COVID-19 Vaccine Supply Reality Check – Now What?

A bit more than a year ago, as the world was responding to the COVID-19 pandemic and pharmaceutical companies were jumping in to develop a new vaccine, we were musing about the challenges that introducing a new vaccine would bring to the world, and particularly to low- and middle-income countries (LMICs). 

Now, more than a year later, there are 20 approved vaccines for COVID-19; 65% of Americans over 12 years old have received at least one dose; and more than 100 million doses of these vaccines have been distributed to LMICs through the COVAX Facility. The world has made amazing progress in its pandemic response, despite the many bumps in the road.

Many of the concerns that we highlighted last year manifested and we have seen other areas for concern—as well as celebration—with the first shipments and administration of these new vaccines to LMICs. Globally, we are in a unique position: an abundance of vaccines are expected to become available in the next few months to LMICs. 

The COVAX Facility alone is expecting to distribute 19 billion doses by the end of 2021; 19 times more than what was distributed in the first six months of the year. And this does not include the vaccines procured through bilateral deals. Certainly a daunting task, but we can build on what we have learned in these first months of introducing and administering these vaccines around the world to avoid hiccups.

Initial limited supply will shift dramatically in the coming months 

As expected, initial availability of these vaccines has been limited, and the majority of those available have gone to high-income countries. Even with the efforts to introduce an equitable approach by setting up the COVAX facility and with the multiple manufacturers and vaccines, it is a fair to say that LMICs still have less access and fewer vaccine options than high-income countries. However, with available vaccines and close planning, the majority of health care workers and initial high-risk populations around the world have been vaccinated—a success given the short time frame of this process.

The supply of multiple vaccines from multiple manufacturers is expected to expand exponentially in the next months, with millions of doses being delivered to LMICs by the end of the year. This will present its own challenges to managing the supply of multiple vaccine brands, tracking different temperature requirements and administrative processes, monitoring coverage, and reaching intended audiences.

Unique supply chain requirements will become more complicated

In terms of supply chain requirements, the first round of vaccines that have been delivered to LMICs have been somewhat easily absorbed into existing immunization supply chains. The first available vaccines required the 2-8 degree Celsius range, which made it possible to leverage existing cold chain equipment and supply chain practices. The quantities were small (compared to the full set of vaccines immunization programs typically manage in a year), and generally speaking, all countries had sufficient cold chain capacity, particularly as initial campaign sessions for health workers and high-risk populations were located in larger areas.

The next phase of vaccine distribution will bring a different set of challenges: vaccine quantities are greatly increasing and some vaccines being donated will require more extreme cold chain conditions (even if just for initial delivery). 

The COVID-19 vaccine rollout is an opportunity, however, to strengthen the overall health system and management processes. For example, it could be an opportunity to explore options of leasing existing cold chain equipment for the initial surge of vaccines instead of purchasing new equipment, so as to avoid the long-term requirements of managing more equipment, which has proven challenging. This is also an opportunity to establish clear protocols for health workers who may have to manage multiple vaccines with different cold chain requirements and administrative methods. 

Supply chain systems can be agile and more efficient

As the vaccine has been introduced, immunization supply chain managers have had to adjust and adapt. Changing contexts, different target populations, unknown delivery dates of vaccine shipments, short expiration dates, and unknown quantities being received must all be considered. The circumstances required reactive rather than proactive planning and management. 

While LMICs succeeded in distributing and administering millions of doses of vaccines so far, there have been numerous inefficiencies: vaccines were re-distributed to other countries due to overstock and insufficient time and resources to administer all of them; doses had to be destroyed when they expired or were exposed to heat; and low demand, often due to hesitancy and rumors, resulted in overstock and wasted vaccines.

We have also seen the diversion of attention and resources from routine supply chain management to meet the more immediate and high-profile need for COVID-19 vaccine distribution. These inefficiencies show up in distribution trucks that are only 20% full, and stockouts of essential medicines and products that are still required for a functioning health system.

One of the clear lessons is the urgent need for global supply chain planning to coordinate shipments based on country-level cold chain capacity, while ensuring demand-side considerations. This goes with strengthening the overall system and integrating the COVID-19 vaccine into the regular system to move away from the high level of effort required of a campaign. 

Rapid adaptation of communication strategies is key

As with any new vaccine, health workers and members of the public are bound to have questions about safety and efficacy, as well as if, how, and when they can access it. 

Confidence in the COVID-19 vaccine has varied across countries and the variety of vaccines complicates people’s understanding of the vaccination program and the ability of health workers to communicate with confidence about the vaccines. The COVID-19 variants are also casting doubt on the efficacy of the vaccines, and shifting campaign strategies and target populations make it difficult to keep track of eligibility and availability. Furthermore, in countries where vaccine supply is inconsistent, trust in the immunization program wavers and the reliability of the health system comes into question. There is also concern that doubts about the COVID-19 vaccine will spill into routine immunization, aggravating services that have already experienced a slow-down in the past year. 

To build confidence in the COVID-19 vaccines, communications strategies and messages should be continuously updated in response to community concerns. Countries can engage in social listening to determine how communities feel about the vaccine and what questions need to be answered, and use this information to adjust communication strategies and identify actions to prevent the spread of misinformation. Key to dispelling misinformation and encouraging behavior change is giving health workers clear, consistent, and concise information about the different vaccines—and their associated safety, efficacy, and schedules—and the interpersonal communication skills to talk with community members about them. 

As LMICs prepare for a significant increase in the vaccine supply, there is an opportunity to learn from experience and prioritize funding for communication strategies and approaches to strengthen demand for the vaccine. 

Resources: you can’t serve tea without a cup

One of the biggest breakdowns that we have seen is the lack of operational funds for the vaccine introduction. LMICs have received hundreds of thousands of doses without the financial support to distribute them to health facilities or to support outreaches and communication campaigns to dispel rumors and create demand. 

Many countries have been unable to identify where key populations are and how to reach them with either the first or second dose. Nor have health workers been trained on how to administer all the vaccines, communicate their safety, efficacy, and side effects, or provide updated key messages in a timely manner. Furthermore, funds have been diverted from other health services, including routine immunization, which weakens the overall health system. 

Final thoughts

We have made amazing and important advances in responding to the COVID-19 pandemic, but LMICs are still at a disadvantage. We can and must do better, and now is the time to build on what we have learned and shift our approach and priorities to ensure all people everywhere have access to these new vaccines.

Written by: Kate Bagshaw and Wendy Prosser