Vaccine equity is when every individual has a fair and just opportunity to be vaccinated, regardless of socioeconomic status, race, ethnicity, geographic location, or other determinants of health. Barriers to vaccine equity include decisions on which vaccines are developed, affordability of vaccination, production, allocation, logistics of deployment, and effective communications to impacted populations.
Establishing and Defining Vaccine Equity Vaccine equity means ensuring that everyone in the world has equal access to vaccines. The importance of vaccine equity has been emphasized by researchers and public health experts during the COVID-19 pandemic but is relevant to other illnesses and vaccines as well. Historically, world-wide immunization campaigns have led to the eradication of smallpox and significantly reduced polio, measles, tuberculosis, diphtheria, whooping cough, and tetanus.
Establishing global vaccine equity is imperative to mitigate the spread of global pandemics. There are multiple factors that contribute to the emergence and spread of pandemics, including the ability of people to travel long distances and therefore widely transmit viruses. A virus that remains in circulation in one location is likely to spread and recur in other areas. As a virus becomes more widespread and affects larger and more diverse populations, it is more likely it is to evolve to be increasingly transmissible, virulent, and vaccine resistant. Vaccine equity is essential to stop both the spread and the evolution of a disease. Ensuring that all populations receive access to vaccines is a pragmatic means towards achieving global public health. Failing to do so increases the likelihood of further occurrences of a disease.
Infectious diseases are disproportionately likely to affect those in low and middle-income neighborhoods and countries (LMICs), making vaccine equity an issue for local and national public health and for foreign policy. Ethically and morally, access for all to essential medicines such as vaccines is fundamentally related to the human right to health, which is well-founded in international law. Economically, vaccine inequity damages the global economy. Supply chains cross borders: areas with very high vaccination rates still depend on areas with lower vaccination rates for goods and services.
Achieving vaccine equity requires addressing inequalities and roadblocks in the production, trade, and health care delivery of vaccines. Challenges include scaling-up of technology transfer and production, costs of production, safety profiles of vaccines, and anti-vaccine disinformation and aggression.
Barriers to vaccine equity also involve consistent misinformation and lack of clear language within attempts to educate general populations on vaccine benefits and vaccines themselves, especially in rural areas and populations.
Patterns of vaccine inequality The wealthy generally have better access to vaccines than the poor, both between and within countries. Within countries, there may be lower rates of vaccination in racial and ethnic minority groups, in older adults, in families headed by vaccine skeptics, and among those living with disabilities or chronic conditions. The distribution and accessibility of vaccines show significant disparities between urban and rural areas especially in low- and middle-income countries. Some countries have programs to redress this inequality. Political, economic, social, and diplomatic factors can limit vaccine availability in some countries.
Factors Achieving control of a disease (such as COVID-19) requires more than just developing and licensing vaccines. It also involves producing them at scale, pricing them so they are globally affordable, allocating them where and when needed, and deploying them to local communities. An effective global approach to achieving vaccine equity must address challenges in the dimensions of vaccine production, allocation, affordability, and deployment.
Doctors Without Borders (MSF) lists five major obstacles to vaccine equity, taking into account that many of those to be vaccinated are children: Vaccine prices; new vaccines are on-patent and expensive (affordability) Getting vaccines to children; this is expensive and gets even more difficult in conflict zones and natural disasters (affordability, deployment) Five clinic visits in the first year of life is often too many; for people in remote areas with many children, it can be much more costly and difficult to get to a clinic. (deployment) Keeping vaccines cold; see cold chain. (deployment) Age-out; children who don't get vaccinated on-schedule often have to pay for their shots. Disruption from natural disasters or conflict can mean that entire generations go unprotected.(affordability, deployment)
Achieving vaccine equity depends on having a sufficient supply of affordable vaccines available for global use. Ideally, a vaccine that is suitable for global use will be based on established technology; will have multiple available suppliers of the materials and equipment needed for production; be appropriate to the regions where it is to be produced or deployed, in terms of scalability of production and storage conditions; and be supported by local infrastructure for its production, delivery and regulation.
Vaccine development Developing a new drug and gaining regulatory approval is a long and expensive process that involves multiple stakeholders. The time required to develop a new drug can range from 10 to 15 years or longer. The average cost of developing at least one successful epidemic infectious disease vaccine from preclinical to the launch phase, taking into account the cost of failed attempts, has been estimated at from 18.1 million to 1 billion in USD.
