Family Foundation.

Vaccinating the world is an ethical, moral, and humanitarian responsibility and important to the health of everyone, says Krishna Udayakumar, MD, director of the Global Health Innovation Center at Duke University. “So long as the COVID-19 pandemic continues to rage in any part of the world, we will see more variants emerge. And it’s only a matter of time until we see the emergence of a new variant that can pierce our vaccine immunity, and that puts us and everybody else back to square one.”

No country is safe, he says, noting that the United States cannot “isolate itself from a pandemic.”

At a COVID-19 virtual summit he convened last week, President Joe Biden acknowledged that the U.S. is not an island.

“We also know to beat the pandemic here, we need to beat it everywhere,” he said.

The reasons for slow vaccine rollouts in many nations are many, including manufacturing issues that have hampered the ramp-up of production on a global scale. Wealthier countries have been the first to get the bulk of vaccine doses because they have the factories to make them.

But now, “we’ve got the supply, we’ve got the technical skills, what we really need is leadership and political will” to vaccinate the rest of the world, Udayakumar says.

U.S. Steps Up, but Urgency Lacking

Udayakumar credits Biden for taking the lead with the COVID-19 summit and for setting a target to vaccinate 40% of the world by the end of 2021 -- delivering 2 billion doses the U.S. and other countries have pledged -- and 70% by September 2022.

The World Health Organization, the member countries of the G-20, and nongovernmental organizations have endorsed these targets.

Biden said the U.S. would donate 1.1 billion doses of the Pfizer vaccine. That includes 500 million that it promised the world in June and another half-billion that will be delivered next year. The European Union will donate 500 million doses.

The doses will be shared with low- and middle-income countries through COVAX, a private nonprofit that’s acting as a purchasing pool for less-wealthy nations.

As of Sept. 20, just 140 million of the U.S. doses have been delivered to 93 countries, about half of which are low- and middle-income nations, according to the Kaiser Family Foundation.

Duke has also been tracking donations, and it shows that the U.S. is the top donor, with 638 million doses pledged as of Sept 10, before the COVID-19 summit. The U.K. (100 million pledged) is second, followed by China (74 million), France (60 million), Japan (42 million), Germany (31 million), Australia (21 million), Italy (15 million), Canada (13 million), and India (11 million).

Only about 300 million of the U.S. doses will be shipped by the end of 2021, Udayakumar says.

“What’s actually most important right now is the urgency with which we can get doses around the world,” he said.

Peter Maybarduk, director of Public Citizen’s Access to Medicines program, agreed that urgency seems lacking.

“Purchasing doses for donation sometime next year is helpful, but it does not meaningfully expand the global supply, and it is not justice,” he said in a statement.

Oxfam America President and CEO Abby Maxman also expressed concern.

“While we commend President Biden for rallying world leaders to commit to vaccinate 70% of the world by this time next year, we have yet to see an effective plan to meet this goal,” she said.

The virus is spreading now, said Tom Kenyon, MD, chief health officer at Project HOPE, a nongovernmental organization that helps communities solve public health issues. Waiting until next year “is not aggressive enough,” he said.

Are Boosters Delaying Global Progress?

Some have called on wealthy nations to forgo booster shots until the rest of the world is at least partially vaccinated. In early September, WHO Director-General Tedros Adhanom Ghebreyesus, PhD, said the easiest path to hitting the 40% target would be to heed his call for a moratorium on boosters through the end of 2021.

COVAX said in early September that it would receive 25% fewer vaccine doses in 2021 than it had been expecting. Restrictions on exports -- particularly from the Serum Institute of India, a key supplier -- scale-up challenges at manufacturing sites for the Johnson & Johnson and AstraZeneca vaccines, and uncertain timing of approval [AGS1] of several vaccines, including one from Novavax, are all cutting into supplies.

While 105 COVID-19 vaccines are in various stages of testing, just eight have been fully approved and 13 have some type of early or limited use worldwide, according to the New York Times vaccine tracker.

The Independent Allocation Vaccine Group (IAVG), established by the WHO, said it is concerned about “the prioritization of bilateral deals over international collaboration and solidarity, export restrictions and decisions by some countries to administer booster doses to their adult populations.”

Many nations have authorized or begun offering boosters, including the U.S., and, according to Reuters, Austria, Belgium, Britain, Cambodia, Canada, Chile, China, the Czech Republic, Denmark, the Dominican Republic, Ecuador, Finland, France, Germany, Greece, Hungary, Indonesia, Ireland, Israel, Italy, Russia, Poland, Serbia, South Korea, Spain, the United Arab Emirates, Thailand, Turkey, and Uruguay.

