COVID-19 vaccines for the European region: an unprecedented challenge
Authors: Hans Kluge, Martin McKee
Journal: The Lancet (2021)

Almost 4 months have passed since the first COVID-19 vaccines became available in the European region of WHO. As vaccination programmes roll-out across the region, at a time when COVID-19 cases are increasing in some European countries,1WHOWHO Coronavirus (COVID-19) Dashboard.https://covid19.who.int/Date: 2021Date accessed: March 23, 2021Google Scholar it is a good time to consider the challenges ahead and what can be done to address them. There have been questions about the speed with which COVID-19 vaccines were authorised for use in Europe, about the timetable for supplying vaccines to some countries in the region, and about the safety of COVID-19 vaccines in some countries. These issues are being addressed by relevant authorities, including national regulators, the European Medicines Agency, and WHO, concluding that the benefits of COVID-19 vaccines far outweigh any possible risks.2European Medicines AgencyCOVID-19 Vaccine AstraZeneca: benefits still outweigh the risks despite possible link to rare blood clots with low blood platelets.https://www.ema.europa.eu/en/news/covid-19-vaccine-astrazeneca-benefits-still-outweigh-risks-despite-possible-link-rare-blood-clotsDate: 2021Date accessed: March 18, 2021Google Scholar, 3WHOWHO statement on AstraZeneca COVID-19 vaccine safety signals.https://www.who.int/news/item/17-03-2021-who-statement-on-astrazeneca-covid-19-vaccine-safety-signalsDate: March 17, 2021Date accessed: March 23, 2021Google Scholar However, these questions should not overshadow some remarkable successes, including the speed of development and deployment of a portfolio of COVID-19 vaccines and the rapid roll-out in some countries, such as Israel and the UK.4Rosen B Waitzberg R Israeli A Israel's rapid rollout of vaccinations for COVID-19.Isr J Health Policy Res. 2021; 10: 6Crossref PubMed Scopus (181) Google Scholar, 5Baraniuk C Covid-19: how the UK vaccine rollout delivered success, so far.BMJ. 2021; 372: n421Crossref PubMed Scopus (54) Google Scholar Encouraging signs of reductions in severe illness and COVID-19 deaths in these countries show what can be expected as COVID-19 vaccination coverage increases across the region.6Rossman H Shilo S Meir T Gorfine M Shalit U Segal E Patterns of COVID-19 pandemic dynamics following deployment of a broad national immunization program.medRxiv. 2021; (published online Feb 9.) (preprint).https://doi.org/10.1101/2021.02.08.21251325Google Scholar, 7Bernal JL Andrews N Gower C et al.Early effectiveness of COVID-19 vaccination with BNT162b2 mRNA vaccine and ChAdOx1 adenovirus vector vaccine on symptomatic disease, hospitalisations and mortality in older adults in England.medRxiv. 2021; (published online March 2.) (preprint).https://doi.org/10.1101/2021.03.01.21252652Google Scholar On March 10, 2021, Moldova was the first country in the European region to receive a delivery from the COVAX Facility, a partnership between WHO, the Coalition for Epidemic Preparedness Innovations, Gavi, The Vaccine Alliance, and UNICEF. Four other countries in the European region (Georgia, Albania, Uzbekistan, and Tajikistan) have since received vaccines from the COVAX Facility. However, there is still much work to be done. A commitment of WHO's European Programme of Work is to "leave no-one behind",8WHO Regional Office for EuropeEuropean Programme of Work (2020–2025)—"United Action for Better Health in Europe".https://www.euro.who.int/en/health-topics/health-policy/european-programme-of-work/about-the-european-programme-of-work/european-programme-of-work-20202025-united-action-for-better-health-in-europe2Date: 2020Date accessed: March 18, 2021Google Scholar which is especially important in the COVID-19 vaccine roll-out. The effectiveness of the available vaccines, shown in clinical trials9Voysey M Clemens SAC Madhi SA et al.Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK.Lancet. 2021; 397: 99-111Summary Full Text Full Text PDF PubMed Scopus (3265) Google Scholar, 10Polack FP Thomas SJ Kitchin N et al.Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.N Engl J Med. 2020; 383: 2603-2615Crossref PubMed Scopus (9517) Google Scholar and now in real-world data,11Dagan N Barda N Kepten E et al.BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting.N Engl J Med. 2021; (published online Feb 24.)https://doi.org/10.1056/NEJMoa2101765Crossref PubMed Scopus (1723) Google Scholar provides reassurance that immunised individuals are likely to obtain protection, especially against severe disease or death. There is reassuring evidence that COVID-19 vaccines reduce transmission and thus extend protection to people around those who have been vaccinated.12Hall VJ Foulkes S Saei A et al.Effectiveness of BNT162b2 mRNA vaccine against infection and COVID-19 vaccine coverage in healthcare workers in England, multicentre prospective cohort study (the SIREN Study).SSRN. 2021; (published online Feb 22.) (preprint).http://dx.doi.org/10.2139/ssrn.3790399Crossref Google Scholar However, even greater benefits arise if the threshold is reached for population immunity. What uptake of vaccination is needed to achieve population immunity is unclear, given uncertainties about the emergence of new SARS-CoV-2 variants13WHO Regional Office for EuropeRedoubling public health measures needed due to COVID-19 virus variants.https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/news/news/2021/2/redoubling-public-health-measures-needed-due-to-covid-19-virus-variantsDate: Feb 2, 2021Date accessed: March 23, 2021Google Scholar and the duration of immunity, but it is likely to be high. Attention needs to be given to people who have the opportunity to become vaccinated but decline to do so. Left unaddressed, vaccination hesitancy will make it difficult to achieve population immunity. Fortunately, there are some indications that vaccine hesitancy has declined since COVID-19 vaccines became available.14Hertie SchoolWillingness to take COVID-19 vaccines increases across Europe.https://www.hertie-school.org/en/news/detail/content/willingness-to-take-covid-19-vaccines-increases-across-europeDate: 2021Date accessed: March 18, 2021Google Scholar However, this is a rapidly changing situation and there is continuing concern about vaccine hesitancy in some countries in the region and some communities within them. Consequently, there is no room for complacency and it is important that all countries monitor the messages that jeopardise vaccine acceptance which are circulating within their countries, especially those spread on social media, and take action to counter them with strong but succinct refutations and use of positive stories that resonate with their audiences.15Steffens MS Dunn AG Wiley KE Leask J How organisations promoting vaccination respond to misinformation on social media: a qualitative investigation.BMC Public Health. 2019; 191348Crossref PubMed Scopus (93) Google Scholar Another crucial concern is reducing inequalities in vaccine uptake. Researchers in the UK have documented how people who live in socially and economically disadvantaged areas, and especially members of some minority ethnic populations, are less likely to be vaccinated for a combination of reasons that include barriers to access and mistrust in authorities.16MacKenna B Curtis HJ Morton CE et al.Trends, regional variation, and clinical characteristics of COVID-19 vaccine recipients: a retrospective cohort study in 23·4 million patients using OpenSAFELY.medRxiv. 2021; (published online Jan 27.) (preprint).https://doi.org/10.1101/2021.01.25.21250356Google Scholar However, only a few countries, such as the UK and Norway,17Cookson C Milne R Nations look into why coronavirus hits ethnic minorities so hard.The Financial Times. April 29, 2020; Google Scholar are systematically collecting data that can reveal ethnic disparities in vaccine uptake. If inequalities in COVID-19 vaccine coverage are effectively invisible, it can be difficult for policy makers to take effective measures to tackle them. WHO has placed inequalities high on its agenda for many years, informed by analyses on the social determinants of health.18Marmot M Allen J Bell R Bloomer E Goldblatt P WHO European review of social determinants of health and the health divide.Lancet. 