Lessons learned in shaping vaccine markets in low-income countries: a review of the vaccine market segment supported by the GAVI Alliance

The role of global health partnerships in vaccine equity: A scoping review

The emergence of global health partnerships (GHPs) towards the end of the twentieth century reflected concerns about slow progress in access to essential medicines, including vaccines. These partnerships bring together governments, private philanthropic foundations, NGOs, and international agencies. Those in the vaccine field seek to incentivise the development and manufacture of new vaccines, raise funds to pay for them and develop and support systems to deliver them to those in need. These activities became more critical during the COVID-19 pandemic, with the COVAX Facility Initiative promoting global vaccine equity. This review identifies lessons from previous experiences with GHPs. Findings contribute to understanding the emergence of GHPs, the mechanisms they leverage to support global access to vaccines, and the inherent challenges associated with their implementation. Using Arksey and O'Malley's method, we conducted a scoping review to identify and synthesise relevant articles. We analysed data thematically to identify barriers and opportunities for success. We included 68 eligible articles of 3,215 screened. Most (65 [95%]) were discussion or review articles describing partnerships or programmes they supported, and three (5%) were commentaries. Emerging themes included policy responses (e.g., immunisation mandates), different forms of partnerships arising in vaccine innovation (e.g., product development partnerships, public-private partnerships for access), and influence on global governance decision-making processes (e.g., the rising influence of foundations, diminishing authority of WHO, lack of accountability and transparency, creation of disease silos). If global health partnerships are to maximise their contributions, they should: (1) increase transparency, especially regarding their impacts; (2) address the need for health systems strengthening; and (3) address disincentives for cooperative vaccine research and development partnerships and encourage expansion of manufacturing capacity in low and middle-income countries.

Assessing readiness to implement routine immunization among patent and proprietary medicine vendors in Kano, Nigeria: a theory-informed cross-sectional study

BACKGROUND

Patent and proprietary medicine vendors (PPMVs) are widespread in communities and can potentially be used to expand access to routine immunization especially in underserved areas. In this study, we aimed to assess their readiness to implement routine immunization in Kano, Nigeria and identify factors associated with it.

METHODS

We conducted a cross-sectional survey of PPMVs aged 18 years and above in Kano metropolis, Nigeria, using cluster sampling technique. A 10-item Likert scale-based measure was used to estimate readiness score. The relationship between selected factors and readiness score was examined using multilevel linear modeling technique.

RESULTS

A total of 455 PPMVs with median age of 36 years participated in the study. The median raw score for readiness was 4.7 (IQR: 4.3 - 4-8) (maximum obtainable was 5). The mean readiness score (obtained through factor analysis) was 5.28 (SD: 0.58). Readiness score was associated with factors such as knowledge of immunization and task demand, engagement by other public health programs among others.

CONCLUSION

This study demonstrated the feasibility of measuring the level of readiness for implementing routine immunization among PPMVs. Given the high level of readiness, policy makers should consider the possibility of expanding access to immunization through PPMVs.

The impact of vaccine procurement methods on public health in selected European countries

Introduction: Across Europe, immunization programs have brought immense benefits to the prevention of infectious diseases. The vaccines used are procured through a variety of models such as tenders and Pricing & Reimbursement. However, to date, the impact of the procurement method on the performance and sustainability of vaccination programs and on public health has received little attention.Areas covered: Drawing on a review of the academic and policy literature, complemented by an interview program with stakeholders involved in the procurement of vaccines, the authors have documented the relationship between procurement method dynamics and the level of protection against vaccine-preventable diseases in Germany, Italy, Spain and Romania for, measles-containing vaccines, hexavalent and influenza vaccines.Expert opinion: Price-based tenders can contribute to vaccine supply issues, discourage the provision of value-added services supporting vaccination coverage and disincentives future R&D. Although it is observed that price-based tenders can intensify competition in the short term, there can be unintended consequences such as damage to long-term competition. As European countries are committed to strengthen their immunization programs, they should consider the implications of current vaccine procurement models on the vaccine ecosystem and on public health.

