PHOTO: SIA KAMBOU/AFP VIA GETTY IMAGES1546 24 DECEMBER 2021 • VOL 374 ISSUE 6575 science.org SCIENCE
A
fter facing setback after setback this
year, the nonprofit formed to make
sure COVID-19 vaccines reach the
poorest countries of the world may
finally live up to its promise in 2022.
A 14 December report shows the
COVID-19 Vaccines Global Access (COVAX)
Facility is close to meeting a revised target of
1.42 billion available doses this year. And last
week, the effort got a huge boost when the
World Health Organization (WHO) gave its
first emergency use listing (EUL) to a vaccine
that COVAX is counting on for up to 1 billion
doses next year.
Despite COVAX’s recent successes and its
optimistic new supply forecast, delivering the
prized shots to needy countries
isn’t the last word in achieving
global vaccine equity: Many na-
tions may still struggle to dis-
tribute their supplies and, in
some cases, overcome vaccine
hesitancy. “Supply still needs
attention, but we have pivoted
to delivery and absorption as
the main issues,” says Seth
Berkley, CEO of Gavi, the Vac-
cine Alliance.
Established by Gavi, WHO,
UNICEF, and the Coalition
for Epidemic Preparedness
Innovations (CEPI), COVAX
initially set a goal of vacci-
nating 20% of the population
in every country—enough to
cover health care workers and
the people most at risk of de-
veloping severe disease. To accomplish this,
COVAX said it needed to have 2 billion doses
available by the end of this year. The latest
COVAX forecasting report shows the effort
will fall far short of that, with 1.38 billion
doses available by year’s end.
COVAX set out to buy vaccines in bulk and
then provide them to 1.8 billion people in
92 low- and middle-income countries at lit-
tle or no cost. But many wealthy countries
ordered far more doses than they needed,
bumping COVAX to the end of the purchas-
ing line. COVAX also counted on the Serum
Institute of India to supply up to 1.1 billion
doses, but it backed out of the arrangement
in March in order to protect India during its
Delta variant surge.
Supply steadily increased as wealthy coun-
tries began to donate excess doses and more
vaccine manufacturers received EULs from
WHO, a COVAX requirement. Last month,
Serum also began to export again. And on
17 December, WHO issued an EUL for the
protein-based vaccine made by Serum on
behalf of its U.S. biotech developer, Novavax.
The COVAX forecast projects it will
have made 2.39 billion doses available by
March 2022. It has options for a total of
more than 6.5 billion doses by the end of
next year. “I think we’re at a tipping point
of the problem being demand-driven ver-
sus supply-driven,” says Nicole Lurie, U.S.
director of CEPI.
For now, vaccine disparities between rich
and poor remain stark. As of 16 December,56.5% of the people in the world have re-
ceived at least one of the 8.56 billion doses
of COVID-19 vaccines administered, accord-
ing to Our World in Data. But in low-income
countries, that figure drops to 7.5%.
Half of COVAX’s 92 priority coun-
tries now have access to enough doses to
cover more than 20% of their population,
Berkley notes. “Of course, it is not enough
and there are still horrible inequalities.”
The large numbers of doses soon to
be “available” may not resolve inequities
quickly. “The supply forecast number is cer-
tainly important to track, but it is not the
most important measure of how many peo-
ple are actually getting access to vaccines
from COVAX,” says Krishna Udayakumar,who heads the Duke Global Health Innova-
tion Center.
Once manufacturers offer the vials,
COVAX must allocate them, based on re-
quests from countries and their ability
to “absorb” the shipments. There’s a 4- to
6-week lag between availability and deliv-
ery, which means at most, COVAX will de-
liver a total of 1 billion doses this year.
Delivery isn’t the finish line, Udayakumar
stresses. “Delivery for COVAX just means it
showed up in an airport, and it takes several
weeks if not months beyond that and an
enormous amount of effort at the country
level to get from airports to arms.”
Udayakumar points to several, more nu-
anced issues that will likely continue to
create problems for COVAX. High-income
countries that donate vac-
cines often don’t give recipi-
ent countries a timeline for
delivery and sometimes pro-
vide vials that are near their
expiration dates, making it
difficult to administer doses
in time, he says.
“The attempt to vaccinate
the world is going to run into
more intractable problems
than the supply issue,” agrees
William Moss, an epidemiolo-
gist at Johns Hopkins Bloom-
berg School of Public Health.
Political instability afflicts
countries that have the lowest
COVID-19 vaccine coverage,
whereas others have yet to ex-
press much demand. “There
are many settings where CO-
VID is just not the priority,” Moss says.
Lurie says COVAX recipients have also
become increasingly discriminating about
the vaccines on offer even though WHO
has given them all an authorization. “We’re
seeing countries say more and more ‘We
want the same vaccines used in America.’”
Vaccine misinformation and the attendant
skepticism and hesitancy have also become
global challenges, she adds.
Berkley says COVAX is now moving away
from trying to do a blanket distribution of
vaccines to hit the 20% mark and instead
is focusing on helping the 25 countries that
have the lowest coverage. “We are creating
bespoke plans for each one to deal with
their specific bottlenecks,” he says. jAfter a slow start, COVAX is increasing vaccine deliveries to nations such as Ivory Coast.By Jon Cohen
COVID-
Will global vaccine shortfalls end in 2022?
Novavax vaccine authorization bolsters COVAX’s optimistic new supply forecast
NEWS | IN DEPTH