Mumbai: As the race to defeat the COVID-19 pandemic gathers pace, with COVID-19 vaccination efforts under way in several countries including India, it is time to ask how and where vaccine doses are being distributed, and who is being prioritised for vaccination.

Gavi, the Vaccine Alliance, has helped immunise more than 822 million children in 73 low-income countries for various diseases, preventing more than 14 million deaths. Now, Gavi is coordinating the COVAX initiative along with the World Health Organization and the Coalition for Epidemic Preparedness Innovations, which aims to distribute two billion COVID-19 vaccine doses by end-2021. The COVAX initiative brings together both self-financing countries, who are wealthy enough to purchase their entire vaccine supply, and low-income countries who will need support including funding to inoculate their populations, a recognition that cooperation is essential to reaching global herd immunity and a return to the pre-COVID normal. Two-thirds of COVAX's two billion doses will go to low-income countries among its 190 participating countries.

Gavi has pledged 200 million doses, worth $1.4 billion (Rs 10,200 crore), to India for the first phase of vaccination. IndiaSpend asked Anuradha Gupta, deputy chief executive officer of Gavi, about the logistics of implementing such a mammoth vaccination effort globally. Gupta is also a member of the board of the Partnership for Maternal, Newborn and Child Health, and formerly a mission director of India's National Health Mission.

IndiaSpend asked Gupta if the vaccination drive will coincide with the possible spread of herd immunity in India, and whether existing COVID-19 vaccine candidates--approved and in the pipeline--will be effective against new COVID-19 variants that have recently emerged.

Edited excerpts:

What is the projected total global demand right now for COVID-19 vaccines, and what is the vaccine supply chain looking like?

The COVID-19 pandemic is still raging, with cases crossing 100 million. Two million people have lost their lives. There has been a sharp surge in many countries, with several new variants now rearing their heads, which are spreading faster and could also be more lethal. As a result, many countries have imposed new lockdown restrictions and travel bans. So, it's a very encouraging trend that we have a growing portfolio of vaccines being approved for use and rolled out in many countries, including in India, and vaccines that are ready for approval.

However, I would like to emphasise that the vaccination effort is not a sprint. We have to brace ourselves for a very long and arduous marathon. There are challenges relating to supply and demand, funding and logistics. We would need steadfast global solidarity and national preparedness to put an end to the acute phase of the pandemic.

What is the perceived vaccine demand globally, right now? Where do we stand, as a planet, in terms of meeting that demand? And what role will Gavi play?

The demand for COVID-19 vaccines is global because it is a pandemic. There is no country which is untouched by this disease. We need to vaccinate at least high-risk populations in every country because, in a highly interconnected world, nobody is safe until everyone is safe. Thus, the demand for COVID-19 vaccines in 2021 is going to far outstrip supply.

Gavi's projection is that through the COVAX facility, which brings together 190 countries--both rich and poor--we should be able to deliver two billion doses in 2021. The doses could start to flow into countries as early as February, with a ramp-up in March. But it is really in the second half of this year that we would start to see scaled-up efforts in most countries. So, in 2021, we might see about 40% to 50% of the population covered in richer countries, but roughly about 20% of the population covered in all countries, at a minimum.

What is the difference between the vaccine doses that Gavi is rolling out, and the vaccines that are already being administered in many countries, including the United States, Europe, Middle East and India?

Gavi is at the forefront of COVAX, which is a global effort to bring together all countries to plan for fair and equitable supply of COVID-19 vaccines around the globe. There should be a global solution to a global problem. There shouldn't be 'vaccine nationalism', or hoarding of vaccines by one country. We should try and work together to make sure that there is a fair distribution of these vaccines, and also at speed and at scale. Because demand in 2021 is going to outstrip supply, we have to take a very targeted approach to use the vaccines that are going to be available. That is the key to success. If we are able to protect the health workforce, the elderly and those with comorbidities, that itself should have an impact on reducing severe COVID-19 cases requiring hospitalisations, and deaths. That would save health systems from getting overwhelmed.

Through the COVAX facility, we are going to support 92 countries which may not have the fiscal capacity to buy COVID-19 vaccines themselves. Our goal is to mobilise more than $7 billion [Rs 51,000 crore] to help these countries, and deliver about 1.3 billion doses to them in 2021, so that they can cover up to 20% of their population and possibly more, starting with high-priority groups. Richer countries are also a part of the COVAX facility and are self-financing participants, meaning they pay for their vaccines. COVAX pools vaccine demand globally, and that helps us manage the distribution and supply of vaccines in a much more equitable fashion. The rich countries also are mobilising funding to pay for COVID-19 vaccines for these 92 countries, in line with the Gavi model, which is predicated on providing access to vaccines in low-income countries.

Do the vaccine doses that COVAX is holding, or will source, come from the same pool of manufacturers from whom rich countries are buying vaccines directly? Is COVAX sourcing the doses from the same manufacturers?

It is a mixed picture. Some rich countries have struck bilateral deals. There are also rich countries who do not have bilateral deals, who would be receiving doses only through the COVAX facility.

