7 COVAX innovations that could help us fight the next pandemic

With 1.7 billion doses delivered to more than 140 countries and territories, COVAX is the largest, most complex vaccine rollout in history. The innovations made along the way could play an important role in fighting the next pandemic.

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© UNICEF/UN0579044/Kanobana
 

 

COVAX was conceived in January 2020, when COVID-19 was only just beginning its march across the globe, with a simple aim: to ensure no country, rich or poor, missed out on vaccines against this new threat if and when they became available.

This straightforward goal quickly confronted a far more complex reality. Nothing like this had ever been attempted before, and in that first year COVAX had to overcome a succession of inequities and barriers to access before it shipped its first doses in January 2021.

COVAX’s answer was the largest scale-up of ultra-cold chain technology in history. COVAX financed, coordinated and delivered 800 ultra-cold chain freezers to nearly 70 countries in 2021, enabling the delivery of mRNA vaccines to the countries that needed them.

Meeting these challenges required innovation on the part of staff at COVAX partners Gavi, CEPI and WHO, with UNICEF as a delivery partner. New solutions were devised and implemented, and as set out in a new White Paper published by COVAX this month, these hold important lessons that could help the world prepare better for the next pandemic.

1. The COVAX AMC

The COVAX Advance Market Commitment (AMC) is central to COVAX’s model. In previous pandemics, lower-income nations were always forced to the back of the vaccine queue. It was clear that, if this inequity was not addressed this time around, not only would millions of people be left needlessly at the mercy of COVID-19, but the pandemic would continue to spread and evolve.

The AMC set out to change that. Building on Gavi’s experience with the Advance Market Commitment for pneumococcal conjugate vaccines and the Advance Purchase Commitment for Ebola vaccines, the COVAX AMC would take funding from donor governments and “self-financing” participants and use it to make Advance Purchase Agreements with vaccine manufacturers, securing supplies of vaccines specifically for 92 low- and middle-income countries and territories around the world. These would then be delivered at no cost to countries, guided by a fair allocation framework developed with the WHO to prioritise those most at-risk.

Overcoming well-documented supply challenges in early 2021, the AMC has achieved some notable milestones, reaching its target of 20% population coverage – enough to cover vulnerable health worker and older populations – in early 2022. Today, more than 51% of people in AMC countries have received a full primary series of vaccines. Within the most vulnerable groups prioritised by COVAX, health workers and older adults, coverage stands at 75% and 63% respectively.

One key lesson from building and launching the AMC in 2020 is around the speed of delivery. COVAX’s early difficulties securing supply is partly down to the fact that it did not have the ‘at risk’ funding – support for the procurement of vaccines before they were developed and approved for use – in place early enough to secure early volumes of doses. Having contingent financing in place to fund at-risk procurements will be vital to ensure vaccine equity in future.

2. Dose donations

The fact that so much of the global vaccine supply in 2021 was concentrated in high-income countries meant COVAX had to be creative again to unlock doses for vulnerable nations. By calling for dose donations from countries with excess supply, COVAX set up a dose donation mechanism from scratch, involving complex “tri-partite” legal agreements between COVAX, donating countries and manufacturers.

Unlocking these doses through donations made an immediate impact and today more than 800 million donated doses have been distributed to more than 100 countries via COVAX. While the model was not perfect – early volumes often came at short notice and on an ad hoc basis – the development of dose donations could be an important tool for equitable access in the future.

3. An actively managed portfolio

It’s easy to forget that in the early months of the pandemic, when COVAX was created, there was no guarantee that any of the vaccines in development would be effective and no clear timeframe for when they would become available. Investing in a broad range of vaccines at the start of the pandemic enabled COVAX to build the world’s largest vaccine portfolio, now encompassing 11 vaccines across four technology platforms.

4. A No-Fault Compensation programme

All vaccines rolled out to the general public go through rigorous testing, strict safety protocols and continuous monitoring to ensure they are safe and effective. COVID-19 vaccines are no exception. However, as with other vaccines, drugs and medical products, vaccines that are approved for general use may, in rare cases, cause serious adverse events in some individuals.

Ordinarily, vaccine manufacturers would deal with this risk with tools such as product liability insurance. However, the scale of the COVID-19 vaccine rollout, with billions of people receiving the jab, as well as the fact that vaccines were being approved under an ‘Emergency-Use Listing’, meant these tools were not available. Instead, governments buying COVID-19 vaccines indemnified manufacturers against any financial losses they incurred. In resource-strapped low-income economies, this roadblock could have put an end to COVAX before it even started.

In response, COVAX created the world’s first and only global vaccine injury compensation mechanism: the COVAX No Fault Compensation Programme. By providing a no-fault, lump-sum compensation settlement to any claims associated with a COVAX-supplied vaccine, a fair, efficient global compensation system was developed that any country, not just wealthier ones, could participate in.

5. Model indemnity and liability language

Linked to the No Fault Compensation programme is the development of model indemnity agreements between AMC countries and vaccine manufacturers. Previously any country would have to negotiate their own legal agreements to indemnify the manufacturers and agree on liability issues. This would have led to separate agreements for each manufacturer and recipient government, taking valuable time and resources.

Instead, COVAX negotiated and developed pre-agreed uniform language across most manufacturers, ensuring the right legal safeguards were in place for all AMC countries. This cut red tape dramatically, enabling faster access to vaccines, as well as access from manufacturers that might not have otherwise made their product available.

6. Supporting country readiness

Procuring and shipping vaccines would only make a difference if countries were able to turn them into vaccinations. Many lower-income countries’ health systems were already stretched to the limit before COVID-19. To identify how best to support them, COVAX performed a detailed readiness assessment in more than 80 countries.

The upshot of this global action was more than 75,000 health workers trained in the administration of COVID-19 vaccines as well as bespoke guidance, reviewed by more than 200 immunisation experts, for each country and territory on their National Deployment and Vaccination Plans.

Today, COVAX continues to offer COVID-19 Delivery Support (CDS): money that is funding supply, communications, data and the human resources needed to carry out a vaccine campaign of this scale. This effort is complemented by the COVID-19 Vaccine Delivery Partnership, set up by WHO, UNICEF and Gavi to focus on countries where vaccine administration rates are among the lowest in the world.

7. Scale-up of Ultra-Cold Chain (UCC)

For vaccines to reach the people who need them, they need to be kept at a cool temperature during the transportation and storage process. In lower-income countries this can be a challenge, which is why Gavi has been investing in this cold chain for two decades, giving many countries a headstart as COVAX began delivering.

More was needed: COVAX provided additional support to improve regular (2°C to 8°C) cold chain for COVID-19 vaccines in 73 countries, however the use of mRNA vaccines, which need to be stored at ultra-cold (-60°C to -80°C) temperatures, meant the use of vaccine freezers which weren’t available in most of the lower-income countries supported by the COVAX AMC.

COVAX’s answer was the largest scale-up of ultra-cold chain technology in history. COVAX financed, coordinated and delivered 800 ultra-cold chain freezers to nearly 70 countries in 2021, enabling the delivery of mRNA vaccines to the countries that needed them. Without this investment, most lower-income countries would have been unable to roll out the mRNA vaccines that have made such a difference in fighting this pandemic.

At the start of the pandemic COVAX began on a playing field that was anything but level. Inequities and barriers to access for lower-income countries were faced at every turn, and it took creativity and months of hard work to overcome them. The innovations we created made a difference; implementing them in future pandemics would help lessen the inequity that we saw this time round.