Abstract: Pandemics such as COVID-19 are gendered with regard to who is infected, who dies, who provides care, who is secured against violence and economic change, and who leads and makes decisions.1Azcona G Bhatt A Davies SE Harman S Smith J Wenham C Spotlight on gender, COVID-19 and the SDGs: will the pandemic derail hard-won progress on gender equality?. UN Women, New York2020Google Scholar Vaccines are no different and there is a need to address male bias in vaccine development to make women safe from deadly diseases.2Criado Perez C Invisible women: exposing data bias in a world designed for men. Random House, London2019Google Scholar For example, clinical trials that are not done in both men and women can raise adverse outcomes during implementation due to sex-based differences in immunological response.3Gibney E The researcher fighting to embed analysis of sex and gender into science.Nature. 2020; 588: 209Crossref PubMed Scopus (4) Google Scholar The excitement and awe at the speed of COVID-19 vaccine development and delivery needs to be attentive to the social and political dynamics in which the vaccine is delivered—women's work and their security are at the heart of this. The delivery and facilitation of COVID-19 vaccines will disproportionately depend on the unpaid labour of women. Vaccine uptake partly depends on the free labour of women within the household, impacting women's economic and personal security. Unpaid labour will generally fall to women as parents or family carers; women will typically have the responsibility for arranging when and how children and wider family members, such as older relatives, get immunised. This process is likely to be more onerous with vaccines requiring two doses, such as the Pfizer–BioNTech, Moderna, and Oxford–AstraZeneca options.4Polack FP Thomas SJ Kitchin N et al.Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine.N Engl J Med. 2020; (published online Dec 10.)https://doi.org/10.1056/NEJMoa2034577Crossref Scopus (9498) Google Scholar, 5Jackson LA Anderson EJ Rouphael NG et al.An mRNA vaccine against SARS-CoV-2—preliminary report.N Engl J Med. 2020; 383: 1920-1931Crossref PubMed Scopus (2270) Google Scholar, 6Knoll MD Wonodi C Oxford–AstraZeneca COVID-19 vaccine efficacy.Lancet. 2020; (published online Dec 8.)https://doi.org/10.1016/S0140-6736(20)32623-4Summary Full Text Full Text PDF PubMed Scopus (448) Google Scholar This effort to practically access COVID-19 vaccines will add to the already exploitive care burden placed on women during the COVID-19 pandemic.7Power K The COVID-19 pandemic has increased the care burden of women and families.Sustain Sci Pract Policy. 2020; 16: 67-73Crossref Scopus (674) Google Scholar Women in care roles may have to give up time otherwise spent on paid work or education, and incur out-of-pocket expenses related to travel and other costs of accessing vaccines for those they care for and themselves, which could require multiple different trips depending on national vaccination strategies.8Hilber AM Bosch-Capblanch X Schindler C et al.Gender and immunisation: summary report for SAGE. Gavi, the Vaccine Alliance, Geneva2010https://www.gavi.org/sites/default/files/document/2019/immunization_gender_report_without_graphics.pdfDate accessed: December 18, 2020Google Scholar This is likely to be particularly true for women in precarious work and those who live in poverty or in rural areas. The delivery and administration of COVID-19 vaccines also depends on the paid labour of women as the majority of health-care workers. Administering the doses and vaccine delivery could increase exposure to other harms and increased workloads. Attacks on health-care workers and immunisation teams are a real concern in global health settings and have occurred during polio campaigns and Ebola vaccination efforts.9Abimbola S Malik AU Mansoor GF The final push for polio eradication: addressing the challenge of violence in Afghanistan, Pakistan, and Nigeria.PLoS Med. 2013; 10e1001529Crossref PubMed Scopus (65) Google Scholar Such violence is distinct in that it can take place in conflict and non-conflict settings and is linked to both suspicion of the motives and legitimacy of the vaccinators and the vaccine itself.10Larson HJ Stuck: How vaccine rumors start—and why they don't go away. Oxford University Press, New York, NY2020Google Scholar Given that most health-care workers are women, such attacks could be seen as a form of violence against women. As has been seen during COVID-19 thus far, violence against health-care workers exists11George AS McConville FE de Vries S Nigenda G Sarfraz S McIsaac M Violence against female health workers is tip of iceberg of gender power imbalances.BMJ. 2020; 371m3546Crossref Scopus (13) Google Scholar and might be amplified over access to the finite resource of COVID-19 vaccines. Access to, and delivery of, COVID-19 vaccines is thus not only a security concern with regard to vaccine nationalism, cyber security, and as a protected commodity, but is also a concern for women, peace, and security agendas, given the feminised nature of the health-care workforce and vaccination teams responsible for vaccine delivery. The feminised nature of violence surrounding vaccines extends to sexual violence and exploitation of women who access vaccines. During the Ebola vaccination programme that began in 2018 in Kivu, Democratic Republic of the Congo (DRC), some male health-care workers offered the Ebola-related services, including vaccination, in exchange for sexual favours from women and girls.12Holt K Ratcliffe R Ebola vaccine offered in exchange for sex, Congo taskforce meeting told.The Guardian. Feb 12, 2019; http://www.theguardian.com/global-development/2019/feb/12/ebola-vaccine-offered-in-exchange-for-sex-say-women-in-congo-drcDate accessed: December 18, 2020Google Scholar This contributed to a wider picture of sexual exploitation and violence within the DRC that mired the response to the outbreak of Ebola virus disease in 2018–20, including reports of alleged sexual abuse by aid workers13The GuardianMore than 50 women in DRC allege abuse by Ebola aid workers.The Guardian. Sept 29, 2020; http://www.theguardian.com/world/2020/sep/29/women-in-drc-say-aid-workers-sexually-abused-them-during-ebola-crisisDate accessed: December 18, 2020Google Scholar and wider mistrust towards the global health and vaccine community.14Vinck P Pham PN Bindu KK Bedford J Nilles EJ Institutional trust and misinformation in the response to the 2018–19 Ebola outbreak in North Kivu, DR Congo: a population-based survey.Lancet Infect Dis. 2019; 19: 529-536Summary Full Text Full Text PDF PubMed Scopus (340) Google Scholar Although the DRC may be an extreme example as a state with a history of sexual violence and protracted conflict,15Autesserre S The trouble with the Congo: local violence and the failure of international peacebuilding. Cambridge University Press, Cambridge2010Crossref Google Scholar it showcases how gender-based violence is an important factor in responding to pandemics and in access to vaccines. Debate over COVID-19 vaccines has rightfully focused on discovery and development, vaccine hesitancy, and equitable access. Vaccine delivery depends on the paid and unpaid labour of women around the world in ways that can threaten their economic and physical security. Vaccines are thus both an important component of the gendered nature of pandemics such as COVID-19 and of the relation between gender and global health security. We declare no competing interests. Considering gender-based violence in vaccine prioritisation strategiesWe are delighted to see Sophie Harman and colleagues1 advocating the clinical and logistical considerations for the equitable and safe development, delivery, and administration of the COVID-19 vaccine to women. Additionally, there exists an area of gendered vaccine inequality, concerningly neglected to date, relating to the prioritisation of vaccines for survivors of gender-based violence (GBV). Full-Text PDF