14 May 2021

In this issue

1. "Bold and ambitious, but achievable": Every region in the world can make vaccines

2. Without testing, vaccine campaigns would be "blind to what is happening"

3. Milestone: ACT-A reflects on its first year in the fight against COVID-19

4. COVAX reaches its first 100 countries

5. ACT-A news flash: Our Special Envoy Carl Bildt appeals to wealthy countries to fully fund ACT-A. Also, responding to India's surge, the push for better health systems, and more

6. On the agenda

“Bold and ambitious, but achievable”: Every region in the world can make vaccines

Most countries don’t manufacture vaccines. They have to import them.

Fewer than a dozen countries are producing COVID-19 vaccines today, while the rest—more than 180 countries—continue to scramble for doses from abroad.

One consequence of such limited manufacturing has been a “grotesque inequity” in the distribution of vaccines, says WHO Director-General Dr. Tedros Adhanom Ghebreyesus. He cites some dire statistics: The world’s more affluent countries have received 82.2 percent of the vaccines, while low-income countries’ share has been just 0.3 percent. As of early May, there were still 14 countries— Burkina Faso, Chad, the Central African Republic, Haiti, Vanuatu and others—that had no vaccines at all.

“Most countries, including most African countries, do not have anywhere near enough vaccines to cover all health workers or all at-risk groups,” Dr. Tedros said. “Never mind the rest of their populations.”

The danger of limiting vaccine manufacturing to so few countries has become harshly apparent in recent weeks. In late March, India, the major vaccine supplier to COVAX, stopped exporting doses that would have gone to low-income countries so that it could deal with record numbers of cases and deaths at home.

Global health leaders say it doesn’t have to be this way. With the right partnerships, knowledge-sharing, training and investment, many more countries can, and indeed must, become vaccine producers.

“We have to start somewhere,” said Dr. John Nkengasong, Africa Centre for Disease Control director. “A continent of 1.2 billion people cannot continue to import 99 percent of its vaccines. That does not square with the world health security that we have been discussing.”

New alliances, new ideas

In March, WHO, Coalition for Epidemic Preparedness Innovations (CEPI) and partners created a special COVAX task force to identify manufacturing plants that could be quickly adapted to carry out some of the steps of vaccine production—a prelude to the group’s longer-term goal of building a widely dispersed, sustainable network of vaccine makers.

“We do need a spectacular increase in volume of production. We’re talking about a tripling or quadrupling of production,” said Dr. Seth Berkley, chief executive officer of Gavi, the Vaccine Alliance, which leads COVAX, the vaccine pillar of ACT-A. “Will we need boosters because of waning immunity? Will we need new vaccines because of variants? Will we need boosters because of variants? Regardless of any of those three issues, we will need more vaccines.”

At a virtual summit in mid-April, the Africa Centres for Disease Control and Prevention and the African Union launched their Partnership for African Vaccine Manufacturing, with plans to create an ecosystem of sustainable vaccine development that would provide for 60 percent of the continent’s routine immunization needs by 2040. That number stands at 1 percent today.

“The vision of a strong African medical supplies and vaccine manufacturing capability is bold and ambitious, but is achievable,” South African President Cyril Ramaphosa told the summit, which drew more than 40,000 participants.

The Partnership plans to set up five vaccine production hubs on the continent over the next 10 to 15 years. The first three hubs, in Rwanda, Senegal and South Africa, would produce mRNA vaccines. These cutting-edge vaccines have only just come into use, developed in response to COVID-19 pandemic.

The difficulties of such an undertaking are many: access to expertise, raw materials, equipment, markets and technology. Regulatory systems will have to be built, intellectual property rights negotiated, and major, enduring sources of funding secured.

“We know of one company that has over 20,000 litres of production capacity but they have not been able to produce vaccines because they don’t have the raw materials and equipment they need,” Dr. Berkley said.

African leaders acknowledged the complicated task ahead by appending, in a communique released after April’s summit, a quote from Nelson Mandela: “It always seems impossible until it is done.”

Another notable outcome of the summit was an agreement between CEPI and the African Union Commission to strengthen ties with the Africa CDC to enhance vaccine research, development and manufacturing.

