Why isn’t the U.S. sharing its extra vaccine doses with the rest of the world? 

America led the world in buying up the messenger RNA vaccines that have proven most effective against Covid-19. It’s now starting to lead the world in not using them. 

Across the U.S., there are more than 27 million unused Moderna Inc. doses and 35 million from Pfizer Inc. and BioNTech SE, according to data compiled by the Centers for Disease Control and Prevention. That’s led to calls by prominent public health voices to pack America’s surplus in dry ice and ship it to places like India, where the outbreak is still raging.

“You’re seeing supply exceed demand here and you just know there are excess doses,” said Monica Gandhi, a physician and professor of medicine at the University of California, San Francisco, who authored a letter with more than two dozen colleagues calling on the U.S. to ship spare Moderna doses to India. 

As American vaccinations slow and doses accumulate, the U.S. is at a health, ethical and diplomatic crossroads. China is exporting more doses than any other country, lifting its international profile and adding to its influence.  Should the U.S. continue to buy and distribute millions of mRNA vaccines a week, targeting them at people who are in no hurry to be vaccinated or who are lower-risk? Or should it pare back its orders and free up drugmakers to send more doses to other countries in need?

Press harder

While it might seem simple to box up the spares and send them out, the reality is far more complex. There is no stockpile of tens of millions of Moderna doses in a warehouse, ready to go. Most unused U.S. doses are scattered across tens of thousands of locations: state facilities, local pharmacies, vaccination sites and other locations. Gathering and sending them out of the country would be unmanageable, and undercut the U.S. domestic effort.

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Pfizer is already sending some shots manufactured in the U.S. overseas. And there may be millions more unused doses from Johnson & Johnson and AstraZeneca Plc available to send out in the coming weeks or months; the exact date is unknown. 

But with the Biden administration rolling back pandemic guidelines on masking, in part to get vaccine fence-sitters to roll up their sleeves, there’s little indication the U.S. strategy of ensuring more-than-ample supply at home will change any time soon. 

“When you’re winning, you press harder,” Andy Slavitt, the senior adviser to the White House’s Covid Response Team, told reporters this week. The U.S. goal continues to be vaccination of 70% of adults before July 4, he said. 

Vaccines of choice

The two-dose mRNA vaccines have shown the highest efficacy rates of those cleared for use around the globe. They are also the most challenging to store and ship, and have been bought up primarily by wealthier countries. They’ve become the vaccines of choice for Americans, because of their availability and their perceived superiority.

Pfizer’s shots have also been cleared for people ages 12 to 15, making them critical to the domestic effort to vaccinate teens. It may soon be authorized for even younger children, who are at relatively low risk from Covid, reducing what’s available for more defenseless populations abroad. 

“If we were truly interested in taking an ethical approach to vaccination, we would have vaccinated the most vulnerable people wherever they live, but that’s not the political reality,” said Richard Besser, a pediatrician and former acting director for the CDC. “Each country is focused on protecting its own,” and that means turning to American children first, said Besser, who’s now CEO of the Robert Wood Johnson Foundation.

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To understand how many extra shots the U.S. actually has, it’s necessary to understand how its vaccine supply chain actually works. 

Moderna’s shipments are overseen by the federal government. When the company finishes making doses, it gives possession to distributor McKesson Corp., which stores them and sends them on to vaccination sites. 

As of April 12, Moderna had handed over 117 million doses. It’s producing 40 million to 50 million doses a month, which means that as of this week, it’s delivered about 157 million to 167 million. About 140 million of those doses have already been shipped out to vaccine locations and states, according to the CDC.

If another 10 million are on order or in transit — about what ships each week — that leaves just 7 million to 17 million doses that haven’t been sent around the country already to vaccine sites. The government contract with Moderna also says that the government may not use or authorize use of its vaccine order “unless such use occurs in the United States and is protected from liability under a declaration issued under the Public Readiness and Emergency.” Biden would have to strike a deal with Moderna or find a way around that clause to share his doses.

McKesson declined to comment, and the U.S. Department of Health and Human Services didn’t respond to an email seeking comment. A person familiar with the company’s efforts described the production estimates as in-line.

Pfizer, the only other U.S. manufacturer of mRNA vaccines, controls its own distribution. The company is committed to delivering 220 million doses to the U.S. by the end of May. More than 170 million doses have already been dispatched, and the drugmaker is producing more than the U.S. orders each week. 

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That excess, according to a person familiar with the matter, is already being sold abroad, mostly in North and South America, including to hard-hit places like Brazil. Canada, Mexico and Uruguay have all said they’re receiving Pfizer doses. 

As its manufacturing capacity grows, Pfizer plans to sell even more doses overseas, Chief Executive Officer Albert Bourla has said. Because of the way the company’s deal with the U.S. is structured, it doesn’t need permission to do so after meeting its domestic obligations. This path, manufacturing more doses than needed in the U.S., is almost certainly the road to getting more mRNA vaccines abroad. 

Donation Stopgap

Unfortunately, even if unused U.S. inoculations were sent abroad, they would likely make barely a dent in the need. The globe needs billions of vaccines, not millions, and the places that are in crisis now may burn through their outbreaks before help could arrive.

“The donation piece is in many ways a stopgap,” said Mitchell Warren, executive director of AVAC: Global Advocacy for HIV Prevention, who also signed onto the letter urging the sharing of Moderna doses. “This would be an initial supply to get emergency relief underway. It’s barely a Band-Aid, but as we understand it, it’s product that’s available and it could be deployed for good.”

The next several weeks will be telling in terms of U.S. needs  — and what could be available for export. Many states have freshened their campaigns with incentives like cash lotteries for people who haven’t yet gotten shots. Colorado has requested the maximum number of doses every week, according to the state health department. Its pace of vaccinations has remained relatively steady at about 50,000 doses a day, according to the Bloomberg Vaccine Tracker. 

Other states are paring down. After peaking at almost 600,000 doses at its peak in April, Illinois’ most recent request was just 8,510, according to the state. It’s also sending unused doses to areas where local demand is higher. 

The Biden administration has said that over the next months it will send out approximately 60 million AstraZeneca doses that haven’t been cleared for U.S. use. There are also tens of millions of J&J vaccines that may become available, likely as the American campaign winds down. 

Those are the vaccines the U.S. doesn’t need or want. But they are likely what it will give.