Tag Archives: logistics

The Coldest Cold Chain: Chilling Effects of Covid-19 Vaccines

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This post first appeared on the International Health Policies (IHP) blog, and is re-posted here. You may access the original post by clicking this link.

Woman receiving an influenza vaccination at the Maternal and Child Hospital in Vientiane, Laos. Photo: CDC via Unsplash

After various stretches of lockdowns and the related dire political, social, and economic consequences, the world has welcomed the news that several companies – including ModernaAstraZeneca and Pfizer – are approaching an effective vaccine for Covid-19. Approximately 200 more are in the pipeline, of which 48 in clinical and 164 in pre-clinical stages of development. While there is thus hope on the horizon, for low and lower-middle income countries the roll-out of the vaccine will be enormously expensive, whatever option is eventually selected. As such, the life-saving vaccine may bring ramifications for future prioritization within domestic health budgets as well as allocations in foreign aid budgets.

In terms of ethics considerations, much of the debate so far has either focused on (1) criticizing high-income countries scrambling to secure vaccines for their citizens for lacking in solidarity and for inadequate support of equitable distribution schemes (COVAX) – or (2) on prioritization of population groups (see herehere and here). Contributing to the emergent analysis of the ethics of Covid-19 vaccination schemes while things are still ‘up in the air’ – the coordinated ‘mammoth operation’ led by UNICEF is in the midst of a vaccine tender process (running 6 weeks from November 12) – in this commentary, we suggest that attention must also be paid to the complex ethics challenges arising from the logistical challenges of distributing specific vaccines.

Taking the Pfizer vaccine, with a storage requirement of -70˚C (-94 F) or below, as our case example, we identify a preliminary list of challenges relating to the feasibility and societal impact of a successful roll-out of an ultra-cold chain dependent vaccine. The cost and the probability of logistics failure is extremely high – and even if a program can be successfully implemented, serious ethical issues with chilling effects on global health outcomes will likely arise. We also suggest that laying out some of the issues related to the Pfizer vaccine, if it were to be rolled out globally, can shed some light on medium and long-term ethics challenges for other vaccines as well, even if some probably present fewer challenges in this regard.

Feasibility

With respect to feasibility, ultra-cold chains require special cooling systems in facilities and during transportation. The tradeoffs involved in successful implementation must be carefully considered. Technical challenges greatly increasing risk include time constraints, freezing units, package sizes, and kitting:

  • The vaccine puts significant constraints on time: The proposed active plus passive cooling in containers will enable keeping vaccines in the required temperature range for 72 hours, after which the combination of power cells (active cooling) and dry ice (passive cooling) deteriorates. Such a short delivery time calls for air transportation; yet carrying dry ice on airplanes, especially passenger planes, is regulated as it consumes oxygen. The same solution has been used for ultra-cold chains before (e.g., STRIVE Ebola vaccine), but the scale of any Covid-19 vaccination programme will be constrained by the global availability of such containers, and the regulations constraining their use.
  • The unaffordability of freezing units is a possible spoiler: The estimated time that vaccines will stay usable after opening a package is 24 hours only. At facilities, including storage, customs, cross-docking, materials handling, and vaccination centers, freezing units will be required to store and appropriately handle the vaccines. In a bidding war, rural, small, and underfunded hospitals will lose out.
  • Proposed package sizes are for 5,000 vs 1,000 units. While optimal for transportation, these sizes do not consider usage patterns: the administration of 1,000 vaccines within 24 hours requires huge distribution facilities and massive manpower. Throwing away unused vaccines comes at an exuberant cost. Locations with lower population density may not be able to use such package sizes and de facto be excluded from the distribution of vaccines.
  • Vaccination programs have a host of material needs: syringes, gloves, PPE, tents for locations etc. Kitting will be of the essence; yet the other parts of these health kits will differ in their temperature control requirements. Inter-agency health kits have in the past been developed for vaccination programmes as well as emergencies, and include from cholera kits to entire field hospitals as a kit. They are composed in a way that regardless of the administering unit, any humanitarian organisation or health centre would know what to find in which box, and which items would need special processes (such as temperature control) in handling and storage. In the case of COVAX, UNICEF has started to procure and stock up on e.g. syringes and gloves, as to say, items that will for sure be needed to be able to administer vaccines.

