To the Editor—Vaccination programs for COVID-19 in ‘high-income countries’ (HICs) have benefited from their ability to secure contracts for preferential supply for several vaccines1. For the rest of the world, vaccine access is much less certain. Although leaders of G20 nations have pledged to ensure fair distribution of vaccines against COVID-19 worldwide, substantial challenges remain. The COVAX Facility aims to ensure that all countries will have equal access to doses and can compete with HICs to acquire doses, but some low-income countries may need to wait until at least 2022 before even the most vulnerable 20% of their populations are vaccinated2.

There are increasing calls for HICs to donate a proportion of their vaccine doses. During the H1N1 influenza pandemic, there was a coordinated effort among HICs to make a vaccine to protect the world’s poorest, including a pledge by US President Obama to donate 10% of the USA’s vaccine supply; this was supported by the general public3.

A key factor that could shape the willingness of governments to make vaccines against COVID-19 available to low-income countries is their public’s willingness to support donations. We provide evidence on this issue obtained through an international internet-based survey4 that was conducted between 24 November and 28 December 2020. The overall study involved 15,536 people from 13 countries who completed an anonymous survey using Qualtrics web-based software. Quota sampling (and, in five countries, additional weighting) was (were) used to obtain a sample that reflected the distribution of age, education, gender and region in each country.

We obtained information from 8,209 adults from a subset of seven HICs (Australia, Canada, France, Italy, Spain, UK and USA). The survey used a visual analog scale to measure agreement (from 0 (‘very much disagree’) to 100 (‘very much agree’)), with three prioritization principles for the global allocation of treatments for and vaccines against COVID-19. We asked if these should be first provided for (i) “those who need them most”; (ii) “those who cannot afford to buy them”; and (iii) “those who live in the country in which they are first developed”. Second, we adapted a question previously used in the context of H1N1 influenza3 and asked whether respondents supported donating some doses of vaccines against COVID-19 for distribution to poor countries with insufficient resources to buy their own vaccines. Those willing to donate indicated whether they favored an amount greater than, equal to or less than 10% of their country’s doses. Proportions and means, including 95% confidence intervals (CIs), are reported, and the data used to estimate these statistics are available from the authors upon request.

For the global allocation criteria for vaccines, the highest average level of agreement was based on need (with average agreement ranging from 70 (95% CI, 68–71) to 80 (95% CI, 78–81)); followed by affordability (62 (95% CI, 60–64) to 70 (95% CI, 68–71)); and finally whether the country developed the vaccine (28 (95% CI, 26–29) to 58 (95% CI, 56–60)). This ranking was consistent across all countries. We present here the opinions on the donation of purchased vaccines (Table 1). The proportion of people supporting donation was more than double the proportion of those who did not support such donation.

Table 1 Preferences of the public for the donation of vaccines governments have purchased, by country

While current supplies are limited, many HICs have pre-purchased supplies that exceed their population size. For example, the USA has reserved more than 1.2 billion doses5, and Canada has pre-market commitments covering more than nine doses per person1. Redistributing some of these supplies would have global benefits. It would reduce the risk of the emergence and spread of new variants and, according to predictions, would benefit the economy, both globally and in donor countries6. In contrast, the economic cost of ‘vaccine nationalism’ (whereby a few countries push to gain preferential access) is potentially high, with a recent report suggesting it could cost up to US$1.2 trillion per year of the world’s economy7.

Although we did not investigate opinions on the timing of donations, national vaccination strategies should be taking into account these broader benefits. Notably, countries such as Norway8 have already pledged to distribute vaccines at the same time that they vaccinate their own populations. Such policies are likely to maximize global health benefits. A recent modeling study suggests that allocating doses internationally in proportion to countries' population sizes would be a close-to-optimal strategy in terms of averting deaths9.

Like prevalence studies, these opinions represent a single point in time, but, notably, our survey was conducted at a time when the distribution of vaccines against COVID-19 was no longer a hypothetical question. More broadly, understanding and potentially influencing public opinion will be important components of any strategies to combat COVID-19 and prevent future pandemics10. This global problem requires global solutions, and our survey indicates that the redistribution of some pre-purchased vaccines to countries most in need has public support.