Bangladesh must act immediately to secure adequate Covid-19 vaccine doses
The stagnant, coronavirus-ravaged world is looking for a way out. An effective vaccine is expected to bring the world back to normal. Although it usually takes five to 10 years to develop a new vaccine, two Covid-19 vaccines so far have received emergency use authorization (EUA) with incredible speed, and a few more are on the verge of success. Now, a fierce competition has started among countries to secure enough vaccines.
Even before the approval of Covid-19 vaccines, all developed countries had already pre-ordered nearly 10 billion doses to protect the health of their people. Some countries (5 high-income and 27 EU countries), comprising 13% of the total world’s population, have confirmed over 5 billion doses by 2021.
Ironically, some countries have contracted with the vaccine manufacturing companies to buy several times more doses than needed to vaccinate the entire population of a country (see Figure 1).
An unequal race to secure vaccines
The potential production capacity of 10 frontline vaccine candidates is around 10 billion doses by 2021. To vaccinate 7.5 billion people in the world, it will require 15 billion doses (two doses per person) of vaccines. High-and middle-income countries have confirmed the required amount through a pre-order agreement with manufacturing companies.
Billions of people in 92 low-middle and low-income countries could be deprived of the Covid-19 vaccines due to unequal competition. According to research conducted by the Duke Global Health Innovation Center, many low-middle and low-income countries may have to wait until 2023-2024 for vaccines; therefore, Bangladesh must act immediately to secure the Covid-19 vaccine doses required to vaccinate its population.
When can Bangladesh get enough vaccines?
The government of Bangladesh has recently entered into an agreement with the Serum Institute, India to procure the Oxford-AstraZeneca vaccine. According to the agreement, 30 million doses will be provided to Bangladesh. The Serum Institute has also entered into agreements with several other countries and the World Task Force (named COVAX). Serum Institute also has to meet the demand of India as a producing country.
Considering all these factors, Bangladesh may get the Oxford-AstraZeneca vaccine by the end of 2021. More importantly, with the procured 30 million doses, only 15 million people (8.8%) can be vaccinated.
On the other hand, the COVAX initiative mediated by the World Health Organization (WHO) and GAVI has been established with a primary objective for equitable vaccine distribution among developed and developing countries. COVAX’s goal is to procure 2 billion doses by 2021 to vaccinate 20% of the population in each country (high-risk groups).
The first target is to vaccinate 3% (health and social workers) of the population and then scale up to 20%. So far, COVAX has only pre-ordered 500 million doses. Due to the unfortunate and unequal pre-order competition, COVAX is likely to deviate from its original purpose and target. Therefore, Bangladesh must not rely only on COVAX to get the required number of doses, and pre-order is absolutely necessary.
Recently, Adar Poonawalla, the chief executive of the world’s largest vaccine manufacturer, Serum Institute, has warned that not enough Covid-19 vaccines will be available for everyone until the end of 2024. “It’s going to take four to five years until everyone gets the vaccine on this planet.”
Why is it necessary to order in advance?
It is the responsibility of the government to ensure the health of the people. Moreover, the issue of “Covid-19 vaccine passport” is circulating in the world media. All developed nations will take every effort to ensure that the horror of the Covid-19 pandemic never comes back. Millions of Bangladeshis go abroad for business, employment, and education. Without vaccination, we may not be allowed to travel abroad and, therefore, the economy will be impacted heavily. So, the government has to act smartly to secure the required doses of Covid-19 vaccines to protect human lives and save the economy of the country.
Which vaccine candidates we should and should not target
The Covid-19 vaccines under development could be categorized based on the technology platforms utilized, namely mRNA technology, adenoviral vector technology, protein subunit, and inactivated vaccines (see Table 1).
mRNA vaccines: Using this technology, the vaccines of BioNtech-Pfizer and Moderna-NIAID have so far proven to show acceptable efficacy and safety profiles.
However, the storage temperatures for BioNtech-Pfizer and Moderna-NIAID are (minus) -70°C and (minus) -20°C respectively. Such (ultra) cold-storage is expected to be a huge logistic challenge for the vaccination program of Bangladesh.
Importantly, according to WHO estimates, over 50% of vaccines are wasted globally just because of not maintaining proper regular temperature (2-8°C). Moreover, those vaccines are relatively expensive -- for instance, the vaccine cost of Moderna-NIAID is $74 per person. Bangladesh may consider BioNtech-Pfizer and Moderna-NIAID vaccines after assuring that (ultra) cold chain storage is properly functional.
