The COVID-19 virus has changed life on a massive scale – disrupting economies, communities, families and individuals. Social distancing and self-isolation have been the first weapons deployed from our armoury as Governments around the world have attempted to delay the virus’ spread. A vaccine now appears close but are we prepared to make use of it properly?
There are currently 248 COVID-19 vaccine candidates in development1, with 49 now being tested on humans in clinical trials around the world. Yet, despite rapid progress in developing vaccines, we face an immense challenge of moving the vaccine to every community and remote village, especially in Low and Middle-Income Countries (LMIC).
According to studies, equitable distribution of the COVID-19 vaccine globally would prevent 61% of subsequent deaths, but were it to be distributed to high-income countries first we would avoid only 33% of those deaths.
Whether a once-only shot or a seasonal ‘booster’, any COVID-19 vaccine will need to reach every corner of the world in a globally networked delivery mechanism. It may be the only way to stop the virus, get civilization back on its feet and kick-start the global economy.
There is, however, a major issue with vaccine distribution – particularly in LMICs. Vaccines must be handled within specified temperature ranges and the protocols to follow for some COVID-19 antidotes may be similar to those for the Influenza vaccine, which must be kept between 2°C and 8°C, while in transport and storage. Some vaccines, such as the Pfizer/BioNTech solution, need to be kept at -80°C, a similar temperature to that of dry ice. This presents a major, new logistical challenge for high-income countries, let alone in LMICs.
Toby Peters, Professor of Cold Economy at the University of Birmingham, is clear on the scale of the challenge facing the agencies charged with delivering a vaccine to the most remote parts of our planet.
“Efforts to find a lasting solution to the COVID-19 pandemic have focused on developing, testing and manufacturing at scale an effective vaccine, but little attention has been given to what is needed to distribute it rapidly at scale.
“In order to protect both efficacy and safety, most vaccines must be maintained at a specific temperature. Storing and transporting a vaccine at -80°C poses a major logistical problem – nowhere on the planet does the logistical capacity exist to distribute vaccines at this temperature and volume without massive investment.
“The problem is particularly acute in the Global South where many rural villages don’t even have a working vaccine fridge. We must take this once-in-a lifetime opportunity to create sustainable solutions for COVID-19 vaccine deployment that also can deliver resilient and sustainable health cold-chain systems, including ultra-low temperature.”
Inoculating all eight billion people on the planet poses an extraordinary challenge – particularly in LMICs where the current cold-chain network is not capable of handling current infant immunisation demand, let alone extraordinarily large quantities of the COVID-19 vaccine – because of insufficient capacity, inefficient and unreliable cooling equipment, poor access to energy, lack of relevant skills, or poor commercial business models.
The Global Alliance for Vaccines and Immunization (GAVI) estimates that only 10% of health care facilities in the world’s poorest countries have a reliable electricity supply while in some countries less than 5% of health centres have vaccine-qualified refrigerators.
The World Health Organisation (WHO) estimates that, as a result of broken cold-chain, there are more than 1.5 million deaths globally from vaccine-preventable diseases every year - 30% of which are among children under five. WHO estimates more than 25% of some vaccines may be wasted globally every year because of temperature control and logistics failure.
Even in countries with robust vaccine programmes, there is not enough capacity to manage the required volume. India has the world’s largest vaccine programme and distributes 400 million vaccines a year to immunise 56 million people. The country’s Health Ministry plans to initially immunise up to 250 million people against COVID-19 within six months once the vaccine is available - some 500 million doses, should two shots be required. This means the amount of COVID-19 vaccines to be delivered in six months would be equal to the amount of vaccinations currently given annually. In order to achieve herd immunity, the numbers increase to some 2 billion vaccines – a five times increase.
And existing vaccine campaigns must be simultaneously maintained. UNICEF and WHO estimate that up to 80 million children are at risk of missing out on vaccinations against vaccine-preventable diseases due to the pandemic.
“Universal vaccine access is already a major challenge. With COVID-19, rapid mass immunisation will probably be required; maintaining a continuous cold chain to rapidly transport and deliver COVID-19 vaccines to all communities, many where electricity supply and cooling infrastructure is often non-existent or unreliable, will be a daunting task,” notes Professor Peters.
“Given most of the technologies deployed today will still be in operation in the next decade, the emergence of sustainable and off-grid cold-chain devices allows us the opportunity to create sustainable solutions for COVID-19 vaccine deployment that also can deliver resilient and sustainable health cold-chain systems as a lasting legacy.”
Working with colleagues at Heriot-Watt University, Edinburgh, Professor Peters is leading a number of international research partnerships that have been analysing just how prepared the global community is to roll out a COVID-19 vaccine. Programmes in Bangladesh, India and Rwanda have analysed the state of readiness to distribute a potentially temperature-sensitive vaccine, whilst creating a sustainable blueprint for distribution.
