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Rapid response to:


Equitable global access to coronavirus disease 2019 vaccines

BMJ 2020; 371 doi: (Published 15 December 2020) Cite this as: BMJ 2020;371:m4735

Linked Research

Reserving coronavirus disease 2019 vaccines for global access

Linked Research

Global, regional, and national estimates of target population sizes for covid-19 vaccination

Rapid Response:

Re: Equitable global access to coronavirus disease 2019 vaccines

Dear Editor

Concern about vaccine nationalism is important and well-founded, but it has overshadowed another key form of injustice: vaccine ageism.

In Indonesia, as in many low and middle-income countries (LMICs), the main form of COVID19 vaccination that will be available over the coming months will be Sinovac, produced in China.

The initial SINOVAC trials in China that led to licensing for use were only conducted on adults aged under 60 [1]. Subsequent trials in Indonesia also exclude over 59 year-olds. The clinical trial research team leader, Kusnandi Rusmil, commented to BBC Indonesia: “"Why do we target people of a productive age? These people can work hard, so the country will not have a deficit" [2]. As a result, there is no information about either its safety or efficacy for people at older ages. Further trials of SINOVAC for people at older ages have since begun in countries such as Brazil [3]. Media reports suggest that SINOVAC may be effective for older people, but at a lower level than for other ages [4]. However, related findings are yet to be published.
Due to the lack of published evidence, the government of Indonesia has decided to exclude people aged 60 and over from their vaccine roll-out [5]. In the (ageist) words of Minister of Health Terawan Agus Putranto, the target is to vaccinate 107,206,544 people aged between 18 and 59, as they are of “productive age”. An article in the national media concludes: “Isn't it strange that if we want to vaccinate them, we will have to fly our children or grandma and grandpa to England?” [5]. This age-targeted vaccination policy will lead to reservoirs of Covid-19 among children and older people, resulting in continuing viral transmission, more hospital admissions and avoidable deaths. The aim of vaccination programmes is not simply to protect individuals, but to achieve herd immunity in order to protect whole populations, including vaccine non-responders and non-compliers [6].

Not all candidate COVID-19 vaccine trials have excluded older people, and it is welcome that ongoing trials of SINOVAC will include them [7]. Whether this will lead to vaccine policy change in countries like Indonesia remains to be seen. There is a long and problematic history of excluding older people from trials of vaccines or treatments for conditions that affect them greatly [8]. There is a long, problematic tradition of infantilising “grandpa and grandma” and of justifying discrimination on the basis of false claims that people aged 60 or more are by definition unproductive and younger adults universally productive. Nationalist self-interest will mean that most LMICs will be at the back of the global vaccine queue; and vaccine ageism will mean that older people will be at the back of the queue in many LMICs.

1. Zhang Y, Zeng G, Pan H, Li C, Hu Y, Chu K, Han W, Chen Z, Tang R, Yin W, Chen X, Hu Y, Liu X, Jiang C, Li J, Yang M, Song Y, Wang X, Gao Q, Zhu F. Safety, tolerability, and immunogenicity of an inactivated SARS-CoV-2 vaccine in healthy adults aged 18-59 years: a randomised, double-blind, placebo-controlled, phase 1/2 clinical trial. Lancet Infect Dis. 2020 Nov 17:S1473-3099(20)30843-4.

2. BBC News (2020) Sinovac-Covid-19 Vaccine: President Jokowi is aiming to vaccinate Indonesians in January 2021 (Sinovac-Vaksin Covid-19: Presiden Jokowi targetkan vaksin diberikan ke masyarakat Indonesia pada Januari 2021) 24.7.20

3. Palacios R, Patiño EG, de Oliveira Piorelli R, Conde MTRP, Batista AP, Zeng G, Xin Q, Kallas EG, Flores J, Ockenhouse CF, Gast C. Double-Blind, Randomized, Placebo-Controlled Phase III Clinical Trial to Evaluate the Efficacy and Safety of treating Healthcare Professionals with the Adsorbed COVID-19 (Inactivated) Vaccine Manufactured by Sinovac - PROFISCOV: A structured summary of a study protocol for a randomised controlled trial. Trials. 2020 Oct 15;21(1):853.

4. Reuters (2020) China's Sinovac coronavirus vaccine candidate appears safe, slightly weaker in elderly. 7.9.20

5. Kompasiana (2020) It turns out that the Sinovac Covid-19 Vaccine is Only for Ages 18-59 Years (Ternyata Vaksin Covid-19 Sinovac Hanya untuk Usia 18-59 Tahun). 11.12.20

6. Atzinger, Lea, and Wolfram Henn. “A classification of the aims of vaccination and its relevance to transgenerational justice.” Journal of global health vol. 10,1 (2020): 010341.

7. Sharma, O., Sultan, A. A., Ding, H., & Triggle, C. R. (2020). A Review of the Progress and Challenges of Developing a Vaccine for COVID-19. Frontiers in immunology, 11, 585354.

8. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ. Institutional ageism in global health policy. BMJ. 2016 Aug 31;354:i4514. doi: 10.1136/bmj.i4514. PMID: 27582131.

Competing interests: No competing interests

21 December 2020
Peter Lloyd-Sherlock
Paramita Muljono, Shah Ebrahim
University of East Anglia
Earlham Rd, Norwich, UK