Access to vaccines for COVID-19 varies dramatically worldwide, with roughly a third of the global population still entirely unvaccinated. Low-income countries (LICs) are the least vaccinated, with only 20.7 percent of eligible individuals in these countries having received at least one dose as of August 2022.¹ While the rate of booster vaccination in LICs hovers close to zero, it is above 50 percent in high-income countries (HICs).² But global populations vary not only in their access to COVID-19 boosters, but also their willingness to take them. Both issues are central to ongoing campaigns against COVID-19.

 As vaccines first widely began to become available in early 2021, public health experts emphasized the need to combat “vaccine nationalism”: the competitive acquisition of vaccines by HICs, perpetuating the idea that each country is only responsible for vaccinating its population.³ The COVID-19 Vaccines Global Access (COVAX) program was established in June 2020 to facilitate more equitable distribution, in part by encouraging high and upper-middle income countries to buy doses through COVAX (in case a country’s own candidates failed in trials). This would allow COVAX to achieve the buying power — augmented by donor funding — to increase vaccine supply to LICs. But with roughly three dozen wealthy nations ultimately buying the majority of their doses through direct agreements with vaccine companies, COVAX’s impact has been blunted. Though COVAX’s contributions are substantial — more than 1.2 billion doses have been delivered to 92 low or lower-middle income countries — the program’s efforts have largely focused solely on distributing COVID-19 boosters, and not on restructuring the underlying inequities of the global manufacturing systems it relies upon.²  

 Public health experts are increasingly calling for COVID-19 “vaccine sovereignty”: increasing local capacities to manufacture vaccines, rather than relying on a global system in which lower income countries receive donated or surplus doses from HICs. Promising efforts are emerging: the African Union’s Partnerships for African Vaccine Manufacturing is aiming to raise the share of vaccines that the continent needs that are manufactured in Africa from one percent in 2021 to 60 percent by 2040, and the Pan American Health Organization has organized around similar manufacturing goals. Companies are entering into agreements with individual LICs to increase their vaccine manufacturing capacity.⁴ Though encouraging, the scale of investment needed (estimated at $1.5 billion for a single facility) requires ambitious public-private partnerships, careful consideration of local circumstances, and sustainable systems for building and maintaining the technologies, workforce, and regulatory systems required for vaccine production and distribution.^{4, 5} 

 India, a lower-middle income country exceptional for its mass production of COVID-19 vaccines, only began offering boosters to the public in April, and at free government centers in June. Between mid-July and mid-August, approximately 70 million doses have been distributed, marking a major surge. Compared to other countries, vaccine acceptance in India is on average high (84 percent, whereas that number stands at approximately 65 percent in the United States).⁶ Still, the percent immunized with a booster across India lags at roughly eight percent (the adult population is 940 million), whereas in the U.S., that number is close to forty percent.⁷  

 It is clear that global uptake of COVID-19 boosters depends on more than manufacturing capacities. One of the countries that have been most successful in administering boosters — with second doses rolled out in 2022 — has been Chile, an emerging HIC. Early on, Chilean universities partnered with a wide variety of vaccine developers to participate in clinical trials, and the government pursued purchasing agreements with stakeholders ranging from a state-owned Chinese laboratory (Sinovac), to private ones based in different countries: United States-Germany (Pfizer-BioNtech), England (Oxford-AstraZeneca); the Serum Institute from India, Russia’s Gamaleya Institute, and others. Pragmatism — in the face of devastating COVID-19 morbidity and mortality, as well as sociopolitical upheaval that began in 2019 — was “the guiding principle” for Chile’s vaccination program, and resulted in wide uptake, scholars have noted. But just as important was a history of vaccine trust, which has evolved over decades, maintained by initiatives like the National Immunization Program (PNI), established in 1978.⁸ 

 In other countries, vaccine acceptance is significantly reduced. In June 2021, vaccine hesitancy was reported most frequently in Russia (48.4 percent) in a survey of 23 countries published in Nature.9 A study of Russian vaccine hesitancy highlights how a general distrust of public institutions and health and science authorities has compelled many to resist the vaccine.¹⁰ Whereas in China, hesitancy to vaccinate with a hypothetical doctor’s recommendation is reported at just five percent, in Russia, that number is 43.6 percent.⁹ When vaccinated individuals in 13 countries were asked if they would get a booster shot if it were available to them that day, intent was highest in Brazil, Mexico, and China (96, 93, and 90 percent, respectively) and lowest in Russia and Italy (62 and 66 percent).¹¹  

 The determinants of vaccine mistrust, including global mistrust of COVID-19 boosters, are multifactorial. Variables like income can shape hesitancy in a variety of ways: in some cases, a lower household income is associated with a greater level of hesitancy, while the loss of income due to the pandemic has been positively associated with vaccine acceptance.⁹ However, how individual experiences translate to vaccine acceptance on a national scale is complex, testifying to the importance of accurate and effective public health messaging — a campaign that must be pursued in conjunction with equitable access. 

 

References 

1. Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus Pandemic (COVID-19). Our World in Data. Published online 2020. https://ourworldindata.org/covid-vaccinations 

1. Yamey G, Garcia P, Hassan F, et al. It is not too late to achieve global covid-19 vaccine equity. BMJ. 2022;376:e070650. doi:10.1136/bmj-2022-070650 

1. Katz IT, Weintraub R, Bekker LG, Brandt AM. From vaccine nationalism to vaccine equity – finding a path forward. N Engl J Med. 2021;384(14):1281-1283. doi:10.1056/NEJMp2103614 

1. Dzau VJ, Balatbat CA, Offodile AC 2nd. Closing the global vaccine equity gap: equitably distributed manufacturing. Lancet. 2022;399(10339):1924-1926. doi:10.1016/S0140-6736(22)00793-0 

1. PLOS Medicine Editors. Vaccine equity: A fundamental imperative in the fight against COVID-19. PLoS Med. 2022;19(2):e1003948. doi:10.1371/journal.pmed.1003948 

1. Dhalaria P, Arora H, Singh AK, Mathur M, S AK. COVID-19 vaccine hesitancy and vaccination coverage in India: An exploratory analysis. Vaccines (Basel). 2022;10(5):739. doi:10.3390/vaccines10050739 

1. COVID-19 vaccine boosters administered per 100 people. Our World in Data. https://ourworldindata.org/grapher/covid-vaccine-booster-doses-per-capita 

1. Castillo C, Villalobos Dintrans P, Maddaleno M. The successful COVID-19 vaccine rollout in Chile: Factors and challenges. Vaccine X. 2021;9(100114):100114. doi:10.1016/j.jvacx.2021.100114 

1. Lazarus JV, Wyka K, White TM, et al. Revisiting COVID-19 vaccine hesitancy around the world using data from 23 countries in 2021. Nat Commun. 2022;13(1):3801. doi:10.1038/s41467-022-31441-x 

1. Schneider-Kamp A. COVID-19 Vaccine Hesitancy in Denmark and Russia: A qualitative typology at the nexus of agency and health capital. SSM Qual Res Health. 2022;2(100116):100116. doi:10.1016/j.ssmqr.2022.100116 

1. Myers J. Would you get a COVID-19 booster shot if offered? World Economic Forum. Published September 10, 2021. https://www.weforum.org/agenda/2021/09/covid-19-booster-shot-if-offered