Societal impact

In terms of societal impact, the following chilling effects of getting an effective vaccine program rolled out urgently need ethical consideration:

  • The Covid-19 response focuses on an increasingly narrow range of options for combatting the pandemic. We are now at a point where the solution – in the form of a vaccine (any of the vaccines) – is steering problem framing. However, even if cold chains can successfully be kept intact in hard-to-reach areas, and the vaccine can be distributed successfully, a vaccine program does not solve the structural problems in public health infrastructure that are greatly exacerbated by the pandemic. Food shortages, lack of access to clean water and basic hygiene, domestic violence and drop-outs will not be magically cured through a vaccine.
  • While the Covax Advanced Market Commitment (AMC) scheme will likely be a useful vehicle to secure health outcomes, it should be noted that GAVI explicitly mentions co-payments: “it is likely that the 92 ODA-eligible countries accessing vaccines through the AMC may also be required to share some of the costs of COVID-19 vaccines and delivery, up to US$ 1.60 – US$ 2 per dose – a mirror of the amount paid upfront by self-financing participants.” Taken together, the knock-on effects of the cost of vaccines and ultra-cold chains constrain future decisions about health budget allocations. Already overwhelmed health budgets in poorer regions will be additionally burdened by high-income countries demanding that vaccine coverage is prioritized to combat Covid-19 once and for all. In other words, the countries with the youngest populations and the highest child mortality will be asked to invest their health budgets to rescue the aging West.
  • Whichever vaccine or set of vaccines are procured for distribution through global mechanisms, this decision will likely determine pathways for foreign aid. For example, once effective ultra-cold chains have been financed and established, there is a likelihood that allocations for vaccines will tie up a significant portion of donor budgets for the short-to-medium time. We argue that the funding of vaccine initiatives –in particular the financing of the ACT-Accelerator through ODA budgets– needs to be subjected to careful ethics impact assessments.

In conclusion, while a vaccine requiring an ultra-cold chain may be the most daunting one logistically, all options come with their own requirements on temperature ranges, but also with differences in vaccine efficacy, and regimes to administer. Technically, if we can manage the Pfizer one, the other ones should follow. Regardless, the ethics of every single vaccine candidate, including its likely logistics pathways and distributive impact on public health, needs to be carefully mapped out.

WFP Logistics – Delivering on the promise (WFP Nobel Series, 6)

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The 2020 Nobel Peace Prize was awarded to the World Food Programme (WFP) for “its efforts to combat hunger, for its contribution to bettering conditions for peace in conflict-affected areas and for acting as a driving force in efforts to prevent the use of hunger as a weapon of war and conflict”. WFP is the world’s largest humanitarian organization, and food insecurity and food aid are much-discussed topics in humanitarian studies. In this blog series, we examine the implications of the award and critically engage in debates on food (in)security, food aid, innovation and technology and the WFP as a humanitarian actor. This is the sixth post in the series. Gyöngyi Kovács is Erkko Professor in Humanitarian Logistics at the HUMLOG Institute, Hanken School of Economics.

Mozambique, Goonda, 24 March 2019 WFP unloading food distributions. Photo: WFP/Marco Frattini

Congratulations to the World Food Programme for receiving the Nobel Peace Prize in 2020! Apart from the fundamental yet difficult relationship between hunger and peace, which has been problematised earlier, it is perhaps time to reflect just how WFP sees to it that food is being available, and/or delivered to people who need it.

For a long time already, WFP logistics has had the mantra of “moving the world”. Their logistics and supply chain team is massive, not only in terms of numbers of vehicles and warehouses, but also when it comes to where these are located. Logistically speaking, food is bulky. In other words, it requires volume, capacity, and the related equipment. Given the volumes WFP needs to be able to move anywhere in the world, it is less surprising that they’ve built up their logistics capabilities, and have therefore also become the lead of the Logistics Cluster.

The “Log Cluster”, as it is often referred to, has an important co-ordination role to play if and when large volumes need to be delivered, and many organisations are involved. This is the case in larger sudden-onset disasters, but also after consecutive droughts, when regions and countries have run out of food altogether. The Log Cluster has though also come a long way in co-ordinating other global efforts in logistics and supply chain management, harmonising templates, contributing to global preparedness, writing a logistics operational guide (the “LOG”) to assist other organisations in their logistical efforts, assessing the logistics capacities of various countries etc. The list of initiatives is endless.

But what’s the link between food supply chains and peace? Food has been used as a weapon of war, as discussed earlier in this series. Delivering food to people who have been deprived of it, and negotiating humanitarian convoys to get secure passage is an important aspect. It is so important that “negotiation skills with warlords” is frequently noted as an eligibility criterion on job ads for humanitarian logisticians (Kovács and Tatham, 2010). Furthermore, the way the supply chain is configured can reinstate interdependencies between conflicting parties. Creating, or reinstating interdependencies of traders and industries across conflict lines has been used as a peacebuilding mechanism already in the Balkans in the 1990s (Gibbs, 2009). In essence, the way (food) supply chains are designed can indeed contribute or undermine local capacities, but also contribute to conflicts or conversely, to peacebuilding.

Yet come to this, do we always need to move food, or any other in-kind goods for that matter? Food is a basic need, yes, but importing food can also undermine the local industry and economy. WFP engages in all sorts of innovation projects, from trying out new types of vehicles (amphibious vehicles, drones, trucks delivered by helicopters – some of which may be problematic in conflict zones to begin with, see “The good drone”), to fortifying local foods. Perhaps the most important innovation is though the combination of cash-based initiatives (CBI) with making food available through bringing (local) retailers closer, ensuring the availability as well as affordability of food. The main