The announcement of three major vaccine breakthroughs in just under a month provided some positive news to an otherwise gloomy festive period. While a huge scientific achievement, vaccine approval is just the first step of what is going to be a demanding journey towards global suppression of COVID-19. 

Vaccinating against coronavirus in countries with pre-existing immunization infrastructure will be challenging enough. Brigadier Phil Prosser, Commander of Military Support for the United Kingdom’s vaccine delivery programme has labelled the exercise “unparalleled in scale and complexity”. 

The hurdles faced in emerging markets like India, Brazil and Indonesia pale by comparison. Despite being the single largest producer of coronavirus vaccines, COVID-19 remains the first mass vaccination programme in India’s history. Public trust and confidence in vaccines across Asia, Africa and South America remains some of the lowest in the world. The battle will be fought on two fronts: ensuring a continuous supply of vaccine doses to both urban and rural areas, while also having the local resources in place to educate communities and administer doses. 

COVAX, the world’s largest portfolio for global vaccine distribution, is aiming to provide two billion COVID-19 doses to high-risk communities by the end of 2021. However, campaigners claim production will not meet global demand until between 2023 and 2024. Regardless of which timeline you pick, emerging markets will be forced to make compromises and face difficult decisions in order to straddle the next two years. 

While AstraZeneca has pledged 64% of its doses to developing nations, the effectiveness of these will be hampered by cold chain requirements, and many developing countries have all but ruled out using these and the Pfizer BioNTech serum in their more immediate vaccination programmes. 

With huge quantities of the major three Western vaccines pre-ordered by the US, UK and EU, and infighting surrounding who first has access to these already arising, it is becoming increasingly clear that emerging markets will be far more reliant on the independently developed vaccines from China and Russia in 2021 and early 2022.

Sinovac, which produces China’s Coronavac serum, has secured purchase agreements with governments in Turkey, Brazil, Chile and Indonesia; while Russia’s Sputnik V vaccine, the first COVID-19 serum to be globally registered, has also been procured by Hungary prior to EU health approval. The vaccine is also close to approval in Pakistan.

Coronavac doses arriving in Sao Paulo, Brazil

Sinovac have built a production plant in Beijing capable of producing 300 million doses a year, and construction of a subsequent Sinovac facility began in Sao Paulo in November. The inactive Chinese vaccine has a significant advantage over its three major Western counterparts, as it can be stored between 2 and 8 degrees Celsius. 

Despite these obvious supply chain advantages in the developing world, its efficacy has been called into question. Clinical trials in Brazil have been recently revised to indicate that Coronavac is only 50.4% effective, just a shade over the 50% requirement set by the World Health Organisation. Phase three trials in Turkey and Indonesia have however reported higher rates of success. 

Bottlenecks in the global supply chain are also fast emerging. The so-called “fill and finish” process, where doses of the vaccine are deposited into glass vials and packaged, looks to be the most critical. The UK government has provided all-important financial support for the process at home; where it occurs at a handful of production plants. However, red tape has already proven to be a problem in Brazil, with the country struggling to access key Sinovac and AstraZeneca reagents that are being manufactured in China. Local reports suggest Rio’s production facility has been idle waiting for these to arrive.  

Pfizer vaccine
The Pfizer BioNTech vaccine needs to be stored at -70 degrees Celsius to remain active

While the Pfizer vaccine may have the most extreme cold chain requirements, being stored at -70C, it is becoming increasingly clear that in emerging markets like India does not have the cold-chain capacity required for even the more accessible vaccines. McKinsey & Co. estimate that 1% of the existing vaccine distribution network has the cold-chain requirements for the available COVID-19 serums. 

In November, public health campaigners labelled India’s cold-chain capacity “inadequate” for even India’s existing vaccination programmes. European manufacturing firms have since flooded the market with infrastructure to develop this. 

Risk factors also remain high, with Brazil, Mexico and India having some of the highest rates of pharmaceutical theft in the world. Limited supply in the early stages of distribution will make this ultra high value cargo a likely target for criminal networks. 

The optimism of a swift global exit from the crisis many had in December now appears a long way away. Emerging markets will now find themselves having to navigate 2021 and early 2022, waiting for production to catch up with demand, and settling for vaccines whose efficacy we are far less certain of in the meantime.

What this does mean is emerging markets will be far better prepared for future global health crises. This creation of a cold chain and immunization infrastructure will place India, Brazil and other emerging economies in a stronger and safer position when it comes to combating disease and public health threats in the future.