How will COVAX's effort to start rolling out vaccine doses from February to poorer countries move logistically? What does the war room look like inside, right now?

For us, of course, it is a war-like situation and we are working on a war footing. We are essentially focused on four key things. First is advocating for global solidarity and multilateral coordination, because that alone can ensure fair and equitable access to COVID vaccines. Second, and very important, is securing agreements with manufacturers to supply two billion doses in 2021 to COVAX countries, both the self-financing ones and also advanced market commitment countries. Third, to raise at least $7 billion to provide between one and 1.5 million vaccine doses to 92 low-income countries. Finally, supporting these 92 countries to effectively deliver the vaccines to priority groups. This is a mammoth undertaking that requires extensive planning, very deft stakeholders' management and dialogue, as well as relentless advocacy.

The number of cases is slowly dropping in India. The number of deaths has also dropped quite sharply. We don't know whether the situation could reverse, as it has known to have done in other countries. But it does look like the pandemic is coming under control in India. Will that change the way COVAX will look at vaccine distribution?

First of all, I do want to emphasise that the COVID-19 virus is still winning and that it is too early to conclude that the pandemic is under control in any country because we have seen big spikes in infections and also mortality in several countries. Containment of cases is directly related to the measures that countries are currently taking in terms of social distancing, lockdown measures and travel bans, and clearly these are not sustainable. India has also imposed a travel ban because the South African variant could not only be more transmissible, but also probably more deadly. To what extent it is amenable to [existing] vaccine [candidates] is still being studied. So, several risks remain. Therefore, it is very important that we start vaccination in all countries and focus on high-priority groups to reduce transmission and save health systems from getting overwhelmed. Also, high-risk groups can actually be saved from unnecessary deaths.

So, regardless of what happens, whether prevalence of COVID-19 goes down in some countries, or rises in some countries, COVAX's original timetable for vaccine rollout, distribution and administering will stand as is?

Absolutely. We are very focused on making sure that every country receives vaccine doses and that we support them in cataloguing their priority populations with care. And then actually making sure that vaccines are injected into the arms of the people who need them.

In India, not many people are turning up to get vaccinated. We are seeing some vaccine hesitancy because of various reasons. These could be traditional, or to do with the lack of data on one vaccine and its trials. How could we address that situation?

Vaccine hesitancy is a global phenomenon, and there are several reasons for that. For example, sometimes, younger populations do not perceive themselves at risk and may not be very keen on receiving vaccines, but with very little understanding that they could actually transmit that disease to elderly populations, or those who are suffering from co-morbidities.

There is also sometimes a fear of adverse events, which is not limited only to COVID-19 vaccines, but is true for all vaccines, including [those administered in] childhood. Then there are a lot of rumours and misinformation. As we always say, along with this pandemic, there is also an "info-demic", where social media platforms are being used to spread misinformation and rumours.

Vaccine hesitancy has to be proactively addressed. Governments, opinion leaders, religious leaders, political leaders, everybody has to join hands in order to make sure that the right information is provided to people, because the best antidote to misinformation is good information. Communities also trust their health providers, so doctors and frontline health workers have a very big role to play. For them to actually inspire confidence in communities, they need to be equipped with the right tools, interpersonal skills and right information.

Finally, I think the trust between governments and people has to be bolstered, because people have to believe that their governments are in charge, are responsible to protect their health and well-being, and that they take that responsibility seriously.

There are new strains of COVID-19 emerging, in Bahrain, the UK and South Africa, and these have been shown to be more dangerous. Was this anticipated at the early stages of Gavi's planning for COVID-19? Or are the variants being encountered only now, which begs the next question: To what extent will these vaccines be effective against the new variants?

The scientific community has always been aware of the risk of mutations, because as the [SARS-CoV-2] virus [that causes COVID-19] spreads, it gets replicated, and also mutates. There is a lot of real-time research of the phenomenon. That is why we are rapidly getting this information about new variants being seen, whether in South Africa, the UK or Brazil. So the [variants] were very much anticipated and there is a lot of research and development under way under COVAX to get prepared to develop vaccines: First, to test the efficacy of approved vaccines against these new variants, and second, to develop new vaccines for new variants, wherever required and at a very rapid pace. The timelines that are being envisioned are very aggressive. One hundred days. And I think that is a testament to the scientific advancement that we have seen during this pandemic. This pandemic has tested human ingenuity and brought out the best in terms of scientific collaboration and global solidarity.

Should people take the vaccine? If yes, what do they need to know?

My fervent plea to everybody would be to come forward to take the vaccine because you are not just protecting yourself, you are also contributing to protecting others. It is also a cause that you are serving by coming forward for vaccination. The pandemic has destroyed people's lives and livelihoods and it is important that so many families don't have to lose loved ones, that the economy gets back on track, that people are not pushed into poverty. Please have trust in the scientific community of your country, and the regulators. It is they who are going to examine and assess the aspects of safety and efficacy of all the vaccine candidates. With that trust in your heart and in your mind, you should absolutely avail the first possible opportunity to get vaccinated.


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