The first billion doses

One billion syringes. A billion alcohol-soaked cotton balls, jabs to the skin and tiny bandages. One billion exhalations of relief. The first Covid-19 vaccine was approved for widespread use in the U.K. on Dec. 2, and less than 150 days later the first billion doses will have been administered to a pandemic-weary world.

Today, more than 96% of the world's people live in countries with active Covid-19 vaccine campaigns. As of April 22, more than 966 million doses have been administered, and the world should cross the 1 billion mark in the coming days. That breadth marks an end to the start-up phase of the biggest public-health effort in history.

What comes next won't be easy. It will take another 21 months to vaccinate 75% of the world's population at the current pace of 16 million shots a day.

How did we get here? And how will we get from 1 billion shots to 10 billion?

The Bloomberg Vaccine Tracker has followed the rollout from the start. For many, the daily accumulation of vaccinations has been a source of hope after a year of unrelenting bad news: 1 million dead in Europe, 568,000 in the US, 378,000 in Brazil. More than 3 million people have died worldwide in spite of the sacrifices made to keep each other safe.

Even before the vaccine campaign started, the US and U.K. made the strategic decision to put themselves at the front of the line for the coming flood of vaccines. The U.K. bought the biggest share of AstraZeneca Plc's shot, while the US snapped up doses by Pfizer Inc. and BioNTech SE, Moderna Inc. and Johnson & Johnson. They've left their neighbors with less: The EU, Canada and Mexico are getting vaccinated at rates more in line with the much slower global average.

'We're not out of it until everybody's out of it'

Vaccine unilateralism played into longstanding rivalries. Europe threatened to block vaccine exports into the U.K. As resentment rose toward America's abundance, China used its own homegrown shots to assert influence, sending millions of free doses to more than a dozen less-wealthy nations—including Algeria, Mozambique and Bolivia—countries that are also linked through China's Road and Belt initiative to invest in global infrastructure.

Chinese President Xi Jinping on Tuesday committed to further vaccine assistance for developing countries. "Big countries," he said, "should behave in a manner befitting their status, and with a greater sense of responsibility."

The global distribution chain of vaccines tells a story of financial and geopolitical influence.

The wealthiest countries bought Pfizer, Moderna and J&J. Less wealthy countries got shots from Russia's Gamaleya Research Institute and Chinese pharmaceutical makers Sinovac Biotech Ltd., CansiSino Biologics Inc. and Sinopharm Group Co.

AstraZeneca's vaccine has been injected almost everywhere—due to bulk distribution agreements struck during early vaccine development. Its use may be wide, but it isn't deep—just a few hundred thousand doses in many places, especially the developing world.

The pharmaceutical balance of power

The drug industry has long been dominated by US and European giants, but the pandemic created a need that couldn't be filled by the legacy players alone. An array of suppliers from around the world rushed in to fill the vacuum.

For the first time, China and Russia have become high-profile bio-pharmaceutical exporters.

China has been incubating its domestic pharmaceutical industry for years, working to create high-technology drugs that could compete abroad. It's relying almost exclusively on homegrown vaccines for its own population. But it's also sending doses abroad—outside China, 14 million doses of vaccines developed by CanSino, Sinopharm and Sinovac had been administered as of April 8, according to a Bloomberg tally.

Russia has filled a gap as well, with its Sputnik vaccine deployed in at least 39 countries. India, a pharmaceutical manufacturing superpower in its own right, has been ramping up production of a new vaccine made by Bharat Biotech.

America's big pivot

Covid-19 hit hardest in the US, which had more deaths than any country in the world. The Trump and Biden administrations both prioritized vaccines at home before thinking about shipping them elsewhere. It's a strategy that has been likened to the emergency instructions from airplane flight attendants: "Secure your own oxygen mask first before assisting others."

But the US vaccination effort is at a turning point. For months, eager vaccine seekers nabbed every new appointment as soon as they became available. Hopeful line-skippers stood outside pharmacies in case extra shots were available at the end of the day. "There's a group, initially, that wanted to be vaccinated no matter what," said Nirav Shah, director of the Maine Center for Disease Control and Prevention.

That's changed. After 219 million doses administered, more than half of all adults in the US have had at least one shot. The eager and able have been vaccinated or will be soon. Those left, says Shah, are the "not able," the "not right now" and the "not ever."

