COVID-19 Vaccine Production and Distribution: Who Gets it First?

The world may need 4.7 billion doses of coronavirus vaccines to reach herd immunity threshold.

According to some reports, the annual manufacturing capacity of vaccines for the entire world is approximately 8 billion doses. India, according to some reports, has a manufacturing capacity of 3 billion. But these numbers are for all vaccines – from essential childhood vaccines to seasonal flus.

Manufacturing of all these vaccines, that saved nearly 10 million lives between 2010 to 2015 according to the World Health Organisation, cannot be stopped to make way for the novel coronavirus vaccine.

So how does the coronavirus vaccine, if and when ready, reach the world? How many vaccines will have to be produced to cover everyone in the world? When will you and I get them? Will we get them?

Where Are We Right Now With Vaccines?

Oxford and AstraZeneca have hinted their vaccine candidate ChAdOx1 could be ready by year end. Pfizer and its German partner BioNTech have also said they may be on track to approach US drug regulators for approvals as early as October, and they will be in a position to manufacture 100 million doses by year end and 1.3 billion doses by fall 2021.

US-based Moderna and US National Institute of Health's vaccine called mRNA-1273 also enters stage 3 trials and officials have said the vaccine will be available for use by year end. There are currently 6 candidates in phase 3 of clinical trials according to WHO's data, including three from China – Sinovac, Beijing Institute and Wuhan Institute of Biological Products.

This is all before any single vaccine has finished phase 3 of clinical trials, cleared efficacy and safety hurdles and obtained licences.

Billions of Doses, But Who Will Get These Vaccines?

Depends upon geography, wealth, ability of governments to strike deals with manufacturers and supply chain. Several countries have already signed deals with vaccine manufacturers and makers to get their hands on the first doses being produced.

UK and US governments have struck a deal with Oxford and AstraZeneca to get their hands on the first doses. Much of the funding for the trials came from the UK government and the pharma major has said that 30 million doses will be available for Britons starting September. The rest will be distributed between other countries and global alliances like Inclusive Vaccine Alliance struck by France, Germany, Italy and Netherlands. US has said it will start stockpiling vaccines starting fall this year. AstraZeneca has also signed deals with The Vaccine Alliance for 300 million doses for lower and middle income countries (more on this below).

For India, Oxford has a deal with Pune’s Serum Institute and the company has said it will make a billion doses of the vaccine, with 400 million by year end for lower and middle income countries. Serum Institute has said a large chunk will be available for Indians.

The UK government has also stuck deals with Pfizer for 30 million doses and with French company Valneva for 60 million doses.

The US has struck deals with AstraZeneca to eventually manufacture 300 million doses and has stuck a deal with Pfizer and BioNTech with an initial order of 100 million doses for $1.95 billion and can acquire up to 500 million additional doses.

China, which has three vaccine candidates in stage 3, has said that it will have first access to the vaccine, even though it will treat the vaccine as global public good.

The Vaccine Alliance and the Rest of the World?

To protect the interest of poor and middle income countries, and thwart vaccine nationalism, GAVI, the Vaccine Alliance, is co-leading the ACT Accelerator, along with the WHO and Coalition for Epidemic Preparedness Innovations (CEPI) and other public health and philanthropy organisations. COVAX is the vaccine arm of the group that will access 2 billion doses of the vaccines.

How does it work?

This 'groundbreaking' global alliance will ensure fair and equitable access to the eventual vaccines. The idea is to pool the purchasing power of wealthy countries (rather than get them to compete with each other) and investing in manufacturing more doses. With the aim that any country, irrespective of what they can pay, gets equitable access.

So far, seventy-five countries have submitted expressions of interest to COVAX Facility. They will finance vaccines for their population by paying for these via their public health funds. Their support will help 90 other countries gain access to vaccines. Each country is assured a certain amount of doses to cover vulnerable 20 percent of population by end of 2021.

This all sounds great, but none of these ‘expressions of interest’ are binding. And so far, only Oxford and AstraZeneca have formally entered into an agreement with the alliance to supply 300 million doses.

There is the challenge of preventing countries from hoarding the vaccines (US, UK and other countries have already announced their intention to stockpile). During the H1N1 pandemic in 2009, Australia, the first to make a vaccine, blocked exports wanting to keep the vaccine for its citizens first.

India has shown an interest in joining this alliance. As middle income country, it will get access to doses for 20 percent of its population.

Who Among People Will Get in First?

How many doses of the vaccine will the world need? To achieve herd immunity, the world will need nearly 4.7 billion doses (if the threshold is 60 percent).

2 billion doses will be required to cover the healthcare workers and other high risk groups. First doses will go to healthcare workers, elderly who are most at risk, other high risk groups in hospitals.

After that, it will be distributed among the population, starting with high risk zones, eventually making it to the last mile.

Worldwide distribution is going to be a massive challenge and will involve exceptional coordination between manufacturers, distribution companies, countries and alliances.

Where Does India Stand?

• India, according to some reports, has a capacity to produce 3 billion doses of vaccines annually.
• India is one of the largest manufacturers of vaccines in the world and produces 70 percent of Unicef's vaccines.
• India's Ministry of Biotech will play a crucial role in upping manufacturing of the vaccine on priority.
• India has shown interest in joining the GAVI alliance, that will ensure supply of vaccines to at least 20 percent of its population.
• Serum Institute, that has a deal with Oxford's vaccine has already said they will have 400 million doses of the vaccine ready by year end, and India will get half of it. Phase 3 trials of the vaccine will get underway in India shortly.
• Serum Institute is also one of the largest manufacturers in India (and the world) followed by Biological E, Panacea Biotech, Bharat Biotech and Shantha Biotech.
• Various other vaccine manufacturers have tied up with several research institutes that have vaccine candidates at various stages of trials.
• But there are issues with investing in manufacturing – right now, we don't know what type of vaccine will eventually work – mRNA (Moderna, Pfizer and BioNTech) is a new type of technology that has never been used before to produce vaccines, several others are using different new technologies and innovations. Manufacturing sites can be finalised once we know what type of vaccine will eventually work.
• If ICMR and Bharat Biotech's indigenous vaccine – Covaxin – shows positive results, India has an upper hand in get it to its population. Covaxin is an inactivated vaccine, and this type of vaccine has been produced in millions for decades.

(The article was first published in FIT.)