Supported by UK Research and Innovation (UKRI), the researchers are leading a programme to assess the capacity and preparedness of Bangladesh’s cold-chain framework - creating a roadmap and model for global COVID-19 vaccination.
Bangladesh has one of the world's largest pharmaceutical and vaccine industries, with a vaccination framework supported by GAVI and WHO, but still lacks capacity to deliver unprecedented, fast-track mass vaccination.
The project unites British academics with counterparts in Bangladesh at BRAC University and Bangladesh University of Engineering and Technology (BUET) to design novel methods and instruments to assess the country’s current cold-chain capacity – aligning renewable energy and energy efficiency solutions with mass vaccination of COVID-19 and future calamities.
“Bangladesh faces the difficult challenge of protecting its people and sustaining the economy. Rapid and efficient mass vaccination is the only way forward, making our work critical – not just for Bangladesh, but many other countries across the Global South,” notes Professor Peters.
“Sustainable cold-chain development will support Bangladesh’s economy and help to support existing immunisation and cold-chain programmes as well as a COVID-19 vaccine. More importantly, this work will help create a blueprint and model for an efficient delivery mechanism to ensure that the vaccine will be provided globally.”
Backed by the Shakti Sustainable Energy Foundation, Birmingham and Heriot-Watt researchers are joining forces with India's Centre for Environment Education (CEE), non-profit, commercial and academic partners in India.
‘Clean cold’ experts from the two British universities are already working with CEE and MP Ensystems to explore how integrated ‘Community Cooling Hubs’ can integrate food cold chains with other cold-dependent services such as community health facilities, social facilities and even emergency services.
“We have a matter of months to engineer a robust, efficient distribution system to ensure any vaccine for COVID-19 can reach the world’s population, whether they are in urban or remote rural areas. A radical approach like community cooling hubs could help meet the different communities’ cooling needs in a clean, affordable and sustainable way while helping to safeguard people’s health,” comments Professor Peters.
Alongside work in India, the researchers are working with the United Nations Environment Program - United for Efficiency team to carry out a fast-track study in Rwanda to explore how the cold-chain is currently used to distribute vaccines in the country.
The Rwanda study will define gaps in infrastructure and develop strategies for sustainable COVID-19 vaccine delivery – its findings will help governments, vaccine development agencies, pharma and logistics companies to plan for the future. The research programme leverages the award-winning Rwanda Cooling Initiative that is accelerating the country’s transition toward more efficient and climate-friendly cooling solutions.
Distribution problems are compounded in LMICs with a large proportion of the population living in rural, remote areas - 65 per cent in India, 83 per cent in Rwanda, 63 per cent in Bangladesh. Much of the immunisation services are provided via outreach and geographical barriers, poor infrastructure already places burdens on health care workers and reduces the ability to deliver frequent immunization sessions. The key challenge is likely to be the ‘last mile’ of distribution and ensuring that each vaccination site is equipped with adequate fixed and outreach cooling equipment. Immunisation success will critically depend on delivering quality vaccines to every community, village and settlement.
“Sub-Saharan Africa faces a daunting challenge, particularly in rural areas where electricity supply and cooling infrastructure is often non-existent or unreliable. Taking Rwanda as a pilot, the majority of its population lives in rural areas and has one of the lowest Gross National Incomes. We’re creating a rapid assessment method to enable such countries to understand available cooling infrastructure and create options for COVID-19 vaccine distribution and beyond,” explains Professor Peters.
Nations around the globe may have little time but must ready themselves for the vaccines and plan an extensive, effective and sustainable delivery mechanism. COVID-19 vaccination will require a new fast-track approach to assess, re-engineer and build cold-chain logistics assets.
Alongside the vaccines themselves a wide range of support materials will be distributed, including disposable syringes and Personal Protective Equipment (PPE) - demanding more volume in transport and storage. Planners need to put in place carefully considered waste management plans for these materials, particularly items that are contaminated or require sterilisation, if health risks and extensive ecological damage are to be avoided along the distribution chain.
“Although the COVID-19 pandemic is a major human tragedy rooted in a crisis of health, economy and social justice, emerging demand for re-engineering existing vaccine cold chains and adding new capacity to create a more sustainable low-carbon distribution infrastructure cannot be ignored; an opportunity to create a global legacy.
“However, we must ask ourselves a key question: how do you kick-start a global economy without vaccinating the world? We can’t ‘build back better’ if lack of access to vaccination has condemned some countries to isolation because they remain COVID-19 hubs.
“Our vaccine logistics projects in Bangladesh, Rwanda and India will help policy makers to enable medical supply chain interventions at regional and national scale for COVID-19 but also other potential future natural disasters and epidemics. A vaccine is the next weapon in our arsenal – we must prepare to use it properly and effectively to protect everyone on Planet Earth.”
Notes
- COVID-19 vaccine development pipeline. https://vac-lshtm.shinyapps.io/ncov_vaccine_landscape/. [Accessed on 25/10/2020].
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