How to Make COVID-19 Vaccines Available to All

At first glance, it may seem as if the world will soon have more than enough COVID-19 vaccines. Manufacturers have produced approximately ten billion individual doses since states began approving inoculations in the middle of 2020. Based on current estimates, they are now capable of making 12 billion doses each year. The World Health Organization has approved ten vaccines; multiple countries, such as Russia, have approved several more; and plenty of additional vaccines are still in development.

This scale-up in production—from zero to ten billion in less than one and a half years—is a remarkable feat, one never seen before in biological manufacturing. But as impressive as this accomplishment is, it will still be insufficient. The first reason for this is well known: dose allocation across countries is extraordinarily uneven. Over 70 percent of the COVID-19 vaccines produced in 2021 were bought by high- and upper-middle-income countries. Less than one percent, by contrast, have gone to low-income ones. The results speak for themselves. Some rich countries, such as Portugal, have fully vaccinated close to or more than 80 percent of their residents. Meanwhile, many poor countries, including Nigeria, have vaccinated less than two percent of their people.

But it is not just a problem of aggregate distribution. The world may appear to have lots of vaccines, but only 27 percent of them are messenger RNA (mRNA) shots, which train the body to make the protein that allows COVID-19 to infect cells and then the antibodies that fight it off. And so far, these are the vaccines that appear able to prevent people from becoming sick with the new, very contagious Omicron variant. These more effective and adaptable vaccines are even more concentrated in rich states than are shots overall.

Omicron’s rapid and sudden emergence highlights the uncertainties in the pandemic’s trajectory. It is possible that the world will need another round of vaccines, further straining supply and encouraging high-income countries to continue stockpiling doses. To prevent such an outcome, wealthy countries, multilateral development banks, and global health agencies will need to expand mRNA manufacturing in regions and countries that have little to no capacity. Doing that would increase overall supply and make it more difficult for a small collection of nations to hoard most doses. It would help distribute mRNA vaccines around the world, lowering prices and making shots more accessible to everyone. And in the long term, more dispersed manufacturing could help countries produce non-COVID-19 inoculations, protecting the world against other diseases—and better preparing it for the next pandemic.

BREAKING THROUGH THE BOTTLENECKS

Of all the COVID-19 vaccines delivered in the United States, the overwhelming majority—roughly 95 percent—are mRNA vaccines: Pfizer-BioNTech and Moderna. It is a statistic that stands in sharp contrast to the rest of the planet. Globally, over 43 percent of the COVID-19 vaccines produced in 2021 were made by Sinopharm and Sinovac using inactivated viruses. Nearly a quarter were produced by the University of Oxford-AstraZeneca, relying on viral vectors. Pfizer-BioNTech vaccines, an outright majority of all U.S. supplies, make up just over 20 percent of the world’s arsenal. Moderna, over a third of what the United States has received, constitutes a little over 5 percent of the planet’s production.

There is nothing inherently wrong with having large supplies of non-mRNA vaccines, which all do a good job of preventing severe disease and death. States should certainly take and distribute these doses if they are the ones they can quickest access. But unfortunately, studies in the lab and in the real world on the Beta, Gamma, and Delta variants showed that both viral vector vaccines and inactivated virus vaccines are not as effective as Pfizer-BioNTech and Moderna. As a result, many countries that previously administered Sinopharm, Sinovac, and Oxford-AstraZeneca have switched to mRNA shots for boosters.

If early results on the efficacy of shots against Omicron hold true in larger studies, there will be even an even stronger demand for mRNA vaccines around the world. But many countries will struggle to gain access to these shots. Right now, almost all mRNA vaccines are manufactured in Europe and the United States. For vaccine production as a whole, capacity is highly concentrated in China, the European Union, India, the United Kingdom, and the United States. The clustering of manufacturing creates a series of challenges. It provides vaccine-producing states, for instance, with undue international influence by giving them the power to use vaccines as a tool of trade and diplomacy. It also means that if countries with large production facilities institute export restrictions so they can vaccinate their own residents first, as India did in March 2021, countries without manufacturing networks may find themselves paralyzed.

Only 27 percent of the world’s vaccines are made with mRNA.

To make distribution more equitable, companies must build mRNA vaccine production sites around the world. They should focus especially on Africa and Latin America—two regions that have mostly been excluded from COVID-19 vaccine manufacturing (and vaccine supply chains generally). Manufacturers should, in particular, add production capacity in small states, such as Costa Rica, Panama, Rwanda, Senegal, and Singapore. Greater dispersion would help minimize the costs of vaccine nationalism. Even if these countries offered doses for their own populations before exporting to others, they would fulfill their domestic needs relatively quickly.

