《柳叶刀》（The Lancet）于1月28日发表的评论指出，迫切需要重新审查包括联合国及安理会在内的全球治理结构，使中低收入国家数十亿人的声音和利益得到更好的体现和认识。新冠疫情表明，没有任何国家可以独善其身。我们都是人类共同体的一部分，这要求我们尊重不同的经历、文化和国家，并建立能够更好服务于各方利益的伙伴关系。
世界卫生组织（WHO）及其合作伙伴从2009年H1NI流感大流行[1]应对行动的不足之处中吸取了教训，建立了获取COVID-19工具加速计划（Access to COVID-19 Tools Accelerator, ACT-A），以促进疫苗、治疗和诊断的公平获取[2]。然而，许多高收入国家已经与新冠疫苗的制造商签署了双边协议[3]。ACT-A的“新冠肺炎疫苗实施计划”（COVAX）已达成协议，在2021年期间交付20亿剂经WHO预检合格的疫苗，但这只占参与国疫苗需求的20%[4]。大多数中低收入国家（LMIC）在获取和向国民提供新冠疫苗和治疗药物时面临困难[5]。COVAX需要全球疫苗免疫联盟（Gavi）、WHO和流行病预防创新联盟（Coalition for Epidemic Preparedness Innovations, CEPI）在其服务的国家/地区的支持下采取果断行动，并为疫苗采购提供资金，以确保全世界人民都能公平地获得新冠疫苗[6-8]。
中低收入国家中80%的人口无法从“新冠肺炎疫苗实施计划”提供的新冠疫苗中获益，对于这部分人群来说，亟需采购或捐赠的资金。政府为应对新冠疫情而采取的措施，以及更广泛的全球金融局势，导致重债国的财政失衡问题日益严重[9]。跨国组织、金融机构和较富裕的国家应考虑采取措施，减轻负债的中低收入国家的负担。世界银行、国际货币基金组织和其他机构需要带头开展一项国际倡议行动，动员更多的人支持那些需要帮助的中低收入国家。
许多中低收入国家并未建立为成年人口接种疫苗的平台[10]。虽然为医疗卫生工作者和其他必要一线工作人员提供新冠疫苗是可行的，但有些中低收入国家由于缺乏识别所有老年人口和共病患者的完善机制，很难有效地覆盖并为这些群体接种两剂疫苗。各国政府和技术领导者在作出决定和解释基于实证的疫苗优先级时，需要遵循透明、负责和公正的流程，同时还要建立对新冠疫苗的信任，并与所有利益相关者合作。
在中低收入国家中的主要城市以外的地区，新冠mRNA疫苗的超冷链要求可能是一个难以逾越的障碍。新冠疫苗的供应将需要大量的投入，包括资源、医务人员，以及细致的规划以避免机会成本，包括常规医疗卫生服务的中断和儿童基本疫苗接种率的下降，但这可能会导致麻疹和其他疫苗可预防疾病的暴发。2019年刚果民主共和国暴发埃博拉疫情后，由于未能保持足够的儿童疫苗接种，因麻疹死亡的人数超过了因埃博拉病毒死亡的人数[11]。许多中低收入国家的疫苗接种基础设施已经不足，全球有1970万未接种疫苗的婴儿，其中大部分就在这些国家[12]。因此，为中低收入国家提供新冠疫苗的各方面准备工作必须在国际合作伙伴的支持下立即展开。
加强中低收入国家开展临床试验的能力并提高其在科研方面的参与度同样至关重要[13]。我们需要更多中低收入国家参与未来的疫苗试验，以及针对不同治疗药物临床有效性的测试，以确保干预措施以及实施适合当地的情况。
追踪不同新冠疫苗随时间在各种人群和环境中的安全性和有效性对改善药物警戒是必要的[14]。许多中低收入国家的监管机构需要加强，还可以从国家和国际支持计划以及区域合作和信任机制中受益[15]。作为国际协调行动的一部分，COVID-19技术和监管指南应当转移至中低收入国家的制造商。努力提高中低收入国家的本地制造能力将有助于实现公平、全球团结和全球健康安全。印度和南非呼吁悬置与新冠疫苗相关的知识产权，以提高中低收入国家获得疫苗的机会，这一举措目前得到了许多其他国家的支持，但遭到了制药行业的反对，他们认为该举措不利于创新[16]。
还有更大的挑战。如同高收入国家一样，中低收入国家的政府拥有强大的私营卫生部门，这些国家需要妥善处理固有的不公平现象，即富人比难以获得私家诊疗的个体更优先接种新冠疫苗，例如老年人和共病患者，而他们可能面临更高的重症和死亡风险。受战争、国内冲突、经济危机或自然灾害影响，或有大量难民以及有特殊需要或易受伤害人口的中低收入国家，需要得到更多支持，以便在极端困难的工作条件下提供疫苗和疫苗接种服务。
迫切需要重新审查包括联合国及安理会在内的全球治理结构，使中低收入国家数十亿人的声音和利益得到更好的体现和认识。对多边机构的全球支持，对于维持对中低收入国家的支持，从而促进全球范围内的疫苗接种至关重要。新冠疫情表明，没有任何国家可以独善其身。我们都是人类共同体的一部分，这要求我们尊重不同的经历、文化和国家，并建立能够更好服务于各方利益的伙伴关系。END
作者利益声明及参考文献
Lancet Commission on COVID-19 Vaccines and Therapeutics Task Force Members
peter.figueroa10@gmail.com
MEB and PH are developers of a COVID-19 vaccine construct, which was licensed by Baylor College of Medicine to Biological E Ltd, a commercial vaccine manufacturer for scale-up, production, testing, and licensure. JPF and GK are members of the WHO SAGE Working Group on COVID-19 vaccines. SG has a ChAdOx1 nCoV-19 patent application licensed to AstraZeneca. MH is Founder and Managing Director of SaudiVax. JHK reports personal fees