Comment TONY KARUMBA/AFP VIA GETTY KARUMBA/AFP TONY a Volunteer Nurse Assesses a Visitor to a Health Centre in Nairobi That Trains the Public on Infection Prevention

Setting the agenda in research Comment TONY KARUMBA/AFP VIA GETTY KARUMBA/AFP TONY A volunteer nurse assesses a visitor to a health centre in Nairobi that trains the public on infection prevention. COVID-19 vaccines: how to ensure Africa has access

John N. Nkengasong, Nicaise Ndembi, Akhona Tshangela & Tajudeen Raji

History must not repeat itself ast month, a grand experiment was to whichever ones prove to be effective. launched. Its aim? To speed up the Under this scheme, even poor nations should — global and continental development of COVID‑19 vaccines and have enough vaccines to protect health-care cooperation are essential. make sure they are distributed equita‑ workers and the most vulnerable 20% of their bly among higher- and lower-income populations. Lcountries. Still, Africa has reasons to worry. Already, This welcome endeavour is called the several high-income countries have signed COVID-19 Vaccine Global Access (COVAX) ini‑ their own contracts with individual compa‑ tiative. It is co-led by the World Health Organ‑ nies to buy selected vaccines. The United ization (WHO), the Coalition for Epidemic States, for example, has made deals worth Preparedness Innovations (CEPI) and Gavi, the upwards of US$6 billion with several firms. An Vaccine Alliance. As of 1 October, 167 countries analysis by the international charity Oxfam have signed up, covering nearly two-thirds of finds that, even if all five of the most-ad‑ the global population. More have expressed vanced vaccine candidates succeed, there interest, according to Gavi. will not be enough vaccine for most of the The initiative covers several vaccines world’s people until 2022. currently in testing. It aims to ensure access We’ve seen a scramble for access to

