The curious case of upper-middle income countries

Weekly Insights and Interesting Trends

The curious case of upper-middle income countries

Author: Andrea Taylor

The global imbalance in Covid-19 vaccines is often framed in terms of wealthy versus poor countries. While it can be summed that way (wealthy countries do have the majority of doses, while low-income countries have almost none), this overlooks the experience of upper-middle income countries (UMICs), such as Brazil, Indonesia, and China.

The challenges faced by UMICs are different than those faced by lower-middle and low-income countries. They do not lack public funding to make vaccine purchases; countries like Mexico and Brazil can finance large purchases. But UMICs were less willing to make these purchases at risk, when there was no indication that any of the vaccines would work. While high-income countries (HICs) purchased from multiple vaccine makers in the summer of 2020, before any efficacy data were released, UMICs tended to wait until there was some indication of efficacy before negotiating a deal.

This put them behind the large orders from HICs for vaccines like Pfizer-BioNTech, Moderna, and Oxford-AstraZeneca and meant their delivery dates were generally later. This issue is compounded by the location of manufacturing capacity for vaccines that have come to market. Most of the doses that have received authorization from stringent regulatory authorities are currently manufactured in HICs, many of which leveraged early investment in manufacturing (and sometimes export controls) to guarantee priority delivery.

So while UMICs have purchased a combined 1.5 billion doses so far, few of these vaccines have been delivered. This translates into low vaccination rates. About a third of UMICs have covered less than 1% of their population with a first dose. Another third have covered between 1% and 5% of their populations, and one-third have covered more than 5% of their population with first doses (according to data on vaccine administration as of March 31, 2021 from Our World in Data).

What is particularly curious about the experience of UMICs is that many of these countries have manufacturing capacity and contracts to produce Covid-19 vaccines, but this isn’t leading to national supply. Brazil, Indonesia, Mexico, and Thailand (among others) have manufacturing contracts in place for a variety of Covid-19 vaccines but actual production has been slow to get going. Russia, which funded the development, testing, and manufacture of domestically produced vaccines, is so limited by domestic bottlenecks in production that it is relying on manufacturing partners in other countries. China, another UMIC with domestically developed vaccines, has far more manufacturing capacity but is still struggling to meet projections for domestic and global production.

The production delays in UMICs have significant epidemiological consequences. In Brazil, for example, the health system is overwhelmed; shortages of hospital beds and oxygen mean acute cases go untreated. The country now accounts for a quarter of daily Covid-19 deaths globally and the death rate among even younger adults is rising rapidly. There are many factors contributing to the unchecked spread of Covid-19 in Brazil, including a chaotic response from the national government, contradictory public health messages, and rampant misinformation. But another crucial factor has been the slow rollout of vaccines.

Brazilian firms have technology transfer agreements in place to manufacture Oxford-AstraZeneca, Sputnik V, and Sinovac’s Coronavac, for domestic and regional distribution. But the doses are not materializing and only 2% of Brazil’s population have been fully vaccinated (9% have received a first dose). If we are going to address equitable access to vaccines, we need to better understand why production in Brazil and other UMICs is so far behind. Clarity on the causes of bottlenecks and delays for UMIC manufacturing will improve decisions about the manufacturing investments and policy changes needed to increase regional production.

Interesting Trends

Significant updates, news, and trends we saw last week:

• WHO expects to have a decision on emergency use listing (EUL) for Sinopharm-Beijing and Sinovac’s Coronavac vaccines by end of April. Receiving EUL status would ease the path to regulatory approval in many countries around the world and make the vaccines eligible for use in COVAX.
• Sinovac reported that, with a third plant up and running, their annual capacity is now 2 billion doses.
• UAE tech company Group 42 announced plans to manufacture Sinopharm’s Beijing-based vaccine, with capacity to produce 200 million doses a year
• However, Group 42, which currently distributes the Sinopharm-Beijing vaccine in the UAE, also reported that some people may need a third dose, due to low immune response.
• CanSino’s single-dose vaccine may also need a booster, six months after the first shot, in order to maintain efficacy.
• A new Covid-19 variation was discovered in Tanzania, with the most mutations yet seen. Tanzanian’s recently deceased president claimed that there was no Covid-19 in Tanzania, which has not officially reported any cases since the spring of 2020.
• The US FDA said that, with the right syringes and needles, providers can extract 11 doses (instead of 10) from Moderna vials. They also gave approval for Moderna to fill vials with up to 15 doses, which may speed the pace of delivery.
• New data show that efficacy of the Pfizer-BioNTech remains high six months after vaccination, with a small drop to 91.3% protection from symptomatic cases.
• Pfizer-BioNTech also reported very positive results in their trial with children ages 12-15, demonstrating 100% efficacy.
• BioNTech said that, together with Pfizer, they will increase 2021 manufacturing capacity to 2.5 billion doses globally.
• In response to recent reports of possible increased risk of blood clots for women under 50 receiving the Oxford-AstraZeneca vaccine, Canada has said they will only use the vaccine in people over the age of 55 while Germany restricted it to people over age 60. 
• Manufacturing partner Emergent reported contamination of the drug substance for up to 15 million doses of Janssen (J&J) vaccine, due to human error.
• Brazil health regulator Anvisa declined to approve the Covid-19 vaccine made by Bharat Biotech in India, saying that it did not meet manufacturing standards. The government of Brazil has ordered 20 million doses. Bharat plans to appeal the decision.

For more information on our research on Covid-19 vaccine supply, please see https://launchandscalefaster.org/COVID-19.