Inequities in the deployment of COVID-19 vaccine in the WHO Eastern Mediterranean Region, 2020-2021

The WHO Eastern Mediterranean Region (EMR) is characterised by a large range in routine immunisation coverage. We reviewed progress in access, deployment efforts, and use of COVID-19 vaccines in the EMR to identify bottlenecks and propose recommendations. We compiled and analysed data reported to WHO regarding the number of vaccines provided emergency use authorisation (EUA) in each country, the number of vaccine doses allocated and delivered by COVAX, the number of vaccine doses received bilaterally, the date of initiation of vaccination, vaccine usage rate and overall vaccination coverage. In June-July and October-November 2021, we conducted two rounds of a regional survey to assess vaccine acceptance and calculated the weighted proportion of individuals who would get vaccinated once a vaccine is available and recommended. We stratified the analysis according to four groups based on their participation status in COVAX, from the highest to lowest income, that is, (1) fully self-financing high-income countries (group 1), (2) fully self-financing upper middle-income countries (group 2), (3) Advance Market Commitment (AMC) countries not eligible to receive Gavi support (group 3) and (4) AMC countries eligible for Gavi support (group 4). As of 31 December 2021, the median number of vaccines provided with EUA was 6 for group 1, 11 for group 2, 8 for group 3 and 9 for group 4. On the same date, COVAX had delivered 179 793 310 doses to EMR countries. Vaccination started on 10 December 2020 in group 1, on 13 December 2020 in group 2, on 30 December 2020 in group 3 and on 20 January 2021 in group 4. The regional acceptance survey (first round) pointed to higher vaccine acceptance in group 1 (96%), than in others, including group 2 (73.9%), group 3 (78.8%) and group 4 (79.3%), with identical patterns in the second round (98%, 78%, 84% and 76%), respectively. Usage of vaccine allocated by COVAX to participating countries was 89% in group 1, 75% in group 2, 78% in group 3 and 42% in group 4. The full dose and partial dose coverage decreased with the income groups of countries, from 70% and 6% in group 1, to 43% and 8% in group 2, to 33% and 11% in group 3, and 20% and 8% in group 4. All 22 EMR countries introduced COVID-19 vaccines by 21 April 2021, but with major inequities in coverage. Additional efforts are needed to address the determinants of unequal vaccine coverage at all stages of the result chain to improve vaccine equity.