Recent weeks have seen a political furore emerge over a perceived delay in receiving our vaccines.
While the Government said last year that the first Covid-19 vaccines would be deployed to border-facing workers in March, that has now been bumped to April. At the same time, Australia has approved one vaccine for use and plans to begin putting needles in the arms of frontline workers by the middle of next month.
Part of this is due to lack of supply. By early December, purchase agreements for nine promising candidates had only been secured for enough vaccines to immunise around half of the world’s population and suppliers only expected to reach a third of the global population by the end of 2021.
Although New Zealand has secured agreements for enough vaccine to immunise the population three times over, Prime Minister Jacinda Ardern says producers may be deferring us in favour of sending the vaccines to countries where community transmission is rampant.
“New Zealand has done a fantastic job of making sure that we are in the mix for early vaccine purchase. We’ve purchased four vaccines and we’ve got agreements in place for those vaccines, but now pharmaceutical companies are in the position of making a decision around when those are delivered and received by countries,” she said.
“It is only right that those countries that are seeing devastating rates of death are receiving those vaccines and have given emergency approval for them to be distributed. New Zealand’s in a very different position and I think everyone in New Zealand understands that.”
In other words, given there isn’t enough vaccine to go around, we might be on the rear end of the queue, at least among those countries that have secured advance purchase agreements. But is that such a bad thing, particularly when New Zealand is planning to deploy vaccines to the general population in the second half of 2021 and when developing countries with raging epidemics may not get vaccines until 2022 or later?
More transmission leads to mutation
To begin with, there’s a pragmatic and even selfish reason New Zealand may want to defer vaccination of the general population – assuming we still have no community transmission. Every time the virus replicates, it has the chance to mutate. These mutations are not inherently harmful, but the wrong mutation in the wrong place of the virus’ RNA could change how it functions.
Speaking to Newsroom in November about reports of the virus that causes the Covid-19 disease, SARS-CoV-2, infecting mink in Denmark, Joep de Ligt, the head of Bioinformatics at the national lab agency ESR warned that any transmission of the virus – in humans or in animals – could result in dangerous mutations.
“Especially now that we’re getting some encouraging news about vaccines, it is more important than ever that we reduced the population size because the less this virus can spread, the less it can mutate,” he said at the time.
“To me, the angle here is really that those massive populations that could get infected with a lot less surveillance happening and a lot less ability to protect them, that’s the real worry here.”
Then, exactly that happened. First in the United Kingdom, then in South Africa, now in Brazil, reports are filtering out of worrying new mutations that are making it easier for the virus to bind to human cells. From an epidemiological standpoint, that means these new variants of SARS-CoV-2 transmit to more people than the original virus.
“I think you have to snap out of the Donald Trump approach to life and start becoming global citizens. If that’s not a debate that can get onto the table, then we’ve got a serious problem in New Zealand, as people.”
There is also some evidence, albeit from small sample sizes, that the variant identified in the United Kingdom, B.1.1.7, could be more lethal than earlier forms of SARS-CoV-2. The variant first found in South Africa, B.1.351, also coincided with an increase in the case-fatality rate in that country, but experts say that could have more to do with environmental factors like an overwhelmed hospital system than biological ones.
Moderna, which has manufactured one of the world’s most effective (and expensive) Covid-19 vaccines, said yet-to-be-peer-reviewed trials against the new variants had proved they were still effective. The B.1.351 variant did reduce the number of neutralising antibodies produced (an important part of the immune response) but Moderna said levels “remain above levels that are expected to be protective”.
The company is nonetheless developing a booster shot to improve efficacy against B.1.351 – an easy feat with the adaptable mRNA vaccine that Moderna and Pfizer/BioNTech have produced.
Vaccinate overseas to protect NZ
However, experts spoken to by Newsroom said the more transmission that occurs elsewhere, the better the chances of a variant evolving that evades the immune response prompted by vaccines.
“If there is not going to be equitable access to vaccines around the world – which there very clearly, at the moment, is not – then there are going to be countries that are not going to be vaccinated for another couple of years. In which case, they may well – depending on where they are and what resources they have – end up having long community outbreaks which result in the evolution of these variants, possibly into variants that evade the vaccine,” University of Auckland microbiologist Siouxsie Wiles told Newsroom.
“So regardless of our population being vaccinated, then that poses a threat.”
“The really important thing is that we need to stop community transmission. Vaccines are one tool for that, so they should be employed in countries that need them.”
– Dr Siouxsie Wiles
David Welch is a computational biologist and expert on bioinformatics at the University of Auckland who has worked on the genome sequencing effort in New Zealand. He agreed with Wiles that dampening transmission overseas helps protect New Zealand.
“Anything that we can do to bring down the absolute number of cases out there is a good thing. The Brazilian example is a good one. It’s just roaring through there and everyone is getting infected and we’re like, ‘That’s that, we don’t need to worry about them’, in a selfish sort of a way. But then this new 501Y.V3 comes out of there,” he said.
“There’s always a chance with immune escape for a virus. It’s just having those sheer numbers out there. Every case is the opportunity to be unique [and produce a dangerous variant].”
Helen Petousis-Harris, an associate professor in vaccinology at the University of Auckland and the chair of the World Health Organisation’s Global Advisory Committee on Vaccine Safety, said mutations were a big issue.
“The longer this thing plays out, the more opportunity there is for the virus to change. Most changes are not consequential but sometimes, like with [the South African variant], they could impact the efficacy. Not completely obliterate but to reduce it,” she said.
