The vaccine conundrum – Is Cambodia a victim of vaccine nationalism?

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The eldest son of Prime Minister Hun Sen, Hun Manet agreed to Covid-19 immunisation to eliminate widespread scepticism over the Chinese vaccine. Heng Chivoan

The vaccination programme globally is beset by a shortage of supply via the COVAX Facility, partly due to vaccine-hogging by advanced economies. It has caused a furore among developing countries who are racing against time to inoculate their citizens

At the time of writing, some 500 persons comprising high-ranking government officials, medical staff and journalists had received the first phase of inoculation by the Sinopharm vaccine, developed by state-owned China National Biotech Group.

The figure is just a teaser to Cambodia’s vision of vaccinating 10 million people in time, which is about two-thirds of the population.

The first batch of 600,000 doses arrived less than two months after Prime Minister Hun Sen’s decision to go with vaccines from China, having reneged from an initial plan of acquiring only World Health Organisation (WHO)-approved vaccines.

Misquoted, as he alleged, or not, Hun Sen’s resolution was seemingly laced with desperation as the number of Covid-19 cases inched up late last year, although there have been no deaths.

To date, 478 cases have been recorded, the latest surge driven by the return of several thousand panic-stricken Cambodian migrant workers who flooded back across the border from Thailand after an eruption of Covid-19 cases there in December.

Despite its 79.3 per cent efficacy, the Sinopharm vaccine, whose science is composed of an inactivated version of Covid-19 that sets off the immune system, comes through as the world battles a war against vaccine nationalism to ensure democratic access to medicines.

One cannot be certain of Hun Sen’s change of heart, but ruminations are that it might be connected to block orders made by rich nations for Western vaccines created by Pfizer-BioNTech, Moderna Inc and AstraZeneca plc.

This has resulted in an apparent shortage of vaccines, which according to international lawyer Chee Yoke Ling, is no surprise.

“Even countries who can afford to buy may not get the volume they need if 75 to 80 per cent vaccination of the population is the threshold for protection,” said Chee, director of Third World Network (TWN), an independent non-profit global research and advocacy organisation.

Thus, acquiring Western vaccines could be a tad onerous for the moment, even though Cambodia is among 92 low and middle-income countries of the Advance Market Commitment (AMC), a financing instrument that offsets some cost of the vaccines.

With a seed capital of $2.4 billion as of December 18, 2020, the AMC is part of the Covid-19 Vaccines Global Access (COVAX) facility that is led by the WHO and Gavi, The Vaccine Alliance.

This year, AMC plans to raise an additional $6.8 billion for research and development ($800 million), COVAX AMC (about $4.6 billion) and delivery support ($1.4 billion).

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Source: COVAX Global Supply Forecast

While AMC leverages on upfront payments for orders via COVAX by 98 high-income economies, doses for poor countries, also procured through the facility, are settled by a separate financial mechanism, largely funded by official development assistance (ODA).

Having said that, the 92 countries accessing vaccines are expected to share some costs of the vaccines and delivery, ranging between $1.60 and $2 per dose, a mirror of the sum paid upfront by self-financing participants (SFP).

“Once a vaccine has been approved by regulatory agencies [and, or] prequalified by the WHO, the COVAX facility will then purchase these vaccines with a goal to try and initially provide doses for an average of 20 per cent of each country’s population, focusing on healthcare workers and the most vulnerable groups.

“Further doses will be made available based on financing, country need, vulnerability and potential threat. [In addition] a buffer of doses will be maintained for emergency and humanitarian use,” Chee told The Post via email.

Her Malaysia-based organisation works on development, developing countries and North-South affairs.

‘No guaranteed supply’

But with an alleged hogging of vaccines by richer nations, the outlook is stark.

It even drew the ire of WHO director-general Dr Tedros Adhanom Ghebreyesus who lamented that the world was on the “brink of a catastrophic moral failure” last year.

For instance, the COVAX interim distribution forecast as of February 4, showed that only 1.2 million doses of the WHO emergency use listing (EUL)-approved Pfizer-BioNTech is presently available for the first quarter this year. (It is the only WHO-approved vaccine, thus far).

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And, this is subject to caveats such as requirements for negotiation and execution of additional agreements, confirmation of acceptance and enforceability of product handling and AMC country readiness, making the distribution even more cumbersome.

In the meantime, evaluation is being carried out on Oxford-AstraZeneca’s vaccine which pledged an “indicative distribution” of 240 million doses in the first and second quarters this year.

That said, there is no certainty to the actual supply, as it is contingent upon factors including the granting of WHO EUL, supply volume or operational constraints and time taken to place purchase orders.