Comment therapies before. It happened with HIV and test kits. At the time of writing, Ethiopia is on structures required for delivery is estimated at H5N1 influenza, for example. And Africa has track to produce some 10 million COVID-19 between $7 billion and $10 billion, according ended up at the end of the queue every time. PCR-based test kits per year for use across to Africa CDC. For comparison, the 2020 US Yet the global economy depends on the con‑ Africa. This is far below its needs, but many PEPFAR budget was $6.9 billion. tinent for its exports of raw materials, food, more than seemed possible when we launched This level of vaccination far exceeds that energy and labour. PACT. in the successful system that immunized This experience — and the fact that other young children against a suite of diseases, at infectious diseases will surely emerge — is Cost and scale least until it was disrupted by the pandemic. why Africa needs a coordinated strategy to The COVAX initiative promises to benefit These include tuberculosis, diphtheria, teta‑ develop, finance, manufacture and deliver Africa, and many people on other continents. nus, whooping cough, poliomyelitis, measles, vaccines across the continent. For the past It hopes to offer lower-income countries equi‑ hepatitis B, yellow fever and the bacterial infec‑ few months, the Africa Centres for Disease table access to a diverse portfolio of potential tion Haemophilus influenzae (which can cause Control and Prevention (Africa CDC) in Addis vaccines at highly subsidized prices. This inter‑ severe infections of the blood or lining of the Ababa, where we work, has been developing national cooperation and solidarity is laudable brain and spinal cord). The WHO’s Expanded this, with leaders from the African Union and and essential. Program of Immunization has delivered mil‑ in global health. So is preparation across the whole of Africa lions of vaccine doses to children in Africa Here we describe what must be done. for testing, purchasing and delivery. Africa, like since 1977. Nothing on this scale has ever been all continents, needs an accessible vaccine to developed to reach adults. Learn from history save the lives and health of vulnerable popula‑ A ‘whole of Africa’ coordinated approach Antiretroviral drugs to treat HIV entered the tions, and to maintain economic development. is needed to prepare for the development, market in the mid-1990s. At the time, one As of 1 October, more than 1.4 million people purchase, access and roll-out of a COVID‑19 of us (J.N.) was working in Côte d’Ivoire as were known to have been infected with SARS- vaccine. That must be built now. Success will part of a US Centers for Disease Control and CoV-2 in Africa, with more than 36,000 deaths. require collaboration between political lead‑ Prevention project that was struggling to As COVID-19 continues to spread, thousands ers on the continent and those elsewhere, combat HIV in the country without access to more lives will be lost. The World Bank esti‑ including the WHO, Gavi, CEPI, regulatory medicine. The prices that companies set for mates that economic growth in sub-Saharan agencies, implementing partners, donors and these drugs put them out of reach. As deaths Africa will decline from 2.4% in 2019 to between the private sector. in rich countries plummeted, infected people �2.1 and −5.1% in 2020, the first recession in the In June, the African Union Commission were left to die across Africa (see ‘Left to die’). region in 25 years. In addition to the coronavi‑ and Africa CDC convened a virtual confer‑ It is estimated that, between 1997 and 2007, rus pandemic, many nations in Africa are reel‑ ence. More than 3,000 political leaders and 12 million Africans died waiting for enough ing from the worst locust plague in 50 years, technical experts discussed COVID-19 vaccine life-saving drugs to reach the continent. The and a terrible drought is predicted to occur in needs and a continental strategy. In August, drugs’ arrival was largely thanks to the efforts East Africa. A COVID-19 vaccine could at least the African Union Bureau of Heads of State of the US President’s Emergency Plan For AIDS help to mitigate this dire situation. and Government endorsed the strategy Relief (PEPFAR) and the Global Fund to Fight To vaccinate 60% of its population (the esti‑ put forward by Africa CDC, reiterating how AIDS, Tuberculosis and Malaria. mated minimum requirement for herd immu‑ past experience in global health shows that In 2004, the highly pathogenic avian influ‑ nity3), Africa will need about 1.5 billion doses of Africa must move decisively, effectively and enza virus H5N1 re-emerged, prompting fears vaccine. (Its population is 1.2 billion, and most collectively to secure access to vaccines and of an overwhelming, global pandemic1. Nego‑ vaccine candidates require two doses.) The life-saving therapy. tiations by the WHO to share and stockpile cost of the vaccine and of building systems and doses of an eventual vaccine broke down. At Three pillars one point, tensions were so high that Indo‑ L The strategy has three pillars. The first is to nesia refused to share H5N1 virus samples When HIV drugs were introduced in the mid-1990s, accelerate African involvement in the clinical that were crucial for surveillance. Five years AIDS-related deaths kept rising in Africa but fell development of a vaccine. The second is to sharply in the United States. It took another decade later, another strain of pandemic flu (H1N1) for deaths to decline in Africa. ensure that Africa can access a sufficient share emerged, and rich countries placed large Africa United States of the global supply. The third is to remove bar‑ pre-orders of vaccine, buying almost all of the riers to widespread delivery and uptake of the 10 years doses that could possibly be manufactured. 1,600 vaccine across Africa. Many of these countries promised to donate vaccines under plans sponsored by the WHO 1,200 Trials in Africa. The best way to make sure and the United Nations. They then reneged or vaccines are safe and effective for an African otherwise moved to secure their own coun‑ 800 population is to test them in Africa, which tries’ supply above that of others. has a long history of participating in clinical Earlier this year, Africa was elbowed out trials. In July this year, Africa CDC set up the 400 of the diagnostics market for SARS-CoV-2 Consortium for COVID-19 Vaccine Clinical — although the situation is now improving. Trial (CONCVACT). It has inventoried sites 0 Shortages of materials were initially the great‑ 1990 1995 2000 2005 2010 2015 that can test vaccines in humans (see ‘Testing est limitation in fighting the pandemic on the COVID-19 vaccines in Africa’ and Supplemen‑ continent2. So, in April, Africa CDC launched tary information) and is working to set up a Partnership to Accelerate COVID-19 Test‑ 80 more infrastructure, such as arranging more ing (PACT). Training was set up, and techni‑ deaths (thousands) AIDS-related training in international standards, including cians in Africa have now conducted more 40 good clinical practice and establishing inde‑ than 14.5 million COVID-19 tests. Countries pendent review boards. CONCVACT is facili‑ including Kenya, Ethiopia, Nigeria, Morocco, 0 tating partnerships and coordination between 1990 1995 2000 2005 2010 2015

Senegal and South Africa have started making vaccine developers, African clinical-trial sites, CDC UNAIDS/US SOURCES:

commercial systems. We also need innovative technology to track distribution. All of these preparations will fall flat if people Egypt are not willing to receive the vaccine, including Trials: 4 follow-up doses. Trust therefore needs to be Senegal built up, to offset high levels of public-health Mali Burkina misinformation and anti-vaccine sentiments. The Faso Gambia How? By giving communities access, infor‑ mation, counselling and support. The WHO Nigeria has a WhatsApp messaging system dedicated Uganda* Guinea- to countering untruths about COVID‑19. We Bissau Cameroon Trials: 1 Trials: 1 intend to launch continent-wide campaigns Côte Ghana* Kenya d’Ivoire Trials: 1 working with social-media platforms and mar‑ Trials: 1 keting agencies. Also essential is engagement TESTING COVID 19 with senior national officials and the recruit‑ VACCINES IN AFRICA ment of local opinion-formers — including pol‑ Clinical trials are under way in many Zambia* iticians, journalists, celebrities and religious places on the continent; other sites have Trials: 1 leaders — to share accurate information and capacity or are developing it. These trials can help to ensure that vaccines are Zimbabwe* encourage safe vaccination. An Africa CDC eective in African populations. Trials: 1 technical working group is developing guid‑ South Africa* Sites for trials (one trial often has many sites) Trials: 5 ance for partnering with stakeholders to make Institution† listed as having capacity to run a trial public-education campaigns more effective, including using behavioural messaging to *The COVID-19 Research Outcomes Worldwide Network for CORONAvirus prevenTION trial has ten sites across five African countries. counter the ‘infodemic’. †Member of Africa CDC Consortium for COVID-19 Vaccine Clinical Trial

