The hysteria that has poisoned the North American perception of vaccination with conspiratorial suspicion has made it simple to forget that the biggest issue with vaccines is not harm derived from immunization, but rather, inaccessibility. Vaccines remain, at their very core, one of the greatest public health achievements of our time. It is precisely this efficacy and impact that has turned vaccine manufacturing into a multi-billion dollar industry. However, to treat the vaccine manufacturing industry as just another profit-driven corporation is to accept that vaccine accessibility will be predicated on personal income or national wealth. This premise motivated Médecins Sans Frontières (MSF) to publicly reject the offer of a million free doses of the pneumonia vaccine from Pfizer as an act of protest against high pricing that makes vaccines unaffordable for many developing nations and humanitarian organizations.


According to the World Health Organization, pneumonia was the cause of death of over 900 000 children worldwide in 2015. The most common cause of pneumonia is infection with Streptococcus pneumoniae. In 2010, Pfizer and GaxoSmithKline (GSK) announced the development of a Pneumoccocal conjugate vaccine (PCV), making them the only two producers of PCV. This duopoly has allowed the companies to keep the price of this much-needed vaccine artificially inflated, making PCV unaffordable for developing countries and organizations like MSF.

cost-943762_1920The Global Alliance for Vaccines and Immunization (GAVI) is an organization that is committed to increasing vaccine accessibility worldwide. GAVI has been instrumental in making Prevnar13, Pfizer’s version of PCV, affordable in over fifty developing countries. GAVI operates by buying vaccines in bulk from the manufacturers on behalf of the countries it supports. Due to this high purchasing power, GAVI has been successful in negotiating the record-low discounted price of USD$3.10 per dose of Prevnar13. Currently, about 60% of GAVI’s contribution to Bolivia’s vaccination program goes directly to covering the cost of the pneumonia vaccine – that is how disproportionately expensive this vaccine is in comparison to other childhood vaccines. However, Bolivia will likely lose GAVI support next year, in which case, the cost to vaccinate Bolivian children will increase by 700%. GAVI support is slowly phased out when any country supported by GAVI reaches a gross national income per capita of $1580 over the previous three years. The practical consequences of this policy mean that as the economy of developing countries exits extreme poverty, they lose GAVI support, leaving these still fragile economies and governments now wholly responsible for the exorbitant cost of vaccines. This is one of the many challenges of subsidized vaccination strategies as a means to combat high vaccine pricing. Although GAVI serves the poorest of the poor fairly well, and developed countries often have no problems covering the cost of expensive vaccines, it is the middle-income countries that are left highly vulnerable to predatory vaccine pricing. Other examples of countries that are expected to lose GAVI support next year include Angola, which will see its vaccine costs increase by 1500%, and Indonesia which will face an increase of 1547%.

[…]as the economy of developing countries exits extreme poverty, they lose GAVI support, leaving these still fragile economies and governments now wholly responsible for the exorbitant cost of vaccines.”

Although MSF vaccinates some of the world’s most vulnerable children, it is ineligible for subsidy from Pfizer. Ever since Prevnar13 was introduced, MSF has tried to negotiate an arrangement with Pfizer, hoping to purchase the vaccine at the same discounted price offered to GAVI. However, the two parties have been unsuccessful in reaching a permanent solution and the price of PCV continued to remain prohibitive. So, when MSF publicly rejected Pfizer’s donation of a million free doses of Prevnar13 in October 2016, many could not understand why MSF would forego the offer of such a badly-needed and expensive vaccine, particularly since this offer came at the peak of the refugee crisis. At the time, MSF was stationed on Greek islands, caring for the flood of incoming migrants from a war-torn Middle East, many of whom had missed childhood vaccinations due to the precarious situation and crumbling healthcare system in their home countries. Grappling with the reality of so many unvaccinated individuals living in poor overcrowded conditions forced MSF to purchase Prevnar13 from local Greek pharmacies at 60 Euros (USD$64) per dose, which is twenty times more expensive than the lowest global price of the vaccine offered to GAVI (USD$3.10). Considering that three doses are required to achieve full immunity, this adds up very quickly, particularly for a humanitarian organization.