Thankfully, vaccine makers—including mRNA manufacturers—are taking steps to build capacity in such places. Pfizer-BioNTech has announced manufacturing partnerships in Argentina, Rwanda, and South Africa. Moderna has announced plans to build a facility in Africa, although the location and other details are not yet available. Johnson & Johnson and Oxford-AstraZeneca already have set up multiple manufacturing sites globally. Singapore has attracted a slate of vaccine manufacturing investments in the last 18 months, including from Pfizer-BioNTech, Merck, and Sanofi. Gennova, an Indian company, has set up its own domestic manufacturing plant and is developing an mRNA vaccine.

But right now, these factories won’t come online fast enough to meet the expected demand for variant-tailored doses. To speed up the process, the G-20 countries should provide new vaccine production sites with financing and technical help. They should also facilitate the flow of equipment and critical raw materials. Finally, major economies must push manufacturers to build more such facilities, offering assistance if needed.

KNOWN UNKNOWNS

Much is uncertain about the future of the pandemic, including what new variants might emerge, how effective different types of vaccines will be against them, and whether companies will be able to produce new, custom-tailored vaccines in response. But in most future scenarios, the world will need more manufacturing capacity for mRNA vaccines, which (in theory) are much simpler to adapt and reformulate than the competition. In the coming months, countries should also consider establishing plants for protein-based COVID-19 vaccines, the first of which—produced by Novavax—was just approved by the European Union and the World Health Organization. Protein-based shots cannot be retooled as quickly as mRNA vaccines, and it is unclear if they will be as effective against new variants. But like mRNA vaccines, protein-based shots use production systems that are simpler than those deployed by viral vector shots. Unlike mRNA vaccines, protein-based shots are not technologically new; the world’s manufacturers have more required technical experience and capacity for production.

Yet to build manufacturing sites that will be useful in the long term, it isn’t enough for countries to build facilities that can produce the kinds of shots needed right now. Companies and governments must construct manufacturing sites that are themselves flexible, so that they can easily switch from making one vaccine to another. The goal is for facilities to be able to quickly start producing different kinds of COVID-19 shots or even move from making COVID-19 vaccines to routine immunizations. Sanofi’s proposed production facility in Singapore offers one possible template. The site would have digital infrastructure and equipment capabilities that allow for quick changeovers, thereby enabling the site to toggle between three or four different types of vaccines. The proposed mRNA site in Rwanda would be a highly modular manufacturing unit, which should shorten the construction period and make it easier to reconfigure individual components if and when needed.

Vaccine manufacturing is a complex task, and it will take time to get new sites running.

Adaptability has its downsides. Flexible facilities could have higher operating and capital expenses compared with dedicated plants that produce extremely large volumes of one product. Gavi, the Vaccine Alliance; the World Bank; and the other multilateral institutions that finance vaccinations—such as the Asian Development Bank—will need to accept slightly higher prices from these new manufacturing sites as a premium for resilience and flexibility. Wealthy countries should also consider offering large, low-interest loans and grants to new facilities so that they can be cost competitive from the start. In the long term, flexible sites may actually have financial and risk advantages over single-use sites, since they can more easily adjust to the world’s needs.

It will take time to get the new sites running. Vaccine manufacturing is a complex task that requires the right equipment, workforce, quality-control systems, and inputs. The learning curve for mRNA manufacturing sites, which employ new technologies, will be especially steep. But recent contract manufacturers for Moderna and Pfizer-BioNTech were able to set up secondary sites in six to eight months, showing that with the right incentives and resources, building new facilities is achievable within a reasonable time frame. The United States and other G-20 countries could help expedite the process by having their biologics-manufacturing scientists to provide technical assistance and by offering financial support. The U.S. International Development Finance Corporation and the International Finance Corporation have already made some investments in additional manufacturing in India, Senegal, and South Africa. These efforts should be expanded and accelerated to bolster production capacity for currently approved mRNA vaccines, second-generation mRNA vaccines, and protein-based vaccines.

Unequal vaccination coverage cannot be magically fixed by creating more equitable manufacturing capacity. To tackle this problem, governments, international institutions, and businesses must take concerted action to improve vaccine deployment, cold chain capacity, and the supply of ancillary goods, such as syringes. National and community leaders will need to combat misinformation and encourage hesitant residents to actually get shots. But by expanding and diversifying vaccine-manufacturing capacity, the world could increase vaccine supply and improve distribution, better safeguarding the planet from infections. The wealthiest countries and companies have a responsibility to help the world as it moves through the Greek alphabet of COVID-19 variants and as it contends with whatever illnesses come next.