Wiles points to tuberculosis as a lesson we could learn. High-income countries developed complex but successful treatments against tuberculosis in the latter half of the 20th century, effectively eliminating it, she says. But they didn’t provide support for low-income countries to eliminate it. Now, new strains of tuberculosis resistant to the original treatments have evolved and are once again threatening the developed world.
“Even with the vaccine, if we allow community transmission to continue apace around the world, then we run the risk of that coming back to bite us,” Wiles said. “The really important thing is that we need to stop community transmission. Vaccines are one tool for that, so they should be employed in countries that need them.”
Welch and Petousis-Harris added that a mutation for immune escape wouldn’t necessarily sink the entire vaccine effort. The mRNA vaccines, for example, can be adapted in a matter of weeks.
“Looking at the numbers, it’s one of those things where you go, what difference does a couple of million vaccinations in New Zealand make?” Welch added.
Ethical arguments for waiting our turn
In addition to the pragmatic argument, there may be a moral reason to wait our turn. Put simply, we don’t need the vaccines to save lives, while many other countries do.
Philip Hill is the co-director of the Centre for International Health, Department of Preventive and Social Medicine at the Otago Medical School. In December, he wrote an article for Newsroom asking exactly these difficult questions.
“We don’t actually have a Covid-19 epidemic at present, so vaccination of New Zealanders is not really a high priority for stopping the global pandemic. Our main reason for having vaccination as soon as possible is so that we can open up our borders again in the presence of ongoing transmission across the world,” he wrote.
“But should we actually adopt a more global perspective? Should we play an international leadership role in adopting a proper global health mindset of first stopping the global pandemic and then stopping a resurgence?”
Speaking to Newsroom, Hill echoed the same concerns.
“If you’re always about New Zealand first, the Donald Trump approach, then you look at arguments about whether we’d be better off for waiting,” he said.
“I think you have to snap out of the Donald Trump approach to life and start becoming global citizens. If that’s not a debate that can get onto the table, then we’ve got a serious problem in New Zealand, as people.”
However, he wasn’t as worried about an overseas mutation rendering our vaccine-induced immunity ineffective.
Petousis-Harris said she understood the desire to prioritise distribution to locations where infection and mortality was at its highest.
At the same time, she said, there were logistical complications that meant this would be no easy feat.
“I don’t think it’s as easy as putting it on a plane and sending it off somewhere else because, of course, wherever you’re sending it needs to have the approval for the particular vaccine,” she said.
“Also, I guess there’s the argument that it cost us money, taxpayer money, so the people of New Zealand have funded these vaccines. If you give them away, that could also be an ethical argument.”
Joanna Spratt, the Advocacy and Campaigns Director at Oxfam New Zealand, also backed Hill’s global citizen approach.
“There’s that broader argument around who should get the vaccine first. I think all countries need to have the ability to at least vaccinate their most vulnerable people as quickly as possible,” she said.
“If you think of us as one human family, we’re all in this together and we all need the vaccine.”
Making vaccines accessible
How can the world go about achieving that goal? For starters, it must acknowledge that the path we’re on now is one of intense inequity.
An analysis by the Economist Intelligence Unit found countries in Africa, the Middle East and South East Asia were more likely than others to begin mass vaccinations from 2022 or later.
The United States and much of Europe, however, would see vaccines widely available by September 2021 and likely wrap up their mass campaigns by March in 2022.
At the same time, however, those same high-income countries (New Zealand included) began to negotiate bilateral purchase agreements with pharmaceutical companies, limiting the global supply left over for COVAX to access. Many countries have, like us, purchased enough vaccine to immunise our population multiple times over. That’s because it remains unclear which vaccines will get the a-okay from medicines regulators. New Zealand has also purchased some extra supply to distribute to the Pacific Islands.
In a report released in December, Amnesty International called on countries to stop “hoarding” vaccines.
“States must and businesses should refrain from making bilateral agreements that negatively affect the global supply of a vaccine and jeopardize availability across countries, which includes ‘hoarding’ of vaccines beyond what is needed for priority, at-risk populations,” the report said.
The countries that don’t have the cash or the sway to purchase vaccines directly from a company will have to compete for some of the two billion doses of vaccine (which, given some vaccines require two shots, will immunise fewer than two billion people) purchased by the COVAX facility.
Amnesty and Oxfam have also backed an effort by developing countries, led by South Africa and India, to relax global intellectual property rules around vaccines. That would allow for increased supply because third-party manufacturers which don’t currently have the rights to make proprietary vaccines like the AstraZeneca shot would be freed up to do so.
Petousis-Harris said this might not be as easy at it sounds either. While the legal rules could be sidestepped, building new manufacturing capacity would be expensive and slow. She estimated it would cost upwards of $1 billion to build a new vaccine factory and receiving WHO approvals for manufacture is extremely difficult.
The New Zealand Government has opposed the effort to waive IP rules, with Ardern telling reporters its contributions to COVAX and purchases for Pacific Island neighbours are good enough.
“We have been very supportive of making sure that we are doing our bit to support countries regardless of their financial position, from having access to vaccines. It would be, I agree, a moral failure for countries not to receive vaccines because of financial hardship or an inability to purchase,” she said.
Wiles disagrees, saying it is hypocritical for New Zealanders to complain about delayed access to vaccines while not doing enough to ensure other countries have timely access as well.
“We can’t be yelling for access on one hand because we want to get back to normal without fighting for all of the other things that allow everyone else to have access,” she said.