Seeded across the world map, manufacturing hubs would not only allow countries to better fend for themselves in a pandemic, leaders say, but to prepare for outbreaks of local diseases, come to the aid of neighbors, and contribute to the huge global shortfall in vaccine manufacturing capacity that COVID-19 has made so painfully clear.

Before the pandemic, the world had the capacity to produce 3.5 billion doses of vaccines a year—shots to protect against measles, polio, tetanus, the flu, hepatitis and other familiar infections. But now, with COVID-19 added into the mix, we need 10 to 14 billion doses a year, said World Trade Organization (WTO) Director-General Dr. Ngozi Okonjo-Iweala.

“Africa is the continent with the lowest rate of vaccine delivery—1.1 doses per 100 people. In North America the figure is over 40. This is morally unconscionable and a serious economic hit,” Dr. Okonjo-Iweala said. She cites World Bank estimates that each month of delay in vaccine access costs Africa $13.8 billion in lost output.

Partners and progress

In South Africa, Aspen Pharmacare is partnering with Johnson & Johnson to supply 220 million COVID-19 vaccine doses from Aspen’s facility in Port Elizabeth, beginning as soon as June.

Canada has signed its first deal to allow a foreign vaccine to be manufactured domestically. The vaccine, from the US-based Novavax company, will be produced in a new government facility in Montreal due to open this year.

On Wednesday, Cuba started a mass-vaccination campaign, becoming the smallest country in the world to manufacture and deploy its own COVID-19 vaccines. Cuba hopes to inoculate its entire population of 11 million by the year’s end and also sell its Soberana-2 and Abdala vaccines to other countries. Latin America, one of the regions hardest hit by the pandemic, stands to benefit.

And the UK, which didn’t make many vaccines before the pandemic, now has several factories churning them out by the millions.

“This has to be just the beginning,” UK Health Minister Matt Hancock said, speaking at the Chatham House think tank in March. “I’m so pleased we’re talking about global solutions today. About how we can broaden access. How we remove tariffs where they apply. How we can better share data on efficacy and trials. How we can oppose vaccine protectionism in all its forms.”

Working in partnership with ACT-A, African leaders are looking hard at the resources they already have as possible starting points for their own industry.

With the right support, factories in Egypt, Morocco, Senegal, South Africa and Tunisia that are now packaging and labeling vaccines, and occasionally filling vials, could broaden their roles. The dozens of African facilities that make sterile injectables could also be tapped.

“We can examine how to turn these manufacturing capacities around so we can have the full value chain of manufacture,’’ said Dr. Okonjo-Iweala, . "We also have capacity for manufacturing animal vaccines and we should look into this.”

India and Brazil could share valuable insight on how they expanded their own generic pharmaceutical industries, leaders say. Over the past year, Indian companies have created the Covaxin vaccine, while forming international partnerships to produce Russia’s Sputnik vaccine and the UK’s AstraZeneca/Oxford University vaccine. Brazilian facilities are making China’s Sinovac, as well as AstraZeneca, and are trialing their own vaccines to protect against dangerous local variants.

In the end, it will be the degree to which countries share resources and wisdom that determines how humanity weathers COVID-19.

“Let’s face it. Only through collaboration will we be able to overcome this devastating pandemic,” said President Ramaphosa, who serves as co-chair of the ACT-A Facilitation Council, the high-level international body that leads and advises the partnership. “In my view there’s no other way in which we can confront this … in a cooperative way, standing together instead of standing against each other.”

For more on Africa’s budding vaccine industry, check out this Q&A with Professor William Ampofo, chairperson of the African Vaccine Manufacturing Initiative

Without testing, vaccine campaigns would be "blind to what is happening"

Everybody’s talking about vaccines. Diagnostics? Not so much.

But without testing there can be no vaccines. They can’t be developed or intelligently rolled out. We can’t tell if they work.

As Dr. Jeremy Farrar, director of the Wellcome Trust, told colleagues at a recent meeting of the ACT-Accelerator Facilitation Council, “Without diagnostics we are blind to what is happening. We do not know how the epidemic is developing. We do not know where there are pockets that will reseed dreadful waves of the epidemic.”