from SK biosciences. GK is an Independent Director of Hilleman Laboratories Private Limited and Vice Chair of the Board of CEPI. HL reports grants and honoraria for training talks from GlaxoSmithKline, and grants and honoraria from Merck as a member of the Merck vaccine confidence advisory board, outside the submitted work. TS reports grants from National Institute of Allergy and Infectious Diseases, research contracts from GlaxoSmithKline, research contracts from ViiV Healthcare, and grants from Fast Grants. SS reports grants from the US Department of Defense, Bloomberg Foundation, State of Maryland, Ansun, Astellas, Cidara, F2G, T2, Shire, Shionogi, and Scynexis; personal fees from Acidophil, Amplyx, Janssen, Karyopharm, Intermountain Health, and Immunome; grants and personal fees from Merck, Reviral outside the submitted work. All other authors declare no competing interests. The authors' views and opinions in this Comment do not necessarily represent the views, decisions, or policies of the institutions, universities, or health systems with which they are affiliated. We thank Jeffrey Sachs, Chair of the Lancet COVID-19 Commission, and Yanis Ben Amor, member of the Secretariat of this Commission, for their invaluable review and feedback.
University of the West Indies, Mona, Kingston, Jamaica (JPF); Texas Children's Center for Vaccine Development, Baylor College of Medicine, Houston, TX, USA (MEB, PH); Médecins Sans Frontières, Rio de Janeiro, Brazil (CB); Koc University Research Center for Infectious Diseases, Istanbul, Turkey (OE); Jenner Institute, Nuffield Department of Medicine, Oxford University, Oxford, UK (SG); Middle East Technical University, Ankara, Turkey (MG); College of Medicine, King Saud University, Riyadh, Saudi Arabia (MH); International Vaccine Institute, Seoul, South Korea (JHK); University of Houston College of Medicine, Houston, TX, USA (BL); London School of Hygiene & Tropical Medicine, London, UK (HL, AW-S); ISGlobal-Barcelona Institute for Global Health-Hospital Clinic-University of Barcelona, Spain (DN); University of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA (TS); Johns Hopkins University School of Medicine, Baltimore, MD, USA (SS); Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany (NS-W); Drugs for Neglected Diseases Initiative, Geneva, Switzerland (NS-W); Center for Global Development, Washington, DC, USA (PY); Harvard Medical School, Boston, MA, USA (PY); Christian Medical College, Vellore, India (GK)
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*中文翻译仅供参考，所有内容以英文原文为准。