From airport to arm: we’re in for a multiyear rollout, and it’s not simple

“We need to settle in for a multiyear marathon of vaccine rollout, not a sprint.”

This was the sobering statement this week from Dr Tim Mastro, a chief scientist from global humanitarian organisation fhi360, during an international webinar about Covid-19 vaccinations.

According to Dr Ernest Darkoh, co-founder of the Broadreach Group – a global health innovation company that hosted the event – “when the vaccines arrive in pallets at the airport, your problems have only just begun”.

There are so many nuts and bolts that need to be in place, he said, applying what he called “the Monday morning test”.

“When people arrive on a Monday for vaccines, what already has to have been accomplished before that can happen?” he asked. The answer is “a lot”.

Darkoh said: “We are obsessed with figuring out what makes programmes tick on the ground, and this pandemic presents unprecedented challenges for the global health community.” 

SA’s goal of 40 million vaccinations would have to look like this to hit the target: over 12 months, you’d get 220 working days. Assuming there are eight hours a day, “you’re looking at vaccinating 182,000 every single day”, or 22,750 per hour.

“This would require a highly efficient engine, and a lot of things would have to go right – assuming also there is no new variant which would complicate it even further. Microplanning is crucial,” he said, adding past vaccine rollouts had shown major challenges.

First, there is the issue of storage. “In the past we have seen the size of the fridges is too small for the number of vaccines. But they have to be held somewhere, and this creates huge mismatches in the ability to vaccinate people who’ve lined up.”

Second, many vaccines have preparation requirements. “If a vaccine has to be thawed for two hours before it is administered, that has to be taken into account.

We need a control-tower approach. It needs to be rational, controlled and evidence-based. And I mean that on the global level as well as the smallest town at grassroots level.

“If you want to start vaccinating at 7am, for example, you’d have to have someone there at 5am. Unless it’s a 24-hour clinic (which is highly rare) you’d more likely only have someone there from 7am to thaw and then you only start vaccinating at 9am and you won’t hit your targets.

“These are the basic things that have to be figured out. There is also a system required for the disposal of syringes, plus the recording of information. Then also you need a 15-minute observation protocol to keep an eye on those who have just been vaccinated, but where do they wait?”

Well-meaning policy can also cause hindrances: if you limit who can administer a vaccine, it decreases the number. 

“For example, if you say only doctors can vaccinate, you might not have enough personnel. Or maybe staff do extra hours to meet targets – those people need extra pay, and you run into labour issues and maybe even strikes,” he said.

There is also the issue of personal data, which people are reluctant to provide.

“We need a control-tower approach. It needs to be rational, controlled and evidence-based. And I mean that on the global level as well as the smallest town at grassroots level.”

Mastro said equitable access to jabs should be paramount, but so far, “health disparities have been accentuated by the Covid-19 pandemic, as there has been an increased burden of both morbidity and mortality among those who started off already disadvantaged, and the strains will be felt for years to come”.

He said the global response to HIV was so inequitable that it amounted to a “catastrophic moral failure” and the world should guard against a repeat performance.

Also in the mix is hesitancy, which he said posed “a substantial issue”.

According to Dr Phionah Atuhebwe, vaccination expert at the WHO, “culture and religious backgrounds play a large role in hesitancy, and also, if the population does not trust the government in place, it will be hesitant – so in that case it’s not about the vaccine but the government delivering it. We are in for trouble in that case.”

Dr Anban Pillay, deputy director-general of the health department, said the government had developed a framework for rollout at national level, but that a “key challenge” was “being able to communicate information to everyone on the ground”.

He added: “Information across the sector is a problem, and many people still have questions about the rollout and how it needs to be effectively managed”.

On the upside, a data system has been developed that can “monitor supply and uptake and the reporting of any adverse events”.

With the three-phased approach, it will culminate in a “mass vaccination programme – and to that end, the electronic data system will be crucial”.

This, Pillay hopes, will ensure people arrive at an allocated time, that the quantity of stock is always right, that there is a full record of who has been vaccinated and that informed consent is properly managed.