Another layer of COVID-19 vaccine inequality

The concerning implications of contradictory vaccine approvals around the world

In July, British travelers vaccinated with U.K.-approved COVID-19 vaccines were barred from visiting their son in Malta. Why? The couple had received Covishield vaccines, the Indian-made AstraZeneca vaccine. Malta — following guidelines from the European Medicines Agency — has not approved this specific COVID-19 vaccine, reported The Independent.

Essentially, the vaccinated couple was considered unvaccinated.

Worldwide, about 146 different COVID-19 vaccines currently exist at different stages of the development, testing and approval process, per data from The New York Times.

Already, geographic and socioeconomic vaccine inequality has become glaringly apparent, reported The Washington Post. But what’s only recently becoming apparent is another layer of vaccine inequality: differing approvals for different vaccine brands.

The question is no longer, “Are you fully vaccinated?” The question has instead changed to, “Which vaccine did you get?” — and the implications of a vaccine hierarchy are concerning, reported Stuff, a New Zealand news outlet.

Even among those vaccinated, there are vaccine haves and vaccine have-nots all based on brands of vaccines, per Refinery. Now, as different vaccine approvals clash with different vaccine requirements, people are getting caught in the crossfire.

And the implications are harrowing.

The worldwide mosaic of COVID-19 vaccine approvals

Right now, more than 75 COVID-19 vaccines are being tested in animals in preclinical trials, according to data from The New York Times. Another 99 different COVID-19 vaccines are being tested in clinical trials on humans. Of these clinical trials, 33 vaccines have reached the final testing stages.

There are so many different COVID-19 vaccines — like Pfizer, Sinovac and Moderna. But there are way too many to keep track of. And at first, the sheer number of vaccines seemed exciting and hopeful.

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Most of these vaccines don’t make headlines internationally — like Cuba’s Abdala vaccine or Iran’s COVIran Barekat vaccine or Kazakhstan’s QazCovid-in vaccine. These three vaccines are all locally developed, used and approved for emergency use but aren’t used widely, reported The New York Times.

Other vaccines, meanwhile, are widely known and widely used.

The World Health Organization has approved seven COVID-19 vaccines for emergency use: Comirnaty from Pfizer’s BioNTech, Covishield from The Serum Insitute of India, Oxford-AstraZeneca from SK Bioscience, Janssen from Johnson & Johnson, Moderna, Sinopharm from Beijing Bio-Institute of Biological Products and Sinovac.

In the U.S., COVID-19 vaccine approvals are determined at the national level by the Food and Drug Administration. The FDA has authorized three COVID-19 vaccines for emergency use: Pfizer, Moderna and Johnson & Johnson.

In the European Union, vaccine approvals are determined regionally by the European Medicines Agency, but individual member states can choose to expand or restrict their own national vaccine approvals. The European Medicines Agency has approved four vaccines for emergency usage: Pfizer, Moderna, Johnson & Johnson and Oxford-AstraZeneca.

If this is confusing, that’s exactly the point.

Some websites have developed entire databases for mapping COVID-19 vaccine approvals worldwide. But there’s a catch beginning to emerge from this mosaic of vaccines: Now, the sheer number is leading to discrimination against specific types of vaccines.

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What was once called a “two-track” pandemic between the unvaccinated and vaccinated could quickly spiral into a multi-track pandemic between those unvaccinated and those vaccinated with different types of vaccines.

The small-scale implications of differing vaccine approvals

The entire European microstate of San Marino — which relied on Sputnik V vaccines — is also not considered vaccinated under E.U. regulations, reported The New York Times. The small country is entirely surrounded by Italy, but San Marino residents cannot enter Italy because the country does not recognize the Sputnik vaccine.

“It’s absurd — we are all vaccinated,” said Carlotta Porcellini, a San Marino resident, per The New York Times. “But we have to stay put in our tiny reality.”

“We did not want to fall into geopolitical struggles,” said Roberto Ciavatta, the health minister of San Marino, according to The New York Times. “We just did not want to die.”

Multiple Kenyans have complained about their European visa applications being rejected despite their full vaccination status with Covishield, which the E.U. has not approved, reported All Africa.

Many people from India — where WHO-approved Covishield is one of the primary vaccines — worry they will face the same issues, reported New Delhi TV.

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And these are just a few of the stories of people affected by this growing issue.

