Ensuring access to affordable, timely vaccines in emergencies

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Bulletin of the World Health Organization
Volume 97, Number 12, December 2019, 789-856
https://www.who.int/bulletin/volumes/97/12/en/
PERSPECTIVES
Ensuring access to affordable, timely vaccines in emergencies
— Kate Elder, Barbara Saitta, Tanja Ducomble, Miriam Alia, Ryan Close, Suzanne Scheele, Elise Erickson, Rosalind Scourse, Patricia Kahn & Greg Elder
http://dx.doi.org/10.2471/BLT.18.228585
Vaccination is an effective intervention to reduce disease, disability, death and health inequities worldwide. Over the last two decades, vaccines have become more accessible in low-income countries; however, significant gaps remain, particularly in humanitarian emergencies, where populations face increased risks of many diseases. In 2013, the World Health Organization (WHO) published Vaccination in acute humanitarian emergencies: a framework for decision-making, to provide guidance on which vaccines to prioritize during emergencies.1 However, substantial obstacles, especially high prices for new vaccines, hinder implementation of this framework and of critical vaccination activities in emergency settings.
In response to these challenges, global health stakeholders held a series of consultations in 2016 and proposed a WHO-based mechanism, the Humanitarian Mechanism, for the rapid procurement of affordable vaccines during emergencies, to be used by nongovernmental organizations (NGOs), civil society organizations, United Nations (UN) agencies and governments.
Here we present the background of the creation of the mechanism from the perspective of Médecins Sans Frontières (MSF), including a description of our past challenges in accessing affordable pneumococcal conjugate vaccine (PCV; Box 1), a critical vaccine during many emergencies. We then describe how the mechanism has so far facilitated access to more affordable PCV and outline steps that could increase its potential for saving lives…
The Humanitarian Mechanism
In May 2017, the Humanitarian Mechanism was jointly launched by WHO, the United Nations Children’s Fund (UNICEF), Save the Children and MSF.8 The mechanism aims to address the high prices of new vaccines and to facilitate rapid access to vaccines for children in emergencies who missed doses or who live in countries where a given vaccine is not yet in the national immunization calendar, but where there is a high risk of exposure. Under the mechanism’s terms of reference, manufacturers commit to supplying a particular vaccine (currently only PCV10 and PCV13) at a set price. UNICEF, through its supply division, and other organizations with their own supply chain capacity, negotiate contracts bilaterally with manufacturers, specifying ordering and delivery terms as well as protocols. When an emergency need for a vaccine is identified, the implementing organization makes a request to WHO, specifying the context, number of doses needed and other relevant details; within two days WHO verifies the emergency context and appropriateness of the request. Upon verification, the order can be placed and the vaccine supplied.8 WHO manages the administrative aspects of the mechanism; once contracts between the implementing organization and manufacturer are in place, the administrative aspects, and the verification process require minimal overhead cost…

Next steps
Building on these initial successes, we see three critical elements of the mechanism, which if fully implemented, could greatly enhance its impact. First, the mechanism needs to be better known among global health actors, including UN agencies and NGOs, who should be encouraged to use it under appropriate circumstances. Second, while the mechanism’s terms of reference includes use by governments responding to emergencies,8 conditions attached to the PCV pledges discussed here (the only pledges to the mechanism so far) exclude governmental use. Manufacturers should allow governments to access the mechanism during emergencies to procure critical vaccines needed to protect their populations. Many middle-income countries already grapple with high vaccine prices for routine immunization programmes and may find the cost of extending vaccination to influxes of displaced people during emergencies prohibitive. While Gavi adopted a fragility, emergencies and refugees policy in June 2017 to allow more flexible use of Gavi-supported vaccine doses in specific contexts, strict criteria exist for how and where this flexibility can be applied, and it can only cover Gavi-eligible countries.12
Finally, the types of vaccines pledged to the mechanism by manufacturers should be expanded: the only commitments to date are for pneumococcal conjugate vaccines. Current and future manufacturers should commit other vaccines with affordability and accessibility challenges to the mechanism, so they can be procured rapidly at the lowest global price

Conclusion
The mechanism is a significant step forward in delivering life-saving vaccines to populations caught in emergencies and conflict. The mechanism’s mandate is strengthened by multiple organizations recognizing the gap between existing technical guidelines and constraints on their implementation, that is, the lack of rapidly available, affordable vaccines. While the mechanism does not address the broader systemic failures of the vaccine market, it was created to specifically address the failure of the global vaccine market to meet relatively small, urgent vaccine procurement needs efficiently and affordably. Further steps are needed for the mechanism to reach its full potential; however, it already provides a critical platform during humanitarian crises for expanding the number of people who can receive life-saving vaccines.