Thursday 23 September 2021

Cold chain process holds back WHO’s call for equitable global access to Covid-19 vaccines in Africa

While older vaccine candidates imposed strenuous cold chain processes there is hope that new candidates will ease the burden of logistical requirements.

By uMbuso weNkosi

Complex Cold chain processes can stand in the way of distributing Covid-19 vaccines to 67.25% of the South African (SA) citizens targeted by the government. This could result in the SA government continuing with economically costly non-pharmaceutical measures to contain Covid-19.

The SA government planned to roll out vaccines in three phases. In Phase one government planned to vaccinate 1.25 million frontline health workers primarily reached through facility-based delivery programmes. Phase two targeted 16 million essential workers, older people, prisoners, homes care workers, and anyone above the age of 18 years with co-morbidities. In the final phase, about 22.5 million adults over the age of 18 years would be vaccinated.

Many developing countries, including SA, managed to secure some of their vaccines through the Covid-19 Vaccines Global Access (COVAX). COVAX coordinates the process of ensuring equitable access to vaccines and is led by the Global Alliance for Vaccines and Immunisation (GAVI), the World Health Organisation (WHO), and the Coalition for Epidemic Preparedness Innovations (CEPI). But given the high demand for immunisation and other logistical challenges, some experts are expecting that developing countries will receive their vaccines from mid-2022, SA being one of them. But many African countries are expected to receive vaccines by 2023 (see diagram 1).

The Director-General of the World Health Organisation (WHO), Dr. Tedros Ghebreyesus has emphasised the importance of equitable access to vaccines. “We now face the real danger that even as vaccines bring hope to some, they become another brick in the wall of inequality between the world’s haves and have-nots,” said Dr. Ghebreyesus. With some developing countries expected to receive vaccines as late as 2023, it seems that the threat that Dr. Ghebreyesus foresaw is now becoming a reality.

The SA rollout plan hit the wall when SA scientists discovered that the Oxford/AstraZeneca COVID-19 vaccine from the Serum Institute of India could not be rolled out since it had 22% efficacy in preventing mild and moderate symptoms of the 501Y.V2 variant. The 1 million doses of vaccines arrived on the 1st of February 2021. SA scientists and the Minister of Health, Dr. Zweli Mkhize, had to move mountains to deal with this disaster and they did this by acquiring 80 000 Johnson & Johnson (J&J) vaccines on the 16th of February 2021. On the 17th of February, it was reported that already 2 260 healthcare workers had been vaccinated along with the President and the Minister of Health. By late February, SA had received the second batch of 80 000 J&J vaccines.

The SA Department of Health said it is ahead of its rollout target despite criticism that it is slow. Opposition political parties are saying that the government has no clear acquisition and rollout strategy, the stakeholders to be involved, and the infrastructural capacity needed in the rollout. Media also weighed in and reported that there are long queues in hospitals assigned to roll out the vaccine with the Steve Biko Hospital reported to be turning private doctors away.

The SA rollout experience has illustrated how unexpected changes such as virus mutations can impose further logistical challenges that can stand in the way of acquisition and distribution plans.

Transportation, storage, and administration of vaccines, barring unexpected complexities brought about by virus mutations, is a complex activity that requires advanced logistical capabilities and abilities.

In a joint media briefing on February 3, 2021, CEPI, WHO, and GAVI indicated that approved vaccines would arrive from the airport coming from the COVAX storage site to the various countries, to the storage units in those countries, and then transported to clinics, doctor sites, and hospitals.

All this needs to be controlled in a cold chain process (a temperature-controlled supply chain). The cold chain is a crucial aspect in the storage of the vaccines. If the prescribed storage temperature is not maintained the vaccine can become unsafe, leading to potential health risks and zero immunity.

Demand for thermal containers and dry ice has since increased as various organisations in the vaccine cold chain process are preparing for shipping and storing the vaccines. However, concerns have arisen over dry ice particularly in the airline industry. Dry ice may turn into a gas that is harmful to human beings.

This would limit the shipping of vaccines to distant areas considering the health risks it poses for airline crew. However, some vaccines are ideal for shipping over long distances because the prescribed temperature to store them does not require high-spec equipment.

These might ease the logistical challenges in the cold chain process thus increasing the probability of global equitable distribution of vaccines in the near term.

Pfizer/ BioNTech’s vaccine needs to be stored at ultralow temperatures of – 80°C and – 60°C degrees and cannot be out of this freezing storage more than four times. This means that Pfizer needs to be shipped in specifically designed thermal containers (allowing for 15 days). However, the company has indicated that it can be stored in dry ice to allow for storage in rural areas where there are challenges of deep freeze storage.

Moderna vaccine is stored at -25°C to -15°C. It cannot be stored in dry ice or below – 40°C. However, this vaccine can be refrigerated between 2°C to 8°C for up to 30 days before its first use.

AstraZeneca vaccine which failed the efficacy test in South Africa can be stored at temperatures of 2°C – 8°C degrees. It was once a viable option for African countries both from a logistical perspective and price consideration before it was discovered that it is inefficient against the SA Covid-19 variant. The manufacturer was intending to make it available at $3 - $4 each compared to the $10 - $50 price tag for Moderna and Pfizer vaccines.

The Chinese Sinovac or Russian Sputnik V vaccines can also be stored at fridge temperatures of 2°C - 8°C however, unlike other candidates they remain stable for three years. Their longevity makes them more attractive.

The J&J vaccine recently approved by USA FDA can also be stored within the 2°C to 8°C fridge temperature storage. The data shows that it is mostly developed countries that use Pfizer vaccines, including Europe, the United States, United Kingdom, Canada, Singapore, and some Middle Eastern countries like Israel, Saudi Arabia, and the United Arab Emirates.

COVAX has not distributed the Pfizer-BioNTech vaccine to developing countries because of infrastructure issues. Hot weather conditions in some of the developing countries in South America, Asia, and Africa make them unideal places for Pfizer-BioNTech vaccine except when they have the well-established infrastructure for their cold chain storage. Distance and time of travel also play a major role in the vaccination as this means shorter traveling time and less spoilage.

South Africa is amongst the few developing countries to receive 20 million vaccine doses from Pfizer. The vaccines are scheduled to arrive at the end of the first quarter (by April 2021). With modern road infrastructure, vaccines can arrive safely at their destinations.

But the tenacious labour disputes in the trucking industry which has seen violent strikes resulting in trucks being torched could stand in the way. Also, erratic electricity supply - with the state-owned electricity provider ESKOM in a crisis- and stifling heat in some areas can make it hard to maintain the prescribed temperatures that keep vaccines stable.

The precarious SA’s health care sector is also another concern. Eastern Cape Province public health service, said to be on the verge of a collapse, could become a hurdle to overcome in distributing vaccines.

The countries that used Pfizer were able to inoculate many citizens because they put more resources into rolling out their plans. In the case of Israel for example (a state with a 9.3 million total population) its four major health insurance funds are incentivised by the government.

For South Africa to distribute the vaccines equitably there is a need for a concrete rollout plan that shows the dates of set vaccination targets for the different phases, the different stakeholders to be involved (private and public), and logistical designs.

Failure to do so will mean that the target of 67.25% might not be reached and another AstraZeneca blunder may happen. That is why supply chain details need to be released to show the cold chain storage capacity, storage scheduling, sites of delivery, and targeted inoculation dates. Failure to do so will mean there is no equitable access to vaccines in the country.

uMbuso weNkosi is a postdoctoral research fellow at the Johannesburg Institute for Advanced Study (JIAS). The views expressed in this article are those of the author not to be attributed to JIAS or Business Unusual.


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