The long road ahead for COVID-19 vaccination in Africa
Authors: Sara Jerving
Journal: The Lancet (2021)

Only 2·5% of Africans are vaccinated against COVID-19. Millions more doses will be needed to meet even modest targets and experts are sceptical of success. Sara Jerving reports. It was more than 2 months after the first COVID-19 vaccine was administered in the UK that the first doses from the COVID-19 Vaccines Global Access facility (COVAX) landed on the African continent—600 000 doses shipped to Ghana at the end of February, 2021. By that time, about 191 million doses had been administered globally, but just ten countries accounted for three-quarters of vaccinations given. Despite the slow start, there was an air of optimism as countries started receiving doses. But it was short lived. COVAX was overly dependent on one supplier—the Serum Institute of India—for its doses. Within weeks, the Indian Government suspended the export of COVID-19 vaccines as it struggled to contain its own domestic crisis. By the end of March, only 16 million doses were delivered to 28 African countries. The following months were bleak. Many African nations entered third and fourth waves of the pandemic, with overwhelmed hospitals and shortages of oxygen and intensive care unit beds. The continent reported a record peak in weekly deaths at the beginning of August. Even with financing, many lower-income countries have struggled to purchase doses as demand outstrips production. In the global stampede to secure vaccines, high-income nations have hoarded vast quantities of doses. The vaccine scarcity began to improve in July, when African nations received more doses that month from COVAX than the entire months of April to June combined. Donated doses began to arrive in the millions, as high-income countries that had already vaccinated substantial proportions of their populations started to slightly loosen their grip on global supplies. Even so, only 2·5% of the overall population across Africa is fully vaccinated. The pace and scale at which vaccination deliveries are happening across the continent still fall short, and there is a long road ahead towards reaching a vaccination threshold that will help most countries manage the pandemic, health experts say, with concerns around the predictability of supplies of vaccines in the coming months. The Africa Centres for Disease Control and Prevention (CDC) previously aimed to vaccinate 60% of the population on the continent—780 million people—by the end of 2022, in order to reach herd immunity. But John Nkengasong, Africa CDC's director, said during a press briefing that he doubts the notion of herd immunity is relevant anymore, given the emergence of the delta variant and the fact that COVID-19 vaccines are only modestly effective at reducing transmission. He now estimates that about 70–80% of the population will need to be vaccinated. In the shorter term, WHO's Regional Office for Africa aims to vaccinate about 40% of the continent's population by the end of 2021. That would require up to 793 million more doses than the 129 million that have already been received. “Right now, it's extremely unlikely the majority of African countries, especially those that are largely dependent on the COVAX facility for vaccine supply, are going to reach that threshold of having 40% of even the adult population vaccinated, let alone 40% of the entire population”, said Shabir Madhi, director of the vaccines and infectious diseases analytics research unit at the University of the Witwatersrand, Johannesburg, South Africa. In an Aug 26 press briefing, WHO Regional Director for Africa Matshidiso Moeti said that 13 million doses had been administered across Africa in the past week, triple the amount in the previous week. But even with an uptick, the continent is not slated to reach the goal of 10% of the population vaccinated by the end of September. Africa has received 129 million doses and is expecting an additional 117 million doses by the end of September, leaving 28 million further doses needed to reach the target. Some African countries have secured vaccine doses of Sinopharm and Sinovac or Russia's Sputnik V on a bilateral basis, which has allowed for higher levels of vaccination. For example, Morocco has fully vaccinated 39% of its population and Seychelles has vaccinated 71%. But others are far behind, including several who have vaccinated less than 0·1% (table). Many countries have been successful in rolling out large quantities of vaccines. About 30 African countries used up more than three-quarters of the vaccines they received, Moeti said during a press briefing at the end of July. Rwanda, which received both AstraZeneca and Pfizer doses from COVAX in early March, administered 96% of the doses within the first 2 weeks. In July, Nigeria announced it had exhausted all of the 3·9 million doses the country was given in the first phases of vaccination.TableAfrican countries with the greatest and least proportion of the population vaccinated against COVID-19Percentage of population (%)Top fiveSeychelles71%Mauritius55%Morocco39%Tunisia18%Cape Verde12%Bottom fiveCameroon0·3%Guinea-Bissau0·1%Burkina Faso<0·1%Chad<0·1%DR Congo<0·1%As of Aug 31, 2021. Source: Our World in Data. Open table in a new tab As of Aug 31, 2021. Source: Our World in Data. Other countries struggled. DR Congo delayed its roll-out of