African Union Strategy on COVID-19 Vaccine

Version	Summary	Created by	Modification	Content Size	Created at	Operation
1		Shimaa Adel Heikal	+ 2903 word(s)	2903	2021-12-16 07:00:44	\|
2	Done	Jason Zhu	Meta information modification	2903	2021-12-24 10:03:49	\|

This entry is adapted from the peer-reviewed paper 10.3390/epidemiologia2040042

The African Union (AU) vaccination strategy seems to be very optimistic, with major challenges that might hinder the achievement of the main goal of vaccinating 60% of the population, even by 2023. Major health system reforms, as well as better resource allocation, will be crucial for countries to achieve better results.

African Union COVID-19 Vaccine Distribution

1. Introduction

The first COVID-19 case detected in Africa was laboratory-confirmed and reported on the 14th of February 2020 for a German tourist who came to visit Egypt during the vacation ^[1]. Despite the slow to spread in Africa compared to other continents ^[2], the impact of COVID-19 has affected most African countries gradually, which urged the African Union (AU) to advance the efforts to deploy the proper vaccination strategy, identifying the continent’s limited infrastructure and resources.

2. Non-Pharmaceutical Interventions

As of the 29th of June, African countries reported 5,442,372 COVID-19 cases and 141,698 deaths ^[3].

Since the start of the pandemic, African countries have had many regulatory interventions that were implemented, including lockdowns and curfews. The extent of implementation of these regulatory actions has differed from one country to another, based on the pandemic situation in the country, including full and partial lockdowns, prohibition of gatherings, and closure of unessential shops, restaurants, and cafes. The duration of implementing these regulatory actions also differed in each country, starting March 2020 and up until September 2020. However, it is not that those interventions effectively helped control virus spread ^[4]. Those interventions were reinforced by supportive packages offered to the African citizens to mitigate the drastic socio-economic impact caused by the pandemic ^[4].

3. AU Response to the Pandemic

Through various high-level meetings and initiatives, the AU, and its specialized technical arm for public health (ACDC), has been working closely with the African member states to support their response and to expand the continent’s resilience capabilities to cope with the spread of the pandemic.

A joint continental strategy for COVID-19 response was developed to prevent severe illness and death from COVID-19 infection in the African Member States and minimize the social disruption and economic consequences of COVID-19 outbreaks. The joint strategy worked on Coordinating the efforts of Member States, AU agencies, World Health Organization, and other partners to ensure synergy and minimize duplication. Besides promoting evidence-based public health practice for surveillance, prevention, diagnosis, treatment, and control of COVID-19. The joint strategy was adopted by the African ministers of health on 22 February 2020, during the first emergency ministerial meeting on COVID-19 ^[5].

In February 2020, the African task force on coronavirus (AFTCOR) was launched, representing the cornerstone in collaborating the efforts for COVID-19 preparedness and response among the African countries. By identifying the main six technical areas of focus, working groups were formed on to include surveillance and screening at points-of-entry, laboratory diagnosis, Infection prevention and control measures in healthcare facilities, Clinical management of severe COVID-19 infection, risk communications, and Supply chain medical supplies ^[5].

To support the joint continental strategy through increasing the capacity for testing COVID-19 to ensure the implementation of evidence-based policy-making process based on the interchangeable situation, Africa CDC has launched the Partnership in May 2020 to accelerate COVID-19 Testing in Africa (PACT). By mobilizing required experts, community workers, and resources to Test, Trace, and Treat the COVID-19 cases, the ACDC set its sight on accomplishing the conduction of 10 million tests for COVID-19. In addition to the training of 100,000 healthcare workers and the deployment of 1 million community health workers to mitigate the impacts of the pandemic in an ongoing project. The initiative also aspired to develop a continent-wide procurement platform for laboratory and medical supplies, which have been achieved and launched in July 2020 ^[6].

The harsh conditions caused by the pandemic and the excessive need for medical equipment and protective tools like facial masks and personal protective equipment, alongside the diagnostic kits, created a necessity for creating a platform that would fulfill the needs of the continent during emergencies and during regular times as well. The online Africa Medical Supplies Platform (AMSP) came to close the gap by creating a partnership with the African Export-Import Bank (Afreximbank) and United Nations Economic Commission for Africa (ECA) with the support other partners across the globe ^[7].