Decisions about what drugs to develop often reflect the priorities of the companies and countries where drug development occurs. As of 2021, the United States had launched the highest number of new drugs and had the largest expenditure overall on pharmaceutical discovery, accounting for approximately 40% of the research done globally. The United States is also the country with the highest profits for pharmaceutical companies, and the highest drug costs for patients.
Emerging and reemerging viruses substantially affect people in low and middle income countries (LMICs), a pattern that may increase due to climate change. Pharmaceutical companies may have limited financial incentives to develop treatments for neglected tropical diseases in poor countries.
International organizations such as the World Health Organization, Unicef and the Developing Countries Vaccine Manufacturers Network support development of treatments for diseases such as West Nile virus, dengue fever; Chikungunya, Middle East respiratory syndrome (MERS), severe acute respiratory syndrome (SARS), Ebola, enterovirus D68 and Zika virus.
Vaccine affordability A major factor in the economics of vaccines is intellectual property (IP) law. IP systems typically grant pharmaceutical companies temporary exclusive rights, which can allow for limited competition over a period of years. Economic models of monopoly pricing suggest that firms may adopt value-based pricing strategies, setting prices based on what the market will bear rather than on production costs. This can result in prices that are unaffordable to some populations compared to cost-plus pricing, which is based on production costs plus a markup.
Price discrimination refers to the practice of charging different prices to different consumers based on their willingness or ability to pay. In some cases, this can lead to higher prices overall compared to those in a fully-competitive market. Critics argue that such pricing strategies may limit access to vaccines in lower-income populations, although companies may state that differential pricing allows for broader distribution across markets.
Organizations such as Amnesty International, Oxfam International, and Médecins Sans Frontières (MSF; Doctors without Borders) have criticized government support of certain pharmaceutical monopolies, on the grounds that they can contribute to higher prices and reduced access to vaccines. During the COVID-19 pandemic, some countries and organizations called for COVID-related IP to be suspended, using the TRIPS Waiver. The waiver had support from many countries but was opposed by others, including members of the European Union (notably Germany), as well as the United Kingdom, Norway, and Switzerland, among others.
Vaccine production Low and middle income countries tend to lack technological expertise and manufacturing capacity for the production of drugs and medical products. This leaves them dependent on diagnostics, treatments and vaccines from manufacturers in other countries and on availability in the global market. There are some exceptions such as China, Cuba, and India, which are actively producing pharmaceuticals to internationally accepted standards.
The COVID-19 pandemic has led to recommendations to diversify pharmaceutical production between countries and increase the productive ability of LMICs. These actions could allow an environment within those countries to better ensure that their own production needs are being met, which would then aid in achieving global vaccine equity. For example, the African Union Commission and Africa Centres for Disease Control and Prevention have called on countries and organizations to enable the production of at least 60% of the total vaccine doses required on the continent by 2040.
However, potential problems with the diversification of vaccine production can involve: Availability of capital, technology, and skills Adherence to quality standards Inconsistent or unsupportive national and international policy frameworks Size of markets, purchasing power, and variable demand for vaccines Lack of national or local infrastructure (e.g. reliable energy, electricity, transportation)
Even when organizations are willing to share their information, knowledge transfer can create serious delays for the production of vaccines. This may be particularly true in the case of novel technologies. LMICs may be better situated to produce vaccines that are based on more established technologies, if those are available.
Vaccine allocation In the absence of well-organized systems to develop and distribute vaccines, vaccine companies and high income nations may monopolize available resources. Organizations such as GAVI, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization have proposed multilateral initiatives such as Covax for the improvement of vaccine allocation. The intention with Covax was to collectively pool resources to ensure vaccine development and production. The resulting vaccine supplies could be fairly distributed to reach less wealthy countries and achieve vaccine equity. Foreign aid and resources from richer countries would cover the cost of distributing doses to lower-middle and low income countries.
As an allocation mechanism, Covax has succeeded in distributing COVID-19 vaccines, beginning with a shipment to Ghana on 24 February 2021. In the next year Covax delivered 1.2 billion vaccines to 144 countries. Covax was not able to acquire doses directly from manufacturers at the levels it had hoped. An estimated that 60% of the doses it distributed in 2021 (543 million out of 910 million) were donated doses from wealthy countries, beginning with the USA (41% of all donated doses).