One big misconception about testing is that its job ends when a vaccine appears. In fact, public health experts point out, diagnostics are hugely important during and beyond a vaccine’s rollout; in other words, right now.

“You’ve got variants. You’ve got reinfections,” said Dr. Gagandeep Kang, professor of microbiology at Christian Medical College in Vellore, India, vice-chair of CEPI, and a leading expert on diagnostics and vaccines. “You don’t know that protection lasts forever.”

Already, testing is discovering that the available COVID-19 vaccines are less effective against some virus variants, which now number in the thousands.

“The emergence of the variants, although inevitable, has been quite an emotional rollercoaster,” said Sarah-Jane Loveday, head of communications at FIND, which with the Global Fund co-leads ACT-A's diagnostics pillar, also supported by WHO. "Right now we have a window of opportunity because most of the tools we have are still effective. But as fast as we are, the virus is always going to be faster—unless we can get it under control."

Every step in a vaccine’s life is shadowed by its less-famous companion, diagnostics. In the development phase, the only surefire way to find out if a new vaccine works is to test how volunteers respond to it in trials. A little further down the road, data from testing helps predict the level of protection a vaccine will provide when it makes the jump from the lab to the real world, and tells public health officials how many people should get a jab to reach herd immunity—the point when there are too few susceptible hosts for the disease to spread.

Today, as COVID-19 vaccines are being rolled out, public surveillance via testing is the only way to know if they are living up to their promise. And if they aren’t? Then health systems can promptly respond by ramping up vaccination campaigns, or getting to work on new vaccines.

“You can measure vaccination but you can’t assess the impact of that vaccination without testing,” Professor Kang said. “How else will you recognize that the vaccines are working?”

Yet fundraising for diagnostics has been tough. ACT-A’s diagnostics pillar needs US$ 8.7 billion for 2021 to keep pace with the demands of the pandemic. Diagnostics is the least funded of the four ACT-Accelerator pillars; contributions have been running eightfold behind the contributions for vaccines.

“I think vaccines sound cool. Diagnostic tests probably don’t,” Dr. Kang said, reflecting on the unevenness in the donations.

A view from the frontlines makes clear how diagnostics fits into the complicated machinery of a pandemic response, and what an historic struggle it has been for countries—especially those with fewer resources—to rise to the occasion.

In Nigeria, for example, there was nowhere near the diagnostics capacity to handle a new, fast-moving pandemic when in late Feb. 2020 an Italian contractor brought the country its first case of COVID-19, which was also the first confirmed case in sub-Saharan Africa.

Nigeria then had only six laboratories with the technology to run COVID-19 molecular tests in a population of 206 million. Health authorities there knew how essential diagnostics would be, not only for identifying cases, but for tracking the movement of the virus through their communities and laying the groundwork for a vaccine.

They saw the towering challenge they faced: Their handful of molecular testing labs, which had been set up for Lassa fever, would have to be adapted to test for COVID-19, and dozens more labs would have to be added. In a race against the virus, lab technicians, contact tracers and sample collectors would have to be hired and trained, and logistics—routes, trucks, warehouses, drivers, storage and many other details—would all have to be sorted out. Drive-in and walk-in testing centers would have to be opened up, and door-to-door testing mapped out.

Fritz Fonkeng, a technical officer for FIND who had been working with Nigeria Centre for Disease Control on Lassa fever, an illness similar to Ebola fever, suddenly found himself in the thick of the once-in-a-lifetime expansion to prepare for the new disease, collaborating with local and international partners allied under the ACT-Accelerator. There were long stretches when staff rarely left work before 11p.m., Mr. Fonkeng said, or didn’t go home at all, and times when the COVID-19 virus sidelined personnel and forced lab closures.

“At the beginning it was too much for us. I don’t think we’d ever had an outbreak of a disease where we tested more than 200 samples a day at the National Reference Laboratory, and in the beginning of Covid-19, we were testing more than 400 samples a day,” Mr. Fonkeng said.