2012; 380: 1011-1029Summary Full Text Full Text PDF PubMed Scopus (954) Google Scholar WHO will continue to support sharing of good practice on this complex issue. Solidarity is important not only within countries but also among them in the Pan-European region. Although there has been a focus on the challenges of vaccine hesitancy and COVID-19 vaccine supply and coordination in some of the wealthier countries in the region, we must not overlook similar and different difficulties elsewhere. Armenia, Bosnia and Herzegovina, Kyrgyzstan, and Turkmenistan have received small donations of COVID-19 vaccines. Albania is vaccinating people crossing the border from Kosovo, which has not yet begun its own vaccination programme, and will donate 500 doses of COVID-19 vaccines for health workers in Kosovo.19ReutersAlbania donates COVID-19 vaccines to Kosovo health workers. Reuters, March 20, 2021https://www.reuters.com/article/us-health-coronavirus-kosovo-idUSKBN2BC0NHDate accessed: March 22, 2021Google Scholar Similarly, Serbia is donating vaccines to its neighbours, including North Macedonia,20Bami X Dragojlo S Balkan countries lacking vaccines look to neighbours for jabs. BalkanInsight.https://balkaninsight.com/2021/03/22/balkan-countries-lacking-vaccines-look-to-neighbours-for-jabs/Date: March 22, 2021Date accessed: March 23, 2021Google Scholar and Romania has donated to Moldova.21Oroschakoff K Romania donates COVID-19 vaccines to Moldova. Politico.https://www.politico.eu/article/romania-donates-covid-19-vaccines-to-moldova/Date: Feb 27, 2021Date accessed: March 23, 2021Google Scholar Uzbekistan, Tajikistan, and Georgia only began to receive COVID-19 vaccines supplies in March, 2021. In the region's disputed territories, such as the South Caucasus, there are particular challenges with COVID-19 vaccine supply and coordination.22McKee M Atun R Beyond borders: public-health surveillance.Lancet. 2006; 367: 1224-1226Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar WHO staff are working with member states and partners to find country-specific and subregion-specific solutions to these difficulties. The logistics of delivering vaccination to the intended groups is complex. Many things need to be in place, including accurate population registers, systems to identify groups with low uptake, adequate numbers of vaccinators, with removal of restrictive rules on who can administer vaccines that remain in some countries, and well functioning logistics systems for vaccines deployment.23Siciliani L Wild C McKee M et al.Strengthening vaccination programmes and health systems in the European Union: a framework for action.Health Policy. 2020; 124: 511-518Crossref PubMed Scopus (55) Google Scholar WHO is providing technical advice in situations where vaccination and associated logistics and management systems are weak, including support for effective vaccine safety surveillance systems and measures to build public trust. A sustainable, integrated, multisectoral response will be key to overcoming these challenges in the long term. The work of the WHO Regional Office for Europe will be informed by a Pan-European Commission on Health and Sustainable Development, chaired by former Italian Prime Minister Mario Monti, that will report in September, 2021. In an interim statement,24Pan-European Commission on Health and Sustainable DevelopmentRethinking policy priorities in the light of pandemics: a call to action (2021).https://www.euro.who.int/en/health-topics/health-policy/european-programme-of-work/pan-european-commission-on-health-and-sustainable-development/multimedia/rethinking-policy-priorities-in-the-light-of-pandemics-a-call-to-actionDate: March, 2021Date accessed: March 18, 2021Google Scholar published in March, 2021, the Commission highlighted several priorities. One is to address the challenges that arise at the intersection of human, animal, and environmental health, known as One Health. Two others are to improve our ability to anticipate and respond to emerging health threats, learning from entities such the Intergovernmental Panel on Climate Change, and to establish a Pan-European Centre for Disease Prevention and Control. There is much still to be done to ensure that no one will be left behind in the unprecedented efforts to vaccinate the people of Europe. HK is WHO Regional Director for Europe, WHO Regional Office for Europe. MM is an adviser to the WHO Regional Director for Europe and is a Commissioner in the Pan-European Commission on Health and Sustainable Development and Chair of its Scientific Advisory Board. We declare no other competing interests.