Op-ed: Don’t repeat the mistakes of past vaccine distribution efforts

In an op-ed for STAT News, Professor Bruce Y. Lee lays out 10 lessons from past vaccine distribution efforts that can be applied to the distribution of a COVID-19 vaccine. 

Don’t repeat the mistakes of past vaccine distribution efforts

By Bruce Y. Lee

December 15, 2020

When it comes to planning how Covid-19 vaccines will be delivered to the people who need them, I hope hindsight will be used to learn from the past and the U.S. and other countries won’t repeat the many problems with vaccine supply chains encountered in the past.

The Public Health Informatics, Computational, Operations Research (PHICOR) team I lead has worked on vaccine delivery and vaccine supply chains around the world for nearly 15 years. A vaccine supply chain is the complex system of manufacturing transportation, equipment, personnel, locations, and processes involved in getting vaccines from where they are made to the people who will receive them.

It’s called a cold chain when vaccines must stay refrigerated or frozen throughout the delivery process. After all, most vaccines consist of perishable materials that don’t last long at room temperature. In fact, with the possibility of new mRNA Covid-19 vaccines that require storage under -80 degrees F or even colder, a “deep freeze” chain may be necessary

The past decade has seen an unprecedented number of new vaccines being introduced to different countries around the world, so many that it was dubbed the Decade of Vaccines. Throughout this decade, my team has used computer simulation modeling to help evaluate, improve, and in many cases redesign vaccine supply chains for UNICEF, the World Health Organization, Gavi, the Bill and Melinda Gates Foundation, ministries of health of various countries, and a number of different nongovernmental organizations.

In the U.S. we have also helped local, state, and federal governments respond to infectious disease threats. During the 2009 H1N1 influenza pandemic, for example, the PHICOR team was embedded in the Department of Health and Human Services, assisting with the national response, using computer modeling to help plan the rollout of the new H1N1 flu vaccines.

From this vantage point, I offer 10 lessons that should have been learned from the past that need to be considered in 2020:

Vaccine supply chains are complex, and can make or break Covid-19 vaccination efforts
I’m surprised — though perhaps I shouldn’t be — at the relative lack of attention being given to the vaccine supply chain. Much of the talk has focused on the development and testing of the new Covid-19 coronavirus vaccines and, to varying degrees, how they will be financed. Talk about how they will be delivered has been comparatively limited and vague.

Few people across the country have a clear idea of how exactly the Covid-19 vaccine supply chains will be organized.

Vaccine supply chains have historically been neglected and underappreciated.

A major part of my team’s work since 2007 has been trying to get more people to pay attention to these chains, since vaccines can’t really do their thing without actually being delivered to people. Getting decision-makers’ attention hasn’t been straightforward. The assumption on their part is often that, once vaccines reach the market and are paid for, vaccine delivery is the easy part and they can somehow magically appear in people’s arms and mouths. Perhaps the dearth of toilet paper on store shelves this spring should be a lesson in the challenges of supply chains.

Since the design and operations of vaccine supply chains are complex — too complex for most people to understand and address without assistance — we have developed and used computer simulation models of vaccine supply chains to help a wide range of decision makers in the same way that meteorological, air traffic control, and manufacturing models have helped decision making in those fields.

Don’t assume that current vaccine supply chains are sufficient to deliver Covid-19 vaccines
Before the Decade of Vaccines, we learned that vaccine supply chains in many countries were not ready for new vaccines such as the rotavirus, pneumococcal, and meningococcal vaccines. In fact, many weren’t even ready to handle the vaccines that they already had.

Their supply chains had inadequate storage, transportation, and personnel capacity, leading to major bottlenecks and the discarding of many vaccine doses because they never made it to their destinations. This led to missed opportunities to avert suffering and deaths, as well as substantial monetary costs.

During the 2009 H1N1 flu pandemic, the U.S. federal plan was to use hubs designed by the McKesson Corporation, a pharmaceutical distribution company, to deliver vaccines to each of the states. In many cases, the states then used the supply chains they already had in place to deliver the seasonal flu vaccine. This led to some vaccination locations receiving too many vaccines and others getting too few.

Routine vaccine delivery is one thing. Getting massive amounts of the population vaccinated as quickly as possible is completely different. Current vaccine supply chains aren’t designed to vaccinate so many people so quickly. Add in the problem that most existing supply chains don’t currently have the capability of storing and transporting vaccines at -90 degrees F and it becomes immediately apparent that current supply chains aren’t adequate for Covid-19 vaccines.

Factor in Covid-19 vaccine wastage when planning vaccine production, delivery, and administration
There are two types of vaccine wastage: closed-vial and open-vial.

Closed-vial wastage occurs when vaccines must be discarded without even being opened. This happens when containers are broken, or when the vaccine becomes unusable because it has been exposed to temperatures that are too cold or too warm.

Open-vial wastage occurs when a vaccine container that holds multiple doses of a vaccine (such as a 10-dose vial) is opened but only some of these doses are used. Depending on the type of vaccine (freeze-dried, liquid, and the like), the remaining doses may need to be properly stored and used within a few weeks, or they may need to be immediately discarded to prevent contamination.

The greater the vaccine wastage, the greater the costs and the more vaccines that need to be delivered through the vaccine supply chain. In this way, wastage rates can greatly affect vaccine supply chain design and operations.