Bigger and better
I would like to expand on an issue in light of a recent letter by several global health experts directed to the White House. (https://www.npr.org/sections/goatsandsoda/2021/08/20/1029263796/theyre-asking-biden-to-vaccinate-the-world-its-not-fair-but-its-not-impossible)
While the US can, should and must do more to combat the threat of COVID across the globe, applying techniques that have already found only mixed success in the United States may not be the most efficient or practical method.
The answer to the global mal-distribution of vaccines is not necessarily to create mRNA-vaccine infrastructure around the world, but should include revamping existing vaccine tech and infrastructure. More traditional vaccines, like the Oxford-AZ and J&J work well enough to combat the disease burden that COVID is creating in lower-resource settings. (https://www.vox.com/22362894/which-covid-vaccine-is-better-moderna-vs-pfizer-video). mRNA vaccines are not essential in these settings in the immediate short-term while other options exist, but they are impressively more expensive and logistically impossible in many places.
These global health experts suggest that manufacturing of vaccines needs to be taken to places with the disease burden. That is true, but it should focus on existing and more practical tech. India manufactures, through the Serum Institute, a disproportionate amount of the world's vaccines and we realized the complications of that arrangement when they stopped exporting any. We need to avoid that in the future, but we can do it with currently-available vaccine vehicles. mRNA may be a vaccine tech of the future, but in the here-and-now, we need more actionable solutions while doing the long, hard, and expensive work of introducing the new and improved.
We should not be putting mRNA COVID vaccines on such a pedestal.
It is still true that the best COVID vaccination a person in lower-resource, higher-burden countries can get is the one they are offered ... and that is going to be simpler and faster with non-mRNA varieties. If we expand mRNA vaccine technologies across the globe, it should not be at the expense of investing in other promising novel technologies that confer several advantages to the traditional “needle-and-syringe” technique of immunisation. While mRNA technology is ground-breaking, it is simply expanding the current box of tools we use to combat poor health around the world. The global burden of disease from vaccine-preventable illness demands that we think outside of it.
If we are to explore new vaccine technologies with an eye to expanding manufacturing and access around the world, I would argue the time has come to focus on delivery methods that can circumvent the cold chain, not amplify it. Before I continue, I should stress that I have no financial incentive to endorse or support any particular commercial entity relating to vaccine manufacturing or distribution. My motivation stems from my daily struggle seeing children die of diphtheria, pertussis, tetanus and many other preventable killers.
There is promising work happening with micro-array patches (MAPs) that can deliver vaccines without needing refrigerators or even syringes and needles. It has been shown to create an immune response comparable to existing flu vaccines and just needs larger trials to be proven clinically effective. (https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003024) UNICEF states that a pivotal move in the fight against vaccine-preventable diseases would involve bringing this technology “to scale” to combat global killers. (https://www.unicef.org/innovation/vaccine-microarray-patches-vmaps)
Why not use some of the dollars we are probably advocating for by endorsing mRNA vaccine expansion and apply it to other promising technology that can circumvent the cold chain, contributing not only to the expansion of COVID vaccine availability, but to the dramatic expansion of all immunization efforts through the elimination of cold-chain requirements? If I can choose between shipping a card-board box full of thousands of 40-degree-celsius-stable vaccine band-aids and shipping a few dozen vials of mRNA vaccines in an amplified cold-chain apparatus, the decision becomes very easy.
In addition to considering an expanded framework on global outreach regarding vaccination, the US must not be led into the common trap of creating a new global health “silo” - in which an isolated health issue dominates the funding and logistics apparatus already stretched in providing health services for the poor around the world. The population structures of less developed areas (https://www.populationpyramid.net/less-developed-regions/2019/) compared to the more affluent nations (https://www.populationpyramid.net/more-developed-regions/2019/) suggest that COVID19 will not be their biggest struggle in the coming years. Focus on COVID19 activities has already created significant problems of diversion of efforts and resources, the results of which may not be apparent for years (https://www.bbc.com/news/world-africa-57657546). As the United States looks to rejoin the global health stage through its return to the WHO and its own efforts to reach out, an eye must be kept on maintaining and strengthening the health systems with regards to essential health services most pertinent to the populations that they serve.
As the US moves forward in joining the global health efforts of the WHO as well as its own aid programs, isolated focus on a specific health issue or a specific technology could create more harm than good for those we are trying to help. I would encourage policy-makers to take a step back from mRNA vaccines, and COVID in general, in order to widen our imaginative efforts and anticipate bigger and better changes ahead.
-Mark Crouch, MD
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