In the meantime, the US is shipping out 28 million doses of vaccine a week but administering just 21 million. In some places, unused doses are beginning to pile up. And standing by are millions of Johnson & Johnson's single-dose vaccines—on safety hold at the moment, but likely to be cleared for use—that could add to the pile. The Biden administration says that was the idea, to "overwhelm the problem" and eliminate barriers to access.

"It's okay if there's not a long line of 1,000 people," said Natalie Quillian, the White House's deputy coordinator of its Covid-19 response. "That's good, that was the plan."

In America, reported vaccinations peaked at 3.4 million a day on April 13—the day J&J's shot was paused for a review of unusual blood clots seen in one out of a million people vaccinated. Even if the vaccination rate resumes its previous climb, there's little question the US is beginning to shift from vaccine scarcity to abundance. What will it do then?

"We're obviously focused on taking care of Americans," Quillian said. "When we have the confidence in our supply, we'll definitely share."

Technology: One shot to rule them all

The pandemic has also given rise to pharmaceutical breakthroughs that could have lasting effects on medicine. Vaccines that use mRNA—a genetic component that turns cells into protein-making factories, triggering an immune response—were first to win widespread approval and quickest to ramp up production.

New vaccine development is typically measured in years, not months. The pandemic brought billions of dollars to bear as well as an endless supply of willing test subjects. Roughly half a billion people participated in vaccine trials around the world, and the raging pandemic meant many of those trials could test their technologies swiftly.

The success of mRNA vaccines in moving from the lab to the front lines in less than a year proved a technology that had tantalized drug researchers for a decade. It was a sharp turn from past outbreaks, like Zika and SARS, when drugmakers had rushed to develop and test vaccines, only to watch the virus flame out and their efforts go to waste.

"They had been burned," Alex Azar, the Trump administration's secretary of Health and Human Services, said in a December interview describing the US effort to recruit drugmakers. "It wouldn't have happened without us. It would have taken years."

The continued pace of Covid-19 infections will require more technological breakthroughs before the pandemic is finished.

Clinical trials are underway for edible vaccines, inhalable vaccines, vaccines for newborns and young children. The US military recently began an early-stage trial for a universal coronavirus vaccine—one that would protect against any mutant strains and even the version of coronavirus that causes as many as a third of cases of the common cold.

The mRNA technology is particularly well suited for rapid deployment against mutant strains of Covid-19. Pfizer and Moderna are both testing variations and say boosters will be ready in the fall if needed. If an annual booster is required, similar to the flu vaccine, today's daily vaccination rate of 16 million shots a day may need to double in order to get 75% of the global population fully protected in 2023.

Who's been vaccinated?

Vaccine access so far has been determined by national wealth. Enough doses have now been administered to fully vaccinate 6.2% of the global population, but countries with the highest incomes are getting vaccinated about 25 times faster than those with the lowest.

Because of the interconnectedness of our modern world and the ability of the virus to mutate, countries can't be protected in isolation, said Naor Bar-Zeev, deputy director of the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health. "A pandemic, by definition, is a global phenomenon," he said. "We're not out of it until everybody's out of it."

Looking for the next normal

The vaccine campaign has made mixed progress. The virus has all but vanished in Israel, which leads the world with nearly all of the adult population vaccinated, but rages unchecked in India. Even some highly vaccinated regions are experiencing outbreaks, leading many to ask whether vaccines can ever be enough to control this disease. In Chile and Bahrain, in Maine and Michigan, hospitals remain full even after 40% of the population has received at least one shot.

Vaccines take time to do their work. After the first prick of the needle, the immune system needs weeks to build its defenses. For people who get sick with Covid, days or weeks can pass between the initial exposure to when a positive test gets reported to the public.

Taking those delays together, it could mean a month or more for the impact of vaccinations to show up in the data. Today's reported cases may only reflect the impact of vaccines administered by early March.

In recent days, high-profile outbreaks in heavily vaccinated places have declined, sometimes sharply: in Chile, Bahrain, Hungary and Serbia, as well as in Connecticut, Vermont, Michigan and New Jersey. The US and EU—both considered in recent weeks to be on the brink of new surges—have instead seen new cases begin to pitch downward.

It will take weeks to know whether the early gains are permanent, or if another wave is on the way. But with each new billion doses administered, the world can breathe that much easier.

Disclaimer: This article first appeared on bloomberg.com, and is published by special syndication arrangement