Shaping markets to benefit global health - A 15-year history and lessons learned from the pentavalent vaccine market

Market shaping for health products used in lower-income countries strives to benefit public health. As a funder of vaccines, Gavi, The Vaccine Alliance (Gavi) has goals for its market shaping efforts, achieved through a strategy developed and implemented by the Gavi Secretariat, UNICEF, the World Health Organization (WHO) and the Bill & Melinda Gates Foundation (BMGF). A case-study of Gavi's fifteen-year engagement with a vaccine against diphtheria, tetanus, pertussis, hepatitis B and haemophilus influenzae type b (pentavalent) provides evidence of the benefits and potential risks of trying to influence markets. During 2001-18, Gavi disbursed US$3.5 billion to support use of 50 million pentavalent doses annually before 2005, increasing to ∼300 million doses annually by 2016. During this time, eight manufacturers invested in vaccine development and manufacturing and the first two manufacturers have subsequently ceased production. Following its strategy, Gavi implemented coordinated market interventions including technical assistance to manufacturers, improving market information transparency, risk-sharing agreements and innovative procurement aiming to stimulate and capitalize on a competitive market. In 2018 supply allows ∼80 million children per year to be immunised, a sixteen-fold increase from 2005, with vaccine-related costs per child for donors and countries of one-quarter the 2005 level. Lessons learned include the importance of frameworks and strategies; the need to adjust interventions with changing conditions; the important role of manufacturers; and the potentially powerful effects of interconnected markets. This case study is limited by its focus on a single health product in a specific market, however the lessons can inform other market shaping efforts when taken in context. While countries and children have improved vaccine access, risks of financial sustainability and continued manufacturer investment in Gavi vaccine markets are being monitored. Gavi should continue implementing a market shaping strategy, adjust with market conditions and expect and measure unintended consequences.

A perspective on global access to insulin: a descriptive study of the market, trade flows and prices

AIM

To describe the global insulin market.

METHODS

Market intelligence data, United Nations Commodity Trade Statistics for insulin trade, the International Medical Products Price Guide for prices of human insulin and additional web searches were used as data sources. These sources were combined to gain further insight into possible links among market, trade flows and prices. Descriptive statistics and Spearman's rank order correlation were used for the analysis.

RESULTS

A total of 34 insulin manufacturers were identified. Most countries and territories are reliant on a limited number of supplying countries. The overall median (interquartile range) government procurement price for a 10-ml, 100-IU/ml vial during the period 1996-2013 equivalent was US$4.3 (US$ 3.8-4.8), with median prices in Africa (US$ 4.7) and low- (US$ 6.9) and low- to middle- (US$ 4.7) income countries being higher over this period. The relationships between price and quantity of insulin (Spearman's r=0.046; P>0.1) and number of import links (Spearman's r=0.032; P>0.1) were weak. The links between price and percentage of total insulin from a country where a 'big three' manufacturer produces insulin (Spearman's r=0.294; P<0.05) and total insulin from the main import link (Spearman's r=-0.392; P<0.05) were stronger.

CONCLUSIONS

This research shows the high variability of insulin prices and the reliance on a few sources, both companies and countries, for global supply. In addressing access to insulin, countries need to use existing price data to negotiate prices, and mechanisms need to be developed to foster competition and security of supply of insulin, given the limited number of truly global producers.

Novel approaches to vaccine development in lower-middle income countries

Purpose

The purpose of this paper is to identify, analyze and describe the novel approaches that affect vaccine development in lower-middle income countries (LMICs).

Design/methodology/approach

The vaccine market in LMICs currently focuses on traditional Expanded Program for Immunization vaccines instead of new ones. Unlike the successful introduction of those traditional vaccines, the introduction of new vaccines appears to be very slow, mainly due to financial issues. This paper systematically reviews a set of published papers on vaccine development and analyzes them against a specific region-setting framework.

