Asia vs Covid (1): the Battle of the Vaccines

There are two weapons that nations can deploy in the fight against a pandemic such as Covid: technology and population management. In this Insight we will focus on how eastern Asia has utilised the available technology – vaccines – and we will focus on the societal challenge in a separate piece.

There is no doubt that the battle against Covid is not yet over. With infections rising in China and Taiwan in recent weeks, and the unvaccinated North Korea revealing not only its first cases but its first deaths, Asia is reminding us that even after two years the virus can still all too easily gain the upper hand. Covid 19 remains a threat to us all; whilst its different variants are associated with different levels of mortality, it can spread rapidly and is capable of killing in unacceptably large numbers.

When the World Health Organisation (WHO) declared covid to be a pandemic, in the spring of 2020, no vaccines against the disease were available. Thus, questions of ‘which vaccine should we use?’, ‘who should be the priority groups for vaccination?’ and ‘should vaccination be compulsory?’ were not relevant. Yet within months the scientists had provided the tools for the job and the rollout had begun. Following medical advice, most countries prioritised vaccinating the old and the vulnerable, with children at the end of the queue. Whilst no vaccine is ever 100 percent reliable, vaccinating the population with whatever was safe and available would be a strong response.

No country has achieved 100 percent coverage and that goal is, in any case, a moving target; but some come close, and numbers are still rising. Eastern Asia leads the world: in Singapore 92 percent of the population is fully vaccinated (two jabs), with China, Malaysia, Japan, Vietnam, Hong Kong and Taiwan all at 80 or above, which is higher than the western European average. The global average is 59 percent. Every other country of southern and eastern Asia has achieved in the region of 60-70 percent, except Myanmar (42 percent), Afghanistan (15) and North Korea. In the latter – isolated from the rest of the world at the best of times – they have had no vaccination policy. Their total lockdown approach has held, so far: but as the dam breaks they are refusing offers of vaccines, perhaps especially from South Korea.

When the history of the 21st century comes to be written the Covid scientists will be in the pantheon of heroes. Their levels of international co-operation, the speed at which they have worked, and the degree of imagination employed in the development of techniques which were previously embryonic have been unprecedented. The result is a plethora of new household names – including the ‘Big Three’ of Astrazeneca, BioNTech/Pfizer and Moderna. All three have been deemed safe enough to use across the world (the principal exceptions to this rule being China and Russia) and they are the most effective of the vaccines available. Alongside the development of vaccines, we have witnessed the creation of new antiviral drugs. A Japanese product currently being tested, S-217622, may be the most effective means yet of ridding infected patients of the virus.

Vaccination is a short cut to herd immunity which is when the vast majority of a population has developed immunity to the disease. Herd immunity can only be achieved in three ways:

- ‘Letting nature take its course’, exposing the population to the virus unchecked from the beginning. Although this approach had its advocates, had it been adopted the covid death toll globally would have been catastrophic.

- In the second approach the population is immunised effectively through vaccination. This was not an option at the start of covid as no Covid vaccine existed and it takes time to roll out a vaccination programme even when vaccines are available.

- The third uses environmental measures to mitigate and slow down the spread of the disease, either as the principal policy or to allow time for the second approach to be introduced.

This ‘third way’ was politically acceptable, technologically possible and almost universally adopted, though it has taken many forms (which we discuss elsewhere).

The technology of vaccination has moved on since Jenner discovered that injecting milkmaids with cowpox protected them against smallpox, although the principle – the use of dead, attenuated, or similar but less malign viruses to prompt a controlled immune response – is still valid. We now know that Jenner’s observations are explained by the human body’s ability to recognise the external shape of the virus, not least its defining ‘spike’, and this is how both the Chinese Sinovac and the Russian Sputnik vaccines work. However, the ‘Big Three’, which were all created in US and Europe, are more sophisticated. They use modern ‘messenger RNA’ (mRNA) technology which recognises and attacks the genetic code within the virus. We now know that mRNA technology both confers immunity more effectively, after either one or two doses, than does Sinovac, which needs three shots to reach maximum effect (see table below). The immunity conferred by the Big Three also lasts longer than does that created by the older technology. The relative brevity of the acquired immunity bestowed by Sinovac is probably a factor in explaining why China is currently experiencing massive peaks in infection, albeit of the omicron variant which has a lower mortality rate than its delta predecessor.

These figures demonstrate the relative effectiveness of the vaccines, where ‘100%’ is the number of infected people who would have died had they not been vaccinated at all:

Table 1: Relative death rates of patients treated with different vaccines

(source: Financial Times)

Death Rate Sinovac BioNTech/Pfizer

After 1 dose 49% 27% BioNTech 2x as effective

After 2 doses 23% 7.7% BioNTech 3x as effective

After 3 doses 1.7% 1.9% Similarly effective

The WHO recommends that people who have had two doses of a ‘spike’ vaccine should have an mRNA variety as their booster; whilst China is developing an mRNA vaccine it is far from ready and they are persisting with their home grown ‘spike’ varieties. These were used to vaccinate 22 million people each day when such activity was at its peak, preventing, China claims, 200 million infections and 3 million deaths.

China’s refusal to countenance alternative vaccines, for either initial or booster use, is contrary to that WHO advice. Officially, the BioNTech vaccine is ‘awaiting approval’ by Beijing, but it has been waiting for a long time and will wait a long time more.