“The AstraZeneca advance purchase agreement that has been made public shows that they signed a ‘best reasonable efforts’ agreement,”Chee said, pointing out that what that means is that there is no guarantee of supply in accordance to the expected volume and schedule.

“We suspect all the similar agreements are on this basis,” she added.

She felt that it might take a few years before poorer countries can get their needed vaccines for up to 80 per cent of the population.

“[Even] if production [is] ramped up, it will still take time. That is why the WHO is suggesting that all frontliners and vulnerable or high risk populations in the world be covered first rather than rich countries vaccinating all their own population first,” she said.

While that happens, it is also important to enlarge the basket of vaccine options.

Although the Pfizer and Moderna’s mRNA technologies are apparently not so complicated, in that it might not be difficult for companies to make them, they are unfortunately new and would take time and investment to set up production.

“Here is where patents, as each vaccine has many patents [and] not just one, and trade secrets relating to technology know-how are barriers,” Chee bemoaned.

As such, a waiver is important for medicines that treat the infected (therapeutic) where more than 100 clinical trials are going on to see which existing medicines can be used for Covid-19.

She said many of the potential ones are patented, meaning that vaccination will take time, even if production and access is increased.

“So, treatment will be needed. Generic medicines will therefore be very important, too, more so for countries that cannot have vaccination,” she added.

Repeatedly met impasse

These impending consequences are what possessed South Africa and India to submit a proposal to the World Trade Organisation (WTO)last October to seek a waiver from certain provisions of the Trade-Related Aspects of Intellectual Property Rights Agreement (TRIPS).

The proposal, adopted by some 100 WTO members, WHO and civil society organisations, asked that provisions relating to copyrights, industrial designs, patents, and protection of undisclosed information be suspended temporarily.

It is unknown if Cambodia adopted the proposal.

Numerous efforts to seek comments from government spokesman Phay Siphan, Ministry of Health spokeswoman Or Vandine, and Ministry of Economy and Finance permanent secretary of state Vongsey Vissoth proved futile.

Meanwhile, South Africa WTO representative Mustaqeem Da Gama, who was quoted by TWN in a February 4 article, said the world was facing vaccine nationalism and artificial scarcity – two challenges that are preventing vaccines from being shared equitably among countries.

Da Gama also rued over the intellectual property monopolies over technology and know-how that relate to COVID-19, pleading that they be shared to ramp up manufacturing.

He also asked that vaccine supply and treatment of the disease be diversified just so everyone everywhere can be vaccinated in the shortest timeframe.

However, the call by the group has repeatedly met an impasse with advanced nations.

Assuming the waiver is approved, it blows open new challenges, said UK-based Fitch Solutions Inc pharmaceutical and healthcare analysis head Beau Noafshar.

“[They comprise] obtaining knowledge of production processes without patent-holders support as well as [a lack of clarity over] how much the global vaccine manufacturing capacity is already widely being put to use in manufacturing vaccines in line with intellectual property law,” he told The Post via email.

Having said that, he found that the waiver, in theory, would improve vaccine supply as companies with vaccine manufacturing capabilities would be able to legally side-step intellectual property protections and produce approved vaccines without the consent of the patent-holder.

“[Although] we don’t see this playing out, as multiple major economies [such as] the US, EU, Japan, Switzerland and Canada are blocking text-based negotiations of the waiver which are essential to its progression,” Noafshar said.

‘Pricing could be an issue’

For now, the Chinese vaccines that arrived on Sunday have been publicised as a donation to Cambodia. It is a sign of “deep relationship” between the nations, said Chinese ambassador to Cambodia Wang Wentian.

With the stress on manufacturing scale as per rising orders, it would appear logical that Cambodia turned to China, though it has been criticised from the outset for failing to disclose its full test results.

Early this month, China vowed to provide 10 million doses to low and lower-middle income countries via the facility, which it joined in October, 2020.

China’s vaccine distribution to Cambodia is aside from COVAX, flowing instead from its transportation and deal-signing activities with developing countries as part of its global vaccine diplomacy.

Back home, Cambodia is armed with nearly $70 million Covid-19 spending money, donated by local tycoons and friendly nations, to buy vaccines - some 11 million of them.

Recently, Minister Vongsey said Cambodia had placed an order with COVAX for seven million doses. A check with the facility’s latest data, however revealed an order of only 1.3 million doses of AstraZeneca vaccines, which COVAX expects to distribute starting end of this month, barring caveats.

Separately, Cambodia hopes to acquire more from China and India, possibly by circumventing the WHO process.

When asked, Fitch Solutions’ Noafshar agreed thatcountries that have adopted a ‘wait and see’ approach will be faced with longer lead times for delivery of vaccines produced by Pfizer, Moderna and AstraZeneca.