By the arrival this March of the first COVAX shipment—nearly four million doses of vaccine—the country had 37 labs, one in every state, and the National Reference Laboratory was testing an average of 1,500 samples a day. Nationwide, about 4,000 samples a day were being tested.

The many months of testing had yielded data from across Africa’s most populous nation that allowed health officials to apportion the vaccine correctly. The foremost recipient became the city of Lagos, which testing had identified as a COVID-19 hotspot.

“We had a clear sense of the high-volume states, and that is how vaccines have been distributed,” Mr. Fonkeng said.

ACT-A is on the offensive as it moves into its second year, with plans for innovations in diagnostics to help finish off COVID-19. Low-cost self-tests are in the works, to help economies reopen by providing quick, accurate results for schools, workplaces or other large gatherings. The self-tests would join a growing diagnostics arsenal; new tools already include rapid antigen tests, introduced last September, which provide results in minutes instead of hours or days. Also on the horizon are new genomic surveillance tools that can provide early detection and monitoring of emerging COVID-19 variants.

“Testing is such a fundamental part of healthcare,” Ms. Loveday said. “It’s the only way you can get the data to make informed decisions, from individual patient care, to measures to break transmission and restore our daily lives. I hope by the end of this pandemic nobody will ever again say, ‘Why do we need diagnostics?’ ”

ACT-A reflects on its first year in the fight against COVID-19

ACT-Accelerator (ACT-A) partners, world leaders and supporters gathered in April to mark the alliance’s first anniversary, praising the most successful global effort in history to fight a disease, but recognizing that lower-income countries are being left far behind in the COVID-19 response.

Speaking at the virtual event, WHO Director-General Dr. Tedros Adhanom Ghebreyesus appealed to companies and countries to correct inequities by immediately share lifesaving resources such as vaccine doses, intellectual property, know-how and technology.

“Around the world, people are dying because they are not vaccinated, they are not tested and they are not treated,” Dr. Tedros said. “This is the time for us to write a new story, a better story that sees nations not as rivals or competitors, but as members of one human family with a common future.”

French President Emmanuel Macron announced at the meeting that his country had just sent out its first vaccine donations, to West Africa, and that at least 500,000 doses would be shared by mid-June. He called on other countries to also share vaccines.

“Our goal with these donations is to allow all countries, especially in Africa, to vaccinate their priority populations, starting with healthcare professionals,” President Macron said.

Several speakers emphasized that the uneven distribution of vaccines threatens not only those countries being left behind, but all of humanity, because the virus can mutate into dangerous new variants as long as it has a place to thrive.

“Viruses and infectious diseases know no borders. COVID-19 quickly spread from China to the rest of the world, and it has so far claimed at least 3 million lives,” Italian Prime Minister Mario Draghi said. “We struggled to understand that what was happening to another country would quickly happen to us, too.”

For the anniversary, ACT-A also released a special publication ACT Now, Act Together: 2020-21 Impact Report, which describes the alliance’s progress in bringing forth new vaccines, tests and treatments, and its cross-cutting work to strengthen health systems.

COVAX reaches its first 100 countries with vaccines

COVAX hit an important milestone on 7 April when it delivered a shipment of COVID-19 vaccines to its 100th recipient, the Caribbean island of Saint Lucia.

“COVAX understands that we all live in a village,” said Prime Minister Allen A. Chastanet, who met the cargo of 24,000 doses on the windy tarmac of the Hewanorra International Airport. “You can protect yourself, but if you do not take care of your neighbors, ultimately it’s going to come back and haunt you.”

The COVAX rollout began on 24 February with a delivery to Ghana, and as of late April had shipped more than 40.8 million vaccines to 117 participating countries and economies.

“COVAX works. The Act-Accelerator works,” said Dr. Bruce Aylward, leader of the ACT-Accelerator hub. He noted, however, that while the number of countries is heartening, the number of vaccines is still far, far too low.

“In high-income countries, one in four people have got a vaccine or can get a vaccine,” Dr. Aylward said. “In the lowest income countries, it’s one in 500. That is not equity.”

ACT-A partners say that to adequately vaccinate the world for COVID-19, governments, suppliers and other partners need to tear down several major barriers: inadequate funding, lack of access to intellectual property, and export restrictions.