Findings

Public–private partnership alone could not ensure long-term vaccine sustainability. Several factors that encourage domestic vaccine development were identified. The findings demonstrate that the regulatory approach of hybrid collaboration and market opportunity strategies can be a major breakthrough for domestic vaccine development in LMICs.

Research limitations/implications

Further research is required to include qualitative and quantitative methods for policy analysis, as all of the discussion in this research focused on literature reviews. The authors did not discuss how strategic decisions are affected from a political perspective and this needs to be specified in future research. Think tanks, considerably and fundamentally, affect policy ideas and decisions. However, important breakthroughs continue to be made at the same time.

Social implications

The development of vaccines in LMICs is expected to be a mechanism to overcome the inadequate access to vaccines in those countries, as solving this problem requires tackling issues from both the supply and demand sides.

Originality/value

This is a literature review that creates recommendation and approaches for domestic vaccine development in LMICs. This review aims to encourage LMICs to produce their own vaccines for sustainability of the vaccine access through vaccine development lifecycle, instead of expecting donor that provides funding and vaccines (vaccine access) in certain period of time. Donor is not always the solution for the problem, since vaccine development requires finance to function infrastructure. There are many efforts in revoking this, including World Health Organization through several reports; however, this effort still has many doubts. Therefore, the article would like to try to see this as a viable solution from the policy perspectives, with several examples to make recommendations more practical.

Forecasting demand for maternal influenza immunization in low- and lower-middle-income countries

Immunization of pregnant women against seasonal influenza remains limited in low- and lower-middle-income countries despite being recommended by the World Health Organization (WHO). The WHO/PATH Maternal Influenza Immunization Project was created to identify and address obstacles to delivering influenza vaccines to pregnant women in low resource setting. To gain a better understanding of potential demand from this target group, we developed a model simulating pregnant women populations eligible for vaccination during antenatal care (ANC) services in all low- and lower-middle-income countries. We assessed potential vaccine demand in the context of both seasonal and year-round vaccination strategies and identified the ways that immunization programs may be affected by availability gaps in supply linked to current vaccine production cycles and shelf life duration. Results of our analysis, which includes 54 eligible countries in 2015 for New Vaccine Support from Gavi, the Vaccine Alliance, suggest the demand for influenza vaccines could be 7.7 to 16.0 million doses in 2020, and 27.0 to 61.7 million doses by 2029. If current trends in production capacity and actual production of seasonal influenza vaccines were to continue, global vaccine supply would be sufficient to meet this additional demand—although a majority of countries would face implementation issues linked to timing of supply.

Challenges for nationwide vaccine delivery in African countries

Vaccines are very effective in providing individual and community (herd) immunity against a range of diseases. In addition to protection against a range of diseases, vaccines also have social and economic benefits. However, for vaccines to be effective, routine immunization programmes must be undertaken regularly to ensure individual and community protection. Nonetheless, in many countries in Africa, vaccination coverage is low because governments struggle to deliver vaccines to the most remote areas, thus contributing to constant outbreaks of various vaccine-preventable diseases. African governments fail to deliver vaccines to a significant percentage of the target population due to many issues in key areas such as policy setting, programme management and financing, supply chain, global vaccine market, research and development of vaccines. This review gives an overview of the causes of these issues and what is currently being done to address them. This review will discuss the role of philanthropic organisations such as the Bill and Melinda Gates Foundation and global partnerships such as the global alliance for vaccines and immunizations in the development, purchase and delivery of vaccines.