Through its initiative, the AMSP launched the COVID-19 vaccine pre-ordering program for the 55 African countries. The program aims to achieve herd immunity by securing the vaccination for 60% of the African citizens. Through negotiating with vaccine manufacturers, the program can secure the required doses of vaccines with competitive prices that would be suitable for the continent’s economic situation. This initiative will ensure equitable access for African member states to procure the required doses of vaccines for their citizens. It is important to mention the support that the Aferximbank has provided in facilitating the payments by offering advance procurement commitment guarantees that would give support of up to US$2 billion to the manufacturers on behalf of the Member States ^[8].

As a step toward closing the gap of equitable access to vaccines and medical supplies, not only for the current pandemic but also for any future health threat, the AU conducted a set of high-level meetings inviting presidents, policymakers and technical experts in the context of expanding the continent’s vaccine manufacturing capabilities ^[9]. The meetings yielded the launch of Partnership for African Vaccine Manufacturing (PAVM), which included the signing of two agreements with the Coalition for Epidemic Preparedness Innovations (CEPI) and Afreximbank. The two agreements aim for increasing the increase in vaccine development research and boosting the local manufacturing capacities in the continent ^[10].

4. Medical Supplies Donations

One of the main gaps that current pandemic exposed was the solidarity among the nations and the support by countries and entities to cope with negative socio-economic impacts. The AU was able during the first and second wave of the pandemic to coordinate all the efforts to allocate donations of medical supplies and medications to the African member states to support their countermeasures facing the pandemic. Donations from governments like China and Canada, in addition to foundations like Jack Ma foundation ^[11], contributed effectively to achieving the goal set by the Joint continental strategy of preventing severe illness and death from COVID-19 infections. As of mid-April 2020, The AU received the third wave of donations that included 4.6 million masks, 500,000 swabs, and test kits, 300 ventilators, 200,000 sets of protective clothing, 200,000 face shields, 2000 temperature guns, 100 body temperature scanners, and 500,000 pairs of gloves. Those tools and kits were distributed to the African countries based on their needs ^[12].

5. COVID-19 Vaccine Strategy Development

The heterogeneous increase of cases in the African countries was a predictor of the uncertainty of the continent’s future, particularly after the massive increase in the reported deaths by December 2020. Hence, a global solution was the optimal decision as the pandemic was a global health emergency, and no country will be safe until all the countries are protected ^[13]. Accordingly, a vaccination plan for the African countries was necessary to combat and contribute to ending the pandemic and to overcome the humanitarian and economic crises that have developed through the extended lockdown.

Realizing the mess that has been caused by the COVID-19 pandemic across the globe, the AU took a step toward unifying the vision of the African member states through drawing the bold framework via the COVID-19 vaccine strategy.

The strategy, which was launched after a virtual conference for the African ministers of health that was conducted on the 24th and 25th of June 2020 ^[14], came to focus on the means of securing the required doses of vaccines by coordinating the efforts with global partners. The strategy also highlights the challenges and obstacles that would be faced during the procurement process and the following rolling-out stage.

5.1. Initial AU Vaccination Efforts

Following the rapid expansion in the COVID-19 situation, Africa CDC initiated some efforts to mitigate the impact of the pandemic. A comprehensive region-wide strategy was the primary step to help all the African countries in preventing the transmission of the virus among their populations, preventing the death of COVID-19 cases through providing improved healthcare procedures, and avoiding the social and economic implications of the epidemic ^[15]. The rollout of an efficacious vaccine that can be safely and widely accessible by all African countries was the key to implementing the strategy’s three objectives.

Developing the First Vaccination Strategy

In June 2020, a conference was hosted by the Africa CDC to discuss the vaccine needs in the region, as well as the opportunities for developing, manufacturing, distributing, and taking up the vaccine ^[16]. More than 3000 leaders and technical experts agreed on the urgent need for immunizing the African population, and based on their recommendations, the first strategy for vaccination of the African continent was developed with a goal of immunizing at least 60% of the African population. The strategy had some objectives, including accelerating the involvement of Africa in the vaccines’ clinical development, guaranteeing the accessibility of African countries to the globally available vaccines, and overcoming any barriers that might hinder the widespread distribution of vaccines in Africa ^[15]. To achieve these objectives, The AU and Africa CDC played an essential role in the implementation roadmap to coordinate between African and global organizations such as member states, regulatory agencies, and other partners.