Most Asian countries have put their faith in the western technology. 100 percent of the vaccines used in Japan have been of the mRNA variety, in Taiwan 96 percent, Vietnam 73. Indonesia is by far the biggest purchaser of the Chinese brands, though Sinopharm is a minor player, only one of four vaccines put to regular use there. Singapore bought a small emergency supply of Sinovac, for use only on the rare occasions that an mRNA vaccine prompts an adverse response in the patient.

China has gifted 1.6 billion doses of its own ‘spike’ vaccines, mostly to Low- and Middle-Income Countries, with Indonesia receiving the most (alongside the supply that it purchased). Although these are not as effective as the mRNA varieties the cost of purchase means that many poorer countries depend upon receiving any donated vaccines that they can get, either through bilateral arrangements or through COVAX. COVAX is an alliance of 184 countries formed to redistribute surplus vaccines, technology, equipment and knowhow for fighting Covid, from those that can afford it to those who need it most. Its principal donors are western countries plus Japan; the list includes 33 nations plus several businesses and charitable foundations. At different times India has been both a recipient and a donor of home-grown Astrazeneca vaccine.

Geopolitics is at play in the bilateral distribution of vaccines. Russia, where vaccine scepticism is rife and only 50 percent of its own population are protected, has its own Sputnik ‘spike’ vaccine and the biggest foreign recipient of this is India. China has donated its vaccine products to, amongst others, no fewer than 49 African countries; this is clearly an expression of ‘soft power’, reflecting Beijing’s broader ambitions in terms of global influence. Despite this, Africa remains the least vaccinated continent, with only about one in six people fully (doubly) protected – and with no booster programme to speak of.

Africa may have a degree of protection from Covid due to a statistical quirk: its population is the youngest of any continent (41 percent are under 15, 3 percent over 65) and the young are less likely to die or become seriously ill from Covid. Many parts of Africa are sparsely populated, reducing the opportunities for Covid to spread – although malnutrition may decrease the body’s natural defences and thus increase susceptibility. Nevertheless, this low level of vaccination is bad news and not just for that continent. Without high levels of immunity, which can only be achieved quickly through vaccination, Africa presents a potential source of future coronavirus pandemics, perhaps involving new variants, for the whole world. That almost every African country is using (to some extent) the less effective, less long-lasting, Chinese ‘spike’ vaccines is putting us all at risk.

China’s resistance to using the best vaccine technology can be interpreted in terms of national pride, an arrogant aversion to being seen to be dependent upon, following or trailing behind the west, rather than delivering what is best for their population. Such hubris needs to be set aside if the long-term battle against covid is to be won.

By 2023 one of the World Health Organisation’s three goals is that ‘one billion people are better protected from health emergencies.’ The goals were laid down by consensus in 2019, but they are not good enough. All people should have the right to be protected from health emergencies (and have access to health care, and enjoy greater wellbeing). This means not just that minimum standards need to be laid down to govern the work towards these goals, but that standards should be able to be made obligatory and thus enforceable. In case of Covid, no member of the WHO should be able to opt out of a vaccination programme where that is the recommended standard, no country should deliberately use a ‘second-best’ vaccine where better is available, not peddle it to poorer countries, and no country should be able to veto membership of WHO to another country, as China does in respect of Taiwan.

Reform of WHO is clearly for the future. In the case of Covid, Europe focused on creating new vaccines from new technology whereas China, a massive and influential player on the world stage, stuck with a tried and tested, less effective, approach. There needs to be greater co-operation and collaboration between Europe (and USA) and Asia on matters like this where the global interest is genuinely and demonstrably at risk. A degree of diversity in approach is helpful to the scientific method – not least in the early days of development – but once one method is proven to be both medically and economically more effective than another then collaboration around a single goal is essential. In this case the mRNA technology should have been the universal option.

It is difficult to see how reasonable safeguards will allow a new vaccine to be developed any faster when the next pandemic comes than it was in respect of Covid; truly a global standard has been set.

Finally, the world needs to vaccinate Africa. Vaccines to tackle global pandemics should be regarded as above political chest-beating and manipulation. In Africa, irrespective of the type of vaccine made available, that rollout has been inadequate. There needs to be greater use of COVAX, with active support of all the world’s great powers, of Asia, Europe and America, to create both the stock for and the effective mechanism of roll-out in lower income countries.

The lessons we have learned from Covid must not be forgotten.

Sources used in this, and its companion Insight, include amongst others:

https://www.ft.com/content/729f1dc0-32d1-42c9-bb62-63a41f1e8de2

https://www.ft.com/content/0e6914ed-3ce5-4f7f-ab91-ce7b0ad68f2c

https://www.eastasiaforum.org/2022/01/31/taiwans-economy-outperforms-amid-covid-19-crisis/

https://www.economist.com/briefing/what-taiwan-can-learn-from-russias-invasion-of-ukraine/21808850

https://www.thetimes.co.uk/article/5ce37c20-c3e9-11ec-8a92-caed1bd1c140?shareToken=6c31c13fd2536a0787ede48ffee0f863

https://www.japantimes.co.jp/news/2022/04/24/national/science-health/covid-19-pill/

https://ourworldindata.org/covid-vaccinations?country=OWID_WRL

https://brill.com/view/journals/coso/20/6/article-p695_1.xml

https://www.economist.com/leaders/2022/04/30/chinas-martial-rhetoric-will-not-help-it-defeat-covid

https://bridgebeijing.com/our-publications/our-publications-1/china-covid-19-vaccines-tracker/