So why then did MSF decline a million free doses of this vaccine? Well, relying on anything that is given or gifted is a dangerous proposition. Vaccine donations, although theoretically beneficial, preclude MSF from its operational independence, forcing the organization to rely on the sporadic goodwill of pharmaceutical companies in order to fulfil its mission. Additionally, vaccine donations often come with strings attached, dictating which patient subgroups should receive the vaccines or to which geographic regions the vaccine should be distributed. Another more principled reason for refusing the donation is that sporadic gifts of vaccines to humanitarian organizations serve as justification for Pfizer to keep their prices high both for developing countries and for other non-government organizations. In short, dependence on donations strips MSF of the autonomy to implement the vaccination program that they believe will be the most effective and allows for the exploitation of poorer countries. Thankfully, the gamble that MSF took paid off and this impasse was resolved in their favour. By the time the finishing touches were put on this article, MSF announced that a deal had been reached with Pfizer. The publicity and awareness garnered by the public refusal of a million free doses of Prevnar13, followed by a successful global call-a-thon preceding World Pneumonia Day on November 12th, resulted in Pfizer acquiescing and providing Prevnar13 to MSF and other humanitarian organizations at a reduced price.

[…]dependence on donations strips MSF of the autonomy to implement the vaccination program that they believe will be the most effective and allows for the exploitation of poorer countries.”

While the resolution of this painful standoff that forced physicians to refuse life-saving vaccines reached a satisfying conclusion, it is important to remember that the roots of vaccine unaffordability lie much deeper than just this one case. The lack of competition and transparency in the field of vaccine manufacturing has led and will continue to lead to more exorbitantly priced life-saving vaccines. Every new vaccine that enters the market bears testament to the profound impact of scientific discovery. So while we celebrate the inclusion of the HPV vaccine in Ontario’s immunization program and think of the lives that will be saved by this vaccine down the line, it is important not to lose sight of the fact that this vaccine, too, is enormously expensive and it is only produced by GSK and Merck. The rotavirus vaccine, which protects against severe diarrhea in children, one of the leading causes of death of children in developing countries, is also under the duopoly of GSK and Merck.

With the vaccine market dominated by a few manufacturing giants like Pfizer and GSK, one runs the risk of both an inadequate supply of vaccines as well as of removing any real impetus to reduce pricing. When the South Korean company SK Chemicals attempted to produce its own PCV, Pfizer swiftly sued them for patent infringement, promptly shutting down the prospect of a new PCV entering the market. Amidst calls for increased competition to dissolve the exclusivity under which companies like Pfizer operate, lies the core of the problem – competing with established vaccine manufacturers is not only a very expensive undertaking but also, at times, an illegal one due to stringent patent laws. As the Serum Institute of India readies itself to manufacture a PCV analogue, MSF has already filed a patent opposition in Indian courts, arguing that Pfizer’s patents are too generic to be awarded under Indian law. If MSF succeeds in its efforts to prevent Pfizer from receiving a patent in India, then the Serum Institute of India would be able to develop a PCV vaccine and sell it to humanitarian organizations for even less than the price negotiated by GAVI, at USD$2 per dose. Besides facilitating the procurement of affordable PCV by MSF, another obvious benefit to this move is the competition that a new manufacturer of PCV will spur, hopefully and potentially, resulting in decreased market-wide prices of PCV and other vaccines down the line.


References:

  1. Cone J. There is no such thing as “free” vaccines: Why we rejected Pfizer’s donation offer of Pneumonia vaccinesMSF [web]. Published October 10, 2016.
  2. MSF calls on GSK and Pfizer to slash pneumo vaccine price to $5 per child for poor countries ahead of donor meetingAccess Campaign – MSF [web]. Updated Jan 19, 2015.
  3. Transition ProcessGAVI [web]. 2017.
  4. Vaccine PricesAccess Campaign – MSF [web]. Updated Jul 2011.
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Sintia Teichman

Co-Editor-in-Chief
Sintia is a PhD student at The University of Toronto studying targeted immunosuppressive strategies for organ transplant rejection. In her spare time she enjoys reading, traveling, experimenting in the kitchen, and spends more time than she should with her head in the clouds.
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