The first case of polio in the U.S. in a decade has triggered intense debate and unease. On Friday, New York Gov. Kathy Hochul declared a disaster after polio virus was detected in the wastewater of a third county in the state.
Health officials are advocating for improving domestic vaccination rates to prevent a resurgence of polio, as they should. But this is only part of the solution. Expanding the vaccine supply is the other part. Without a reliable vaccine supply, there’s no way to ensure all children are vaccinated.
Based on a simulation study I and several colleagues conducted under the auspices of the Routine Immunisation to Secure Eradication (RISE) project — a global initiative that brings together policymakers and academics — the market for polio vaccines will see a major capacity shortfall for the next decade.
Governments and public-private health partnerships must intervene in the polio vaccine market to ensure supply. This can be done by a guarantee mechanism that assures vaccine producers of a minimum purchase over a sufficiently long horizon. Ten years ago, based on an idea by Nobel Prize winner Michael Kremer and colleagues, donors committed $1.5 billion to a pilot advance market commitment to help purchase a pneumococcal vaccine for low-income countries. Suppliers were entitled to a fraction of the fund proportional to their supply commitment at given maximal price points. More than 150 million children were immunized, saving an estimated 700,000 lives.
Covid-19 established another precedent for this. In November 2020, under Operation Warp Speed and after more than 300,000 Covid-19 deaths, the U.S. government announced a package valued at more than $10 billion for developing six vaccine candidates and manufacturing them. The initial goal was to produce 300 million doses of a vaccine whose existence at the time — let alone its effectiveness — was speculative. For polio, safe and highly effective vaccines exist, and have been administered for six decades, so a guarantee mechanism is far less risky to invest in, and the disease is a grave public health threat.
An advance market commitment could be repeated for the polio vaccine. RISE has developed alternative guarantee mechanisms that could be used as an alternative to, or in combination with, such a commitment. One mechanism calls for a flexible purchasing agreement. This allows a purchasing organization like GAVI to determine target orders for a sequence of consecutive years, with the understanding that actual orders can be specified within a range around the target number, characterized by specific flexibility percentages.
To be sure, the U.S. and other countries must also redouble their efforts to immunize children but, in order to do that, supplies must be available to enable the necessary vaccination campaigns.
The U.S. polio case comes on the heels of similar outbreaks in the Western world. For the first time in nearly 40 years, health officials have identified a likely outbreak of polio in London. Since January, 19 cases of paralytic polio have been confirmed in western Ukraine, leading to a declaration of a public health emergency. Russia’s invasion into Ukraine on February 24 “disrupted routine vaccinations and the response to the polio outbreak in Ukraine,” a group of Ukrainian scientists wrote in June. In Israel, eight children have recently been diagnosed, the first such cases since 1989.
These outbreaks demonstrate that a resurgence is inevitable unless stakeholders vigilantly ensure worldwide childhood immunizations, which can be undertaken with concerted action. The Global Polio Eradication Initiative, launched in 1988 with the cooperation of 200 countries and 20 million volunteers, has immunized 2.5 billion children against polio. An estimated 16 million people today are walking who would otherwise have been paralyzed, and more than 1.5 million people have been saved from polio-related deaths.
Ensuring a consistent supply of polio vaccines is compounded by the fact that there are only nine manufacturers worldwide, four of which are ramping up manufacturing plants in China and whose output may not be available for exports, given geopolitical tensions. In our simulation, my colleagues and I project an average shortfall of 600 million to 700 million polio vaccine doses by 2030 if children are immunized with the recommended four dosages each.
High investment costs, uncertainty about future funding and demand volumes, and the relative low prices paid by low- and middle-income countries for vaccines combine to keep potential manufacturers out of the market and existing manufacturers from increasing the number of doses they make. Guarantee mechanisms can incentivize them to enter the market or expand capacities. A call to arms is needed to create adequate vaccine supplies, along with enlisting the cooperation of parents to vaccinate their children.
Awi Federgruen is the chair of the Decision, Risk, and Operations Division of Columbia Business School and a board member of the Routine Immunisation to Secure Eradication project.