“To exclude some people from certain countries because of the vaccine they’ve received is wholly inconsistent because we know that these approved vaccines are extremely protective,” said Dr. Raghib Ali of the University of Cambridge, per The Associated Press.

Still, E.U. vaccine regulations are so complicated that some have developed entire tools just for figuring out if your vaccine qualifies you for travel just within the E.U.’s Schengen Zone. But those vaccinated with Covishield or Sputnik trying to travel to the E.U. aren’t the only ones affected by incongruent vaccine approvals.

“I didn’t realize there were so many layers to vaccine inequity,” Ali said.

Someone vaccinated with Moderna is not considered vaccinated in Brazil, per The New York Times. A person vaccinated with Pfizer is not considered vaccinated in China or Russia. Anyone vaccinated with Oxford-AstraZeneca, Sinovac or Sinopharm — all vaccines approved by the WHO and distributed as part of the COVAX vaccine sharing initiative — is not considered vaccinated in the U.S., per FDA guidelines.

And, as vaccine requirements tighten domestically, the concern goes beyond just entering a country — it extends to being allowed to eat at a restaurant or travel on public transit or attend an event, reported New Delhi TV.

The selective approval of vaccines — like many other vaccine-related inequalities — is coming down hardest on those from lower-income countries.

“​​I am one of the hundreds of thousands who have been inoculated with China’s Sinovac for the simple reason that this vaccine was the one immediately and massively available,” wrote Nini Cabaero, a journalist from the Philippines, in The SunStar.

Many health authorities in lower-income countries feel the same way, having provided whatever COVID-19 vaccines they could secure en masse.

“What choice do we have?” asked Rose Wakikona, a lawyer with the Center for Health, Human Rights and Development in Uganda, per NPR. “Sincerely speaking, what choice do we have? No one has offered us any other (vaccine) options. None whatsoever.”

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The large-scale implications of differing vaccine approvals

Aside from complicating travel, why does it matter if different countries approve different COVID-19 vaccines?

When medical authorities — such as the WHO and the European Medicines Agency — contradict each other, the contradiction can undermine vaccine confidence worldwide, reported The Associated Press.

“This will just give room to all kinds of conspiracy theories that the vaccines we’re getting in Africa are not as good as the ones they have for themselves in the West,” Dr. Ifeanyi Nsofor of Nigeria told the AP.

Already, “some people practice vaccine brand ‘comparison shopping’, although the vaccines are free of charge,” according to a recent study of Filipino adults by Fides A del Castillo in The Journal of Public Health.

“Vaccine disinclination due to brand preference continue to put the health of millions of Filipinos at risk,” A del Castillo said in his study. “COVID-19 vaccine brand preference is a luxury we cannot afford and must be addressed.”

And it's not just an issue in the Philippines.

When countries or regions limit approved vaccines to only a subset of those approved by WHO, people may be discouraged from receiving safe and effective vaccines. This new source of vaccine hesitancy could ripple outward, putting billions of people at risk, according to the WHO.

“People who were already suspicious of vaccines will become even more suspicious,” said Ivo Vlaev, a professor at the University of Warwick, per the AP. “They could also lose trust in public health messages from governments and be less willing to comply with COVID rules.”

In a nutshell, the implications of incongruent vaccine approvals are potentially massive.

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Can this vaccine inequality be avoided?

To avoid these negative implications, the WHO has urged all countries for “equal recognition of vaccines” in a recent statement. Basically, the WHO is calling for the standardization of COVID-19 vaccines approval.

Many medical experts have agreed with this approach.

“Vaccines that have met WHO’s threshold should be accepted,” Dr. Mesfin Teklu Tessema, the director of health for the International Rescue Committee, told the AP. “Otherwise, it looks like there’s an element of racism here.”

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Others have called for an even more inclusive approach to vaccination.

“Leaders of social institutions can work together to correct vaccine elitism,” said A del Castillo. “One way to do this is to change the narrative from ‘Which COVID-19 vaccine brand is best?’ to ‘The best COVID-19 vaccine is the first one that is available now.’”

“Boiling it down to ‘this vaccine is better than the other’ isn’t going to aid our cause,” said Dr. Helen Petousis-Harris of the University of Auckland​, per Stuff.

“It’s not constructive, it’s going to be counterproductive,” she continued. “Look at them as COVID vaccines.” 

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