See this short video on the COVAX delivery to Saint Lucia and learn about how the mechanism works:

ACT-A news flash:

Rich countries must contribute funds and vaccine doses to stop COVID-19, ACT-A envoy says

ACT-A Special Envoy Carl Bildt fears that the handful of wealthy nations with the resources to stop the pandemic might shift their attention away from COVID-19 now that their own domestic situations are improving.

But the pandemic is still "spreading like wildfire in parts of the world", Bildt told Bloomberg this week, and cannot be stopped without the support of high-income countries, namely, generous vaccine donations and the funds to fill an 18.5 billion shortfall for this year's pandemic response.

“The risk is that if people in the U.K., EU or U.S. think the worst is over, the attention will shift,” Mr. Bildt said. “The worst isn’t over.”

Mr. Bildt added that Europeans and Americans have ordered quantities of vaccines substantially in excess of what they need immediately, and the time has come to share.

"The EU and U.S. have been talking about it," Mr. Bildt said. "But we need to go from talking to actually doing it.”

ACT-A's interactive funding tracker shows the donors and pledges thus far.

Help for India's pandemic surge

ACT-A partners are responding to the COVID-19 surge in India with a slate of emergency measures to provide more oxygen, field hospitals, testing supplies, medicines, loans, extra personnel and other help. See details here .

ACT-A leaders push for better connecting countries with COVID-19 tools

In its sixth meeting, the ACT-Accelerator Facilitation Council on Wednesday focused on helping countries build stronger health systems to fight COVID-19 and prepare for future emergencies.

"Today we have the tools to end the acute phase of the pandemic. However, production, distribution, and uptake challenges continue to pose significant barriers to ensuring equitable access to these tools," said Dag Inge Ulstein, Council co-chair and Norway's minister of international development. "We need to support ACT-Accelerator to increase the availability of COVID-19 tools in underserved regions and countries."

The Council also discussed COVAX's new task force on expanding vaccine production, and hosted a session on raising US$ 18.5 billion to finance the global pandemic response through the end of 2021.

Watch a video of the full meeting.

"Vax Live" concert raises funds for ACT-A

Global Citizen's "Vax Live: The Concert to Reunite the World" mobilized US$ 302 million and 26 million vaccine doses for ACT-A, organizers have announced. The 8 May concert in Los Angeles featured appearances by Jennifer Lopez, Prince Harry and Meghan Markel, and included video appearances by Pope Francis , US President Joe Biden, First Lady Jill Biden, and US Vice President Kamala Harris. Read more.

Canada boosts its contribution to ACT-A

Canadian Prime Minister Justin Trudeau on 7 May announced a US $ 375 million contribution to ACT-A, bringing the country's support for the global pandemic response to more than US $ 2.5 billion. Read more.

Gordon Brown joins senior voices in calling for full funding for ACT-A

Former UK Prime Minister Gordon Brown, now special United Nations envoy, urged high-income countries to fully fund ACT-A. Joining Dr. Tedros at his regular press briefing on May 3, Mr. Brown said the funding is needed not only for vaccines, but for vital medical supplies, diagnostics and medical oxygen "currently and shamefully in short supply in India and elsewhere". He spoke ahead of next month's G-7 summit. Read more .

On the agenda:

• 21 MAY: Global Health Summit, Rome, hosted by the European Commission and Italy, chair of the G20. ACT-Accelerator will present an urgent case for burden-sharing among countries to fast-track equitable access to COVID-19 tools. Vaccine sharing, scaling up vaccine production, and reaching full funding for ACT-A will be discussed.
• 24 May-1 June: World Health Assembly. The gathering’s theme is “ending this pandemic, preventing the next: building together a healthier, safer and fairer world.”
• 2 June: COVAX AMC summit, hosted by Japan for Gavi, the Vaccine Alliance.
• 11-13 June, 47th G7 summit, in Cornwall, UK. Funding for ACT-A is expected to be a focal point for discussion.

The next issues of The Accelerator will focus on health systems and treatments. Please direct comments or suggestions to ACTaccelerator@who.int or to masciolac@who.int.