“So, it makes sense that countries, particularly those with good ties to China, will instead opt for nearer term delivery of vaccines from Sinopharm which [have] comparable efficacy to the others,” he said.

Mid December last year, Fitch Solutions noted that its three-speed view for vaccine distribution across Asia-Pacific would include significant supply from Chinese vaccines that could help ease shortages across the others.

“Pricing could, however, be an issue. The latest report of pricing of Sinopharm’s vaccine suggests $30 per dose, higher than all so far except Moderna.

“Overall, countries are likely to adopt a mixed approach using AstraZeneca vaccines through COVAX where available [and] supplemented with doses from Sinopharm and others,” he said.

‘Some fees will be charged’

In the meantime, negotiations are ongoing with one of India’s largest pharmaceutical firms Serum Institute for AstraZeneca doses or Covishield, the local name for the vaccine in the country, the Indian Embassy said via a text message to The Post.

This comes on the heels of Indian Prime Minister Narendra Modi’s promise to supply 100,000 doses of Covishield, which is “over and above” the quantity of doses supplied to COVAX by Indian companies.

The embassy said the supply was cleared as an “urgent measure on a contract basis”. It was done because of the special relationship between the countries, although India also kept in view its own domestic requirements and large requests from partner countries for vaccines.

To be sure, there is a price for the merchandise, which is being negotiated with Serum Institute.

Based on Indian news reports, each dose costs about 200 Indian rupees ($2.75), which is by far cheaper than other Covid-19 vaccines in the market. It is also in line with AstraZeneca’s declaration last year “not to profit” from the vaccine in the pandemic.

Going by a back-of-the-envelope calculation, Cambodia might end up with a bill ofabout 40 million rupees ($550,000) for two dosages per person.

“Some fees will be charged,” the embassy said. “However, consideration will be given to Cambodia’s status as a Least Developed Country while deciding the charges.”

It is unclear when the package would arrive as both parties contemplate over the date.

‘Evidence is accumulating’

In the midst, uncertainty seems to sum up the current situation in terms of additional Covid-19 doses and the efficacy of Chinese vaccines.

For Fitch Solutions, the efficacy of these vaccines based on test results including those developed by Sinovac Biotech Ltd (50.7 per cent in Brazil) and Can Sino Biologics Inc (65.7 per cent) is a major risk to its outlook on Asia Pacific.

So far, the financial information services firm is relying on the efficacy results provided in the pharmaceutical companies’ press releases, which Noafshar opined might hold up in full results.

“[As of now] all the vaccines have been good at cutting the number of severe cases and ultimately this is what matters most for our view,” he said.

China, Russia vaccines equal footing

Moving on, the Cambodian government is undeterred by Chinese vaccines, as leaders including Hun Sen’s kin and cabinet members volunteered to be immunised.

Lauding those who took the vaccine, the premier asked the rest of the population not to be fearful about the vaccine’s brand or country of origin, rather they should be worried about not being vaccinated.

An appeal for people to sign up for the vaccination programme is underway, albeit with a slow take-up, mostly attributed to prevailing scepticism.

Perhaps, TWN’s Chee could allay some doubts. In a joint article with Indian public health activist Achal Prabhala in The New York Times last Friday, the duo wrote that Chinese and Russian vaccines, though dismissed by the West, might be the answer to stark shortages.

They noted that the dismissal was largely due to the perception that they were “inferior” to Pfizer-BioNTech, Moderna or AstraZeneca, and that this perception might have stemmed from the fact that China and Russia are authoritarian states.

“[But] evidence [has been] accumulating for a while that the vaccines from those countries work well, too,” they said, citing interim results published by leading medical journal The Lancet from late-stage trials that show Russian vaccine Sputnik V had a 91.6 per cent efficacy rate.

Chee and Prabhala also highlighted that countries that vetted the vaccines, made informed decisions, based on evidence about safety and efficacy released by the Chinese and Russian manufacturers.

Much of evidence was also published in peer-reviewed scientific journals like The Lancet and JAMA Network, or after running independent trials of their own.

“To assume otherwise is to doubt the ability or integrity of these governments, some of which have health regulatory systems on par with those in the US or Europe,” they said.

In addition, the writers alleged a preferred treatment by the WHO in approving vaccines developed by largely advanced nations in a seemingly faster mode but conversely, pussyfooting those from developing nations such as China or Russia. Unlike the former, vaccines from developing nations, which could be placed on equal footing as Western vaccines, are required to undergo a prequalification process. “In reality, it is an onerous and time consuming process.”

Considering the current predicament, Hun Sen might be making a judgement call by going with Eastern vaccines, even as it plays into the hands of his critics.

Still, it has most likely helped Cambodia steer clear of the crossfire of a raging war against vaccine nationalism.