It was just over one year ago that the coronavirus pandemic officially began. Since then, the virus has claimed more than 2.6 million lives and upended millions more. But COVID-19 vaccines, developed with unprecedented speed, are now rolling out worldwide.

In wealthy countries, vaccines came through deals arranged directly with the vaccine manufacturers. But for many low- and middle-income countries, vaccines are distributed primarily through the COVAX facility. This global initiative, led by the World Health Organization (WHO), the Coalition for Epidemic Preparedness Innovations or CEPI, and Gavi, the Vaccine Alliance, is leading the charge to provide equitable access to COVID-19 vaccines.

HVP Editor Kristen Jill Abboud recently spoke with Seth Berkley, CEO of Gavi, about COVAX’s progress and what else can be done to speed global access to COVID-19 vaccines. An edited version of the conversation appears below.

How quickly did vaccine distribution through COVAX begin and how is it progressing?

As of now, COVAX has shipped more than 29 million doses of vaccine to 46 countries. The first vaccine injection was delivered 43 days after the first injection in the U.K., which was the first non-clinical trial administered COVID vaccine injection in the world. The second country to administer vaccine through COVAX started 83 days after that first injection in the U.K. The first injection through COVAX was administered in India, where the vaccine was produced. But for the next one, which was an export, we had to wait for WHO prequalification, and that was the reason for the delay.

Which vaccines are being distributed?

We’re using three vaccines now: the Serum Institute of India AstraZeneca vaccine, the AstraZeneca vaccine manufactured by SK-Bio in South Korea, and the Pfizer/BioNTech vaccine.

In the case of the Pfizer/BioNTech vaccine, has the ultra-cold chain requirement made distribution difficult in low- and middle-income countries?

In terms of cold chain, we expected that it would be a big problem, and so the participants of the COVAX facility made a decision that they didn’t want large volumes of that vaccine, both because of the cold chain complexity and also because it’s more expensive. But they didn’t want no vaccine either, so we ended up getting a relatively small amount—about 40 million doses—of which the initial allocations were in the hundreds of thousands of doses, and therefore they were being used mostly for healthcare workers in centralized locations where the cold chain requirement wasn’t such a big hassle. Had we needed to set up cold chain all the way down to the periphery to deliver vaccine throughout countries, that would, of course, have been a big deal. But we haven’t had to do that.

Will you be adding other vaccines soon?

Yes, we have an agreement for a half a billion doses from Johnson & Johnson, but they aren’t going to come for a while because the first approval was in the U.S. and the U.S. is not exporting doses yet. We also have doses of Novavax’s vaccine that are coming as well.

Delivering vaccines in low- and middle-income countries just 43 days after they were delivered in the U.K. is a remarkable achievement, something that traditionally would have taken several years, right?

The traditional timeframe was something like 10 years, but, of course, that wasn’t in a pandemic. However, even in previous pandemics, there were very long delays and very limited volumes available. The goal here is to get two billion doses of COVID vaccines administered by the end of 2021.

Despite this progress, there have been concerns raised that there isn’t enough being done to ensure equitable access. What more can be done?

I think we have to think about how we can be better prepared to deal with future epidemics/pandemics. When this pandemic occurred, there was not only no program to move vaccine forward for developing countries, but there was also no money. We had to start fundraising from zero and build all the infrastructure to do this. I think that considering all of that, we’re not in a bad place. If we had a substantial chunk of money available from the start from a contingent facility or something else, we probably could have ordered vaccines earlier and maybe received them earlier. Although, it’s always hard to know because as one would have expected the very wealthy countries were first in line to make deals with the manufacturers in their own countries.

And, in fact many of the wealthiest countries have made agreements to purchase far more vaccine than is needed to vaccinate their entire populations. What is the process for releasing those doses to other countries that don’t have nearly enough?

There are two possibilities. One possibility is that these doses can be donated. We have a dose-sharing policy that some wealthy countries, including Canada, the U.K., and France, are likely to follow, so we’re negotiating that with them.

Another possibility is that if wealthy countries have optional and not fixed-order commitments, they could release their place in the queue and give us access to those doses. It’s not only an issue of the estimated 800 million to a billion doses of vaccines that have been overbought, but there’s also 1.4 billion doses in options that also are out there. Releasing those would free up spaces in the queue, and that would be really important for us. One of our big challenges is getting early doses. We’ve got enough doses to get all countries started and to cover healthcare workers by the middle of the year, but not enough doses to distribute very high volumes of vaccine until the second half of the year.

Has vaccine hesitancy for COVID vaccines generally been less of an issue in low- and middle-income countries than in the U.S.?

It used to be that vaccine hesitancy was much less of a concern in low-income countries because people saw the diseases that the vaccines were meant to protect them against, whereas in wealthy countries, we didn’t see them. With this particular vaccine, however, conspiracy theorists linked to the anti-vaccine community have created rumors that vaccine development was going too fast and without proper safety testing, and this has led to some of the worst rumors I’ve ever heard. What is beginning to happen, though, is that people are seeing other people get vaccinated and that is improving their level of comfort. We don’t really know yet exactly how all of this is going to play out as we haven’t started to roll it out in really large numbers.

You recently co-authored an editorial in Science on the need to initiate efforts on universal coronavirus vaccines. What do you think is needed to coordinate this process?

The first thing that ought to happen is for this to get prioritized in scientific communities. That is important because then there can be financial support through grants to support this work and conferences where people can come together to think about some of the pathways that could help accomplish this goal.

The second thing you need is some type of network that would work on this and that could be coordinated by an independent organization, or it could be managed by a consortium of research institutions such as what Wellcome, the U.S. National Institutes of Health, and others have done. The issue is really about making it a focus, having people think about it, and then developing an organizational plan that makes sense to move it forward.

Interview by Kristen Jill Abboud