However, using the mRNA technology, CureVac is developing another vaccine that is expected to receive emergency use authorization during summer 2021, which can be stored in standard 2-8°C. Bangladesh should pre-order the vaccine of CureVac but effective price negotiation may be necessary.
Adenoviral vaccine: This vaccine technology has proven to be successful in receiving FDA and EMA approvals. For instance, the technology used by Janssen Pharmaceutica (Johnson and Johnson) has received EMA approval for the Ebola vaccine in 2020 (see Table 1).
Moreover, due to its standard storage temperature, relatively cheap price, and capability of manufacturing in huge doses, Bangladesh must consider pre-ordering the Janssen vaccine in addition to more doses of the Oxford-AstraZeneca vaccine. Sputnik-V vaccine of Gamaleya Institute (Russia) should also be strongly considered. Recently, there has been an agreement that Serum Institute of India will manufacture 100 million doses of Sputnik V vaccines.
Protein subunit vaccines: This vaccine technology also has proven to be successful in receiving FDA and EMA approvals. More importantly, the vaccine candidate of Novavax so far has shown acceptable efficacy and safety profiles. In addition, the Novavax vaccine is relatively cheap and, due to its standard storage temperature, Bangladesh should consider pre-ordering this vaccine too.
Inactivated vaccines: It is remarkable that none of the scientifically advanced countries in the EU and countries like the US, the UK, Australia, and Japan have chosen and have not invested their money in inactivated vaccines (see Figure 1). Similarly, Bangladesh should stay away from the inactivated vaccines of Bharat Biotech, Sinovac, Sinopharm, Institute of Medical Biology of Chinese Academy of Medical Sciences, Research Institute for Biological Safety Problems of the Republic of Kazakhstan, and Shenzhen Kangtai Biological Products Co Ltd, among others.
Other than the scientifically questionable efficacy of inactivated vaccines, such vaccines like the Sinovac one ($60 per person) are very costly.
How Bangladesh must act immediately to secure enough vaccines
1. Pre-order frontline vaccine candidates suitable for Bangladesh: The government must start pre-ordering frontline vaccine candidates without any delay. In choosing the scientifically solid vaccine candidates, Bangladesh should also follow those vaccines pre-ordered by the developed countries.
The vaccine candidate of Janssen Pharmaceutica (Johnson and Johnson) should be given the priority as the vaccine technology has proven to be successful in receiving the recent EU approval for the Ebola vaccine.
Moreover, the Janssen vaccine is affordable, its storage temperature is suitable for Bangladesh, and the vaccine will be manufactured over 1 billion per year; therefore, the chance of getting that vaccine in Bangladesh is relatively high.
Bangladesh should also pre-order the vaccine candidates of Novavax and CureVac. Sputnik V could also be an interesting candidate for Bangladesh as Gamaleya Institute has already permitted India and Latin America to produce 100 million doses each.
2. Promote private initiatives to secure vaccines: The whole population of Bangladesh should not wait to receive Covid-19 vaccines through a government funded vaccination program. Studies have shown that nearly 70% of patients seek healthcare service in private hospitals/clinics and, therefore, a significant proportion of the population can afford vaccination from private initiatives.
Therefore, the government should promote reputed pharmaceutical companies to make deals with vaccine developers to ensure that Bangladesh gets priority access to suitable vaccines and secure more doses of Oxford-AstraZeneca vaccine through the Serum Institute.
3. Efforts to acquire bulk lots of vaccines for fill-finish in Bangladesh: Bangladesh could also ask Russia and other vaccine developing companies to utilize the internationally recognized, high quality vaccine fill-finish platform available in pharmaceutical company(ies) in Bangladesh.
This will help tremendously to secure enough doses of vaccines within a short-time.
4. Take an active role in the movement of equitable distribution of vaccines: The people living in developing countries like Bangladesh must not be left behind. Bangladesh should raise a voice and start lobbying for the equitable distribution of vaccines.
Dr Rezaul Karim is an immunologist and former project lead at WHO-Utrecht Centre of Excellence for Affordable Biotherapeutics, The Netherlands. Dr M Shamsul Alam, Immunologist working at the National Institutes of Health, USA. Dr Jubayer Rahman. Immunologist working at the National Institutes of Health, USA. Professor Dr Md Anwar Hossain, Vice-Chancellor, Jessore University of Science and Technology, Researcher on vaccine development. Dr Mohammad Sorowar Hossain, Former Senior Manager (R&D), Biotech Division, Incepta Pharmaceutical Ltd; Associate Professor, Independent University, Bangladesh; Executive Director, Biomedical Research Foundation, Bangladesh.