AstraZeneca vaccines in response to concerns over blood clots. Then, after launching its campaign, the Government returned 1·3 million doses to the COVAX Facility because the doses could not be administered before they expired. South Sudan also returned doses to the facility before expiry, but then used up the remaining doses it had. Some countries resisted launching a vaccination campaign. In a change in stance, the Government in Tanzania commenced its campaign at the end of July. Eritrea and Burundi are the only countries on the continent that have not started national vaccination campaigns. COVAX aims to ship about 620 million doses by the end of the year to the continent, which would vaccinate almost a quarter of the population. Much of the supply is currently coming from donations, including from the USA, the UK, and EU. The facility also signed new advance purchase agreements for doses of the Sinopharm, Sinovac, Novavax, Moderna, Johnson & Johnson, and Clover vaccines since the last forecast it made on allocations. Separately, the USA pledged 500 million Pfizer doses to low-income and lower-middle-income countries, with 200 million of these doses expected for delivery by the end of this year through COVAX and bilaterally. What proportion of these will go to African nations is still unclear. Given that many African nations were left stranded without vaccines earlier this year, there are concerns that COVAX's access to vaccines could again be compromised by disruptions in the global supply chain. “We are fully dependent on vaccines from outside the continent. If what happened in India happens again, somewhere, for example in the USA...we are gone”, said Phionah Atuhebwe, new vaccines introduction officer at WHO's Regional Office for Africa. Aurélia Nguyen, managing director of the COVAX Facility, called on manufacturers to match their words with actions in order for COVAX to help the African Union (AU) reach its vaccination targets. “Too often, manufacturers are finding reasons to defer supplies to COVAX and this is bad for those countries that rely on COVAX for life-saving vaccines and it's bad for all countries, including wealthier countries, whose economies rely on bringing the pandemic under control. Governments can help by insisting they and COVAX have transparency from manufacturers so it is clear if countries or other buyers are jumping the queue.” The AU has separately secured vaccine doses for countries to purchase. It signed a deal with Johnson & Johnson for 400 million doses, partly manufactured in South Africa, for delivery over 18 months. Upfront funding to the company came from the African Export–Import Bank and the World Bank is providing financing to countries. About 6·4 million of these doses were expected for delivery in August, rising to 10 million doses in September. By the end of the year, countries are slated to receive nearly 50 million doses. Production is projected to ramp up so that in January countries are expected to receive around 25 million doses per month. Chinese President Xi Jinping also pledged in August to provide 2 billion doses globally by the end of the year, without specifying if these were donations or sales, and whether the figure included doses already sold globally this year. But even with promised vaccines from COVAX and the AU, a WHO spokesperson said the African continent would still need up to 196 million more doses to meet the 40% target. Hayley Andersen, an associate at the Tony Blair Institute for Global Change, said she has “guarded optimism” about the increased supply of vaccines to African nations, but said it will be a “huge hurdle” to meet the end-of-year goal. There are a lot of risks to the supply chain, any of which could derail current projections. These include challenges at manufacturing facilities, the regulatory approval of Novavax's vaccine, the lifting of export restrictions, childhood immunisations in high-income countries, and the use of booster shots. WHO called for a moratorium on countries giving out third doses to populations until at least the end of September so that countries with very low vaccination rates have a chance to improve coverage. Several countries, including the USA, have disregarded that call. And the timing of all these doses is unpredictable. Andersen expressed concern there will be a “massive dump” of doses in the last 3 months of the year, which could overwhelm countries. “We need a more steady, ongoing supply—not the start–stop, which we’ve seen”, said Jens Pedersen, humanitarian adviser for Médecins Sans Frontières in South Africa. Although vaccine equity advocates encourage high-income countries to donate even more vaccines, public health officials have also cautioned these countries to donate doses with at least a 3–4-month shelf life. A handful of African nations destroyed about 450 000 expired doses after they could not administer them fast enough. The expenses of in-country roll-outs are also often overlooked. Much of the funding available for vaccine purchase and roll-out is available in loans rather than grants, which could discourage some countries from launching large-scale roll-outs, Pedersen said. “I think countries underestimate the amount of resources that will be required to actually scale up vaccination to the rates that would be required to get to that 40% threshold by the end of the year”, Madhi said.