Fair Allocation of Vaccines

Various technical and ethical concerns arise during the implementation of the vaccination strategy, particularly in making the prioritization decisions. The scarcity of resources and vaccines and the limited time were elements to be considered, along with the assessment of target groups before setting up vaccines ^[17]. Accordingly, in December 2020, Africa CDC, and the South African Medical Research Council (SAMRC) developed a framework as a guideline for the fair allocation of vaccines. The framework drew on the expertise and input of more than 1300 policymakers, community advocates, public health experts, and ethicists who worked together to ensure the fairness and equity of vaccine distribution. Although allocating such scarce resources like the COVID-19 vaccines required considerations of the maximized benefits and giving priority to the most vulnerable populations, the equitable distribution of vaccines among Africa was also crucial to develop herd immunity and protect the whole population ^[17]. Hence, the vaccination program aimed to decrease morbidity and mortality of the cases with several values during the allocation of vaccines, including (1) Affirming the others’ humanity through considering societal benefit and the common good when allocating the vaccines; (2) Depending on the best evidence that ensures the survival of the community like when prioritizing the vaccination of healthcare workers; (3) Considering social solidarity issues and the bonds between communities to avoid creating new inequalities; (4) Allowing the active community engagement in the allocation decisions to promote trust ^[17].

The African Vaccine Acquisition Task Team

The African Vaccine Acquisition Task Team (AVATT) was established in August 2020 to lead the continent’s efforts to access vaccines and achieve herd immunity. The WHO supported the team and worked together with the COVAX facility to secure the required vaccine doses for African countries. By Jan 2021, and to achieve the goal of immunizing 60% of the population, AVATT acquired over 270 million doses of COVID-19 vaccines from Pfizer, Johnson & Johnson, and AstraZeneca providing equitable access to doses for the 55 member states of the AU ^[18]. In mid-March 2021, AVATT received a batch of the Oxford-AstraZeneca vaccine as a donation and shipped around 925,000 doses to 13 AU member states. Despite the limited expiration of the vaccine, Africa CDC decided that countries should vaccinate their populations quickly as there is an urgency to save people’s lives.

5.2. Cooperation with COVAX Facility

Given that international collaboration is essential for the fair distribution of COVID-19 vaccines, and to ensure that the financing of vaccines will be then distributed in transparent and coordinated manner, the WHO led different arrangements with organizations and stakeholders to ensure the safe and efficient allocation of vaccines ^[19]^[20]. One of these initiatives is the COVAX facility, which was delineated in September 2020 as a multilateral initiative led by Gavi Vaccine Alliance (Gavi), the World Health Organization (WHO), and the Coalition for Epidemic Preparedness Innovations (CEPI) ^[21]. COVAX was a voluntary arrangement that aspired fair and equitable access of vaccines to all countries by helping them invest in the vaccines while developing the required political and logistical infrastructure for the distribution of the vaccine ^[22].

In addition, the COVAX facility has made investments in several vaccines that were shown to be promising. The pooling of purchasing power from all the participating countries will accelerate the access to vaccines once developed. Moreover, to overcome the obstacle of the initial limited supply of vaccines, the WHO advised that all countries should receive doses once an effective and safe vaccine is approved. Receiving doses proportional to the country’s population size will allow countries to prioritize their vulnerable populations and start immunizing them. The framework of the fair allocation of vaccines through COVAX had the goals of initially allocating proportional doses of vaccines that cover 20% of the country’s population, and to expand the coverage afterwards in the follow-up phase to cover all the populations ^[23].

The Access to COVID-19 Tools Accelerator

The Access to COVID-19 tools (ACT)-Accelerator was a partnership launched in April 2020 by the WHO and partners including UNICEF and Gavi to rapidly e tests, treatment, and vaccines and end the acute phase of the pandemic ^[24]. The ACT-Accelerator had four main pillars that are vital for fighting the pandemic, including diagnostics, treatment, vaccines, and health system strengthening. The access and allocation mechanisms to these tools are also fundamental to the goals of ACT-Accelerator. Immediately after the launch of ACT-Accelerator, UNICEF became a partner in the COVAX initiative to achieve the vaccines pillar through COVAX facility ^[25]^[26]. The goal was that COVAX scales up the delivery of vaccines to at least 2 billion doses by 2021 ^[27].