SOURCE: AFRICA CDC SOURCE: (CONCVACT). The road ahead will be hard. The Africa Task Force for Coronavirus has been meeting weekly sponsors and funders, including the WHO and Roll-out and uptake. African countries will since February. Seven working groups focus the European and Developing Countries Clin‑ need efficient processes to fast-track market on aspects including laboratory diagnosis and ical Trials Partnership. authorization of safe and effective COVID-19 viral subtyping, case management, surveil‑ vaccines. CONCVACT is working out how to lance, risk communication, infection preven‑ Funds and factories. New financing will be harmonize decisions of country-level regula‑ tion and control, supply-chain management required to pay the billions of dollars for tors with global processes (such as the WHO and scientific standards. Africa is seizing this COVID‑19 vaccinations, including advance pre-qualification programme) and expedite opportunity to build up its public-health pre‑ payments to secure supply. The Africa Export roll-out across the continent. This is likely to paredness and response infrastructure at every Import Bank (Afreximbank) has committed include indemnification provisions for man‑ level — continental, regional, national and local. to a vaccine-financing framework for Africa. ufacturers and a pharmacovigilance system We hope that the rest of the world will follow This will allow pooled purchases of medical to monitor adverse events and interface with our lead and embrace cooperation and mul‑ supplies and support for vaccine manufac‑ national regulatory agencies. tilateralism to overcome this pandemic and ture. Countries will issue promissory notes Once a vaccine is approved, it needs to be future ones. Infectious agents span the globe in to Afreximbank, which will arrange about delivered. Existing immunization systems in weeks: vaccinating people on one continent is $4 billion in revolving credit to back orders Africa are set up to vaccinate children, or to essential to the health, wealth and well-being of from African suppliers that have been certi‑ provide highly targeted ‘ring vaccination’ to those on the others. No region can be immune fied by Africa CDC. families, neighbours and co-workers of peo‑ until a meaningful and equitable share of the If a COVID‑19 vaccine needs to be adminis‑ ple infected with diseases such as Ebola. To world’s population is protected — by the tenets tered yearly, importing it might not be relia‑ reach 60% of Africans, existing systems must of good basic public health as well as a vaccine. ble or feasible, especially if the vaccine is liquid be transformed to serve large numbers of (and thus heavy) or requires cold storage. adults and prioritize vulnerable populations, Vaccine-manufacturing capacity in Africa is all without neglecting childhood vaccinations. The authors nascent, but real. Senegal and South Africa In partnership with others, Africa CDC has already produce vaccines for diseases such as set up the Africa Medical Supply Platform, a John N. Nkengasong is director of the Africa yellow fever and tuberculosis. Although these system to coordinate procurement that can Centers for Disease Control and Prevention are made by different technologies from those be adapted for vaccine distribution. Work‑ (Africa CDC), Addis Ababa, Ethiopia. Nicaise likely to be used for COVID-19, the mindset ing with national leaders, we have deployed Ndembi is a senior science adviser at Africa and training required are similar. GALVMed, thousands of community health workers and CDC. Akhona Tshangela is programme an international organization focused on live‑ emergency responders across the continent manager for mortality surveillance at Africa stock vaccines, with offices in Kenya, India and to manage the test, trace and treat strategy. CDC. Tajudeen Raji is head of the division of the United Kingdom, might also be able to pivot They will support the vaccination efforts of public-health institutes and research at Africa to make human-grade vaccines. We have so far the African Union’s member states, and train CDC. identified eight companies or organizations in others to do so. Another task is to work with e-mail: [email protected] several African countries that can reasonably existing distribution systems to deliver vac‑ Supplementary information accompanies this aspire to retool their operations to manufac‑ cines efficiently. For instance, refrigerated article at go.nature.com/2s8eniu ture COVID-19 vaccines. We are working with bottles of Coca-Cola are available in even the 1. Fidler, D. P. PLoS Med. 7, e1000247 (2010). them to assess what is needed in terms of tech‑ remotest areas of Africa. Our health systems 2. Nkengasong, J. Nature 580, 565 (2020). nology transfer, project financing and scale-up. should learn from, and even partner with, such 3. Bartsch, S. M. J. Prevent. Med. 59, 493–503 (2020).