“Wealthy countries must let go of reserved doses and cede their place in the queue, allowing COVAX and the African Union to buy the vaccines the continent seeks and stands ready to finance,” Matshidiso Moeti, MD, the WHO’s regional director for Africa, wrote in a New York Times editorial. Moeti said that only 51 million Africans (3.6% of the continent’s population) are fully vaccinated.

If the world wants to show it is serious, it will send another 150 million or more doses to Africa in the next 2-4 weeks, said Udayakumar, noting that the continent has a goal of vaccinating 10% of its population by the end of September.

On Monday, as Biden rolled up his sleeve to get a Pfizer booster shots in front of cameras and reporters, he was asked about the importance of getting more vaccines to the rest of the world.

"We're doing more than every other nation in the world, combined. We're going to give well over 1 billion, 100 million shots, and we're going to continue going. We're going to do our part," he said, noting that the U.S. has also given funding to the World Health Organization's Covax effort, which is helping to distribute vaccines to lower income countries.

COVAX predicted that Africa would receive from 330 million to 500 million doses by the end of 2021, compared with 395 million to 645 million for Southeast Asia and about 135 million for the Caribbean, Central America, and South America.

And the U.S. will be providing financing to help South Africa produce more than 500 million doses of the Johnson & Johnson vaccine “in Africa, for Africa,” Biden said.

But getting vaccines to African nations is just part of the problem. Not every available vaccine is approved for use across the continent. In fact, AstraZeneca’s vaccine is only authorized in 33 of 54 African nations; 21 countries for approved the use of China’s Sinopham vaccine; Pfizer’s vaccine is in use in six countries, Johnson & Johnson’s in eight and Moderna’s in four.

Waiver of Patent Rights Sought

South Africa and India have asked the World Trade Organization to temporarily allow them to use vaccine makers’ recipes without being sued for patent infringement. The U.S. has backed the request, but Biden did not mention patent waivers at the COVID-19 summit.

Maybarduk of Public Citizen says the WHO “has established an mRNA manufacturing hub in South Africa and will need far more ambitious support than wealthy countries have offered so far,” and that the U.S. “must work with South Africa and other nations among the 100-plus supporters” to enact the temporary waiver.

“President Biden announced his support for the WTO proposal in May, but instead of leading, his administration has largely stayed on the sidelines of the negotiations,” says Maxman, of Oxfam. “During that time, more than 1 million people around the world have died from COVID.”

Udayakumar says that even if countries were able to access the Pfizer vaccine recipe soon, “I just don’t see it having an immediate impact right now.”

Many nations don’t have the infrastructure or experience to make vaccines, which though desperately needed, could not be built overnight, he says

The bigger challenge will be getting vaccines into arms once the doses arrive, Udayakumar says.

Biden said the U.S. would provide $370 million for global vaccine readiness, and he asked other countries to put up $3 billion in 2021 and $7 billion in 2022 to help low- and middle-income nations get shots into arms.

That’s a big step, but still may not be enough, Udayakumar says.

“My biggest worry is that we’re going to get to the end of this year and still see very low vaccination rates in many low- and middle-income countries while we start to see more doses pile up in freezers or in warehouses,” he says.

Show Sources

Kaiser Family Foundation: “Tracking U.S. COVID-19 Vaccine Donations.”

Krishna Udayakumar, MD, director, Global Health Innovation Center, Duke University, Durham, NC.

White House: “Fact Sheet: Targets for Global COVID-19 Summit,” “Fact Sheet: President Biden’s Global COVID-19 Summit: Ending the Pandemic and Building Back Better.”

Launch & Scale Speedometer: “Vaccine Donations.”

Public Citizen: “Statement: Biden’s COVID Summit Will Not Meet This Moment.”

Oxfam: “Oxfam Reaction to Biden COVID Summit.”

World Health Organization: “WHO Director-General's opening remarks at the media briefing on COVID-19 -- 8 September 2021,” “What Needs to Change to Enhance Covid-19 Vaccine Access.”

COVAX: “COVAX Global Supply Forecast.”

The New York Times: “Coronavirus Vaccine Tracker,” “Rich Countries Worry About Booster Shots. They Should Be Worried About Africa.”

Reuters: “Factbox -- Countries weigh need for booster COVID-19 shots.”

World Trade Organization: “Waiver From Certain Provisions Of The Trips Agreement For The Prevention, Containment And Treatment Of Covid-19.”

Office of the U.S. Trade Representative: “Statement from Ambassador Katherine Tai on the Covid-19 Trips Waiver.”

Wego Travel: “AstraZeneca Approved Countries List: Where Has the Vaccine Been Authorized?” ““Moderna Approved Countries List: Where Has the Vaccine Been Authorized?” “Sinopham Countries List: Where Has the Vaccine Been Authorized?” “Pfizer Approved Countries List: Where Has the Vaccine Been Authorized?”

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