COVID-19 Vaccines Advance Market Commitment (COVAX AMC)

In June 2020, Gavi launched the COVAX AMC during the global vaccine summit as a building block of the COVAX facility. COVAX AMC was aimed to be the financing tool to support the 92 low- and middle-income countries participating in the COVAX facility ^[28]. With the coordination of country readiness, AMC will assure the protection of the most vulnerable populations in a country regardless of their income level. Accessing COVID-19 vaccines through COVAX AMC required countries to fulfill several steps starting with the confirmation of participation in the COVAX facility via signing a vaccine request. Then comes the step of preparing and introducing countries to the vaccines which are led by the WHO, UNICEF, and Gavi guidelines. After that, the readiness of the county to receive and use the vaccines is assessed to establish a suitable framework for disseminating the vaccines.

6. Vaccine Distribution in Africa

In February 2021, the COVAX AMC started their campaigns to deliver COVID-19 vaccines to Africa starting with Ghana and Cote ‘d’Ivoire with 60,000 and 504,000 doses, respectively. All the distributed doses were from the Oxford-AstraZeneca vaccine, while the Pfizer vaccine was supposed to be delivered in later distribution batches ^[29]^[30]^[31].

By the end of April 2021, COVAX has supplied many African countries with the initial vaccination doses, mainly the AstraZeneca vaccine (over 92% of all the supplies) ^[32]. So far, 44 African countries are now participants of the COVAX facility and are receiving the vaccine doses from different vaccines that have been approved for emergency use, including AstraZeneca/Oxford, Johnson & Johnson, Moderna, Pfizer/BioNTech, Sinopharm, and Sinovac ^[33]. In addition, 37 countries have received vaccines bilaterally, and 13 countries have received AVATT vaccines.

However, despite all these efforts, as of mid-April 2021, below 2% only of the African population ^[34] was vaccinated, indicating the continent’s struggle to achieve the 60% vaccination goal ^[32]. This lagged situation in the vaccination rate could be referred to for various reasons, most notably the Indian move toward halting vaccine exporting as a result, leading to a delay in COVAX global supply that are significantly assigned for African countries ^[35]. Additionally, the African local vaccine manufacturing capacities are at a very low pace for fulfillment of the continental needs ^[36].

7. Vaccination Coverage

As of the beginning of July 2021, while most countries were progressing toward inoculating a major sector of their population, the African continent was struggling to reach nearly 2% of its population, with 13 million out of 31.6 million doses delivered so far having been administered ^[37]. Additionally, the low vaccination rate was accompanied by an asymmetric pattern in distribution since 93% of the doses were given in 10 countries of the continent ^[37]. The high rates of vaccination rollout in those countries were due to the implementation of strategic planning for identifying priority groups and the effective utilization of resources to quickly achieve the needed outcome. However, it is important to consider other factors that would participate in the false perception of the overall rate of vaccination, like the country’s population compared to vaccination coverage. For instance, Seychelles has the highest vaccination rate, with 140 doses administered per 100 individuals. Yet, it is important to note the Seychelles population is nearly reaching 100 thousand inhabitants ^[38].

8. COVID-19 Cases in Africa after Vaccination

With the vaccine rolling out across the globe, and the notable decrease in the cases for vaccinated populations. This was documented in many countries, especially in the United States, which has experienced, by June 2021, a significant decline in cases that reaches 94% compared to the pandemic peak in January ^[39]. With the expansion in the vaccination coverage, data have shown how effective vaccines are, especially for elderly people. According to the Center of Disease Control (CDC), as of May 2021, 69% of American adults over the age of 65 were fully vaccinated against COVID-19. Consequently, a large decrease in infections, hospitalizations, and deaths was seen ^[40]. On the other hand, Africa was not witnessing the same level of case decline, on the contrary, as of Mid-June 2021, COVID-19 cases jumped 44% to 95,000, while fatalities rose 20% to 1400 over the previous week across Africa ^[41].

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