A forecast of typhoid conjugate vaccine introduction and demand in typhoid endemic low- and middle-income countries to support vaccine introduction policy and decisions

A Typhoid Conjugate Vaccine (TCV) is expected to acquire WHO prequalification soon, which will pave the way for its use in many low- and middle-income countries where typhoid fever is endemic. Thus it is critical to forecast future vaccine demand to ensure supply meets demand, and to facilitate vaccine policy and introduction planning. We forecasted introduction dates for countries based on specific criteria and estimated vaccine demand by year for defined vaccination strategies in 2 scenarios: rapid vaccine introduction and slow vaccine introduction. In the rapid introduction scenario, we forecasted 17 countries and India introducing TCV in the first 5 y of the vaccine's availability while in the slow introduction scenario we forecasted 4 countries and India introducing TCV in the same time period. If the vaccine is targeting infants in high-risk populations as a routine single dose, the vaccine demand peaks around 40 million doses per year under the rapid introduction scenario. Similarly, if the vaccine is targeting infants in the general population as a routine single dose, the vaccine demand increases to 160 million doses per year under the rapid introduction scenario. The demand forecast projected here is an upper bound estimate of vaccine demand, where actual demand depends on various factors such as country priorities, actual vaccine introduction, vaccination strategies, Gavi financing, costs, and overall product profile. Considering the potential role of TCV in typhoid control globally; manufacturers, policymakers, donors and financing bodies should work together to ensure vaccine access through sufficient production capacity, early WHO prequalification of the vaccine, continued Gavi financing and supportive policy.

Adventitious agents and live viral vectored vaccines: Considerations for archiving samples of biological materials for retrospective analysis

Vaccines are one of the most effective public health medicinal products with an excellent safety record. As vaccines are produced using biological materials, there is a need to safeguard against potential contamination with adventitious agents. Adventitious agents could be inadvertently introduced into a vaccine through starting materials used for production. Therefore, extensive testing has been recommended at specific stages of vaccine manufacture to demonstrate the absence of adventitious agents. Additionally, the incorporation of viral clearance steps in the manufacturing process can aid in reducing the risk of adventitious agent contamination. However, for live viral vaccines, aside from possible purification of the virus or vector, extensive adventitious agent clearance may not be feasible. In the event that an adventitious agent is detected in a vaccine, it is important to determine its origin, evaluate its potential for human infection and pathology, and discern which batches of vaccine may have been affected in order to take risk mitigation action. To achieve this, it is necessary to have archived samples of the vaccine and ancillary components, ideally from developmental through to current batches, as well as samples of the biological materials used in the manufacture of the vaccine, since these are the most likely sources of an adventitious agent. The need for formal guidance on such vaccine sample archiving has been recognized but not fulfilled. We summarize in this paper several prior major cases of vaccine contamination with adventitious agents and provide points for consideration on sample archiving of live recombinant viral vector vaccines for use in humans.

Are good intentions putting the vaccination ecosystem at risk?

Vaccination is made possible by an interconnected and interdependent ecosystem of vaccine producers, vaccination policy makers and implementers, and vaccine procurers and funders. The future of vaccination depends on the continued health of this ecosystem and its ability to produce, purchase, deliver, and innovate. However, the number of vaccine producers that also do significant research and development has decreased over the last several years. Many of these R&D-based producers have been forced to cease production of critical vaccines, despite global shortages, so that in several cases only one or two producers remain. We discuss the reasons for these changes and what might be done to maintain a healthy vaccination ecosystem.

The Ebola Vaccine Team B: a model for promoting the rapid development of medical countermeasures for emerging infectious disease threats

In support of accelerated development of Ebola vaccines from preclinical research to clinical trials, in November, 2014, the Wellcome Trust and the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota established the Wellcome Trust-CIDRAP Ebola Vaccine Team B initiative. This ongoing initiative includes experts with global experience in various phases of bringing new vaccines to market, such as funding, research and development, manufacturing, determination of safety and efficacy, regulatory approval, and vaccination delivery. It also includes experts in community engagement strategies and ethical issues germane to vaccination policies, including eight African scientists with direct experience in developing and implementing vaccination policies in Africa. Ebola Vaccine Team B members have worked on a range of vaccination programmes, such as polio eradication (Africa and globally), development of meningococcal A disease vaccination campaigns in Africa, and malaria and HIV/AIDS vaccine research. We also provide perspective on how this experience can inform future situations where urgent development of vaccines is needed, and we comment on the role that an independent, expert group such as Team B can have in support of national and international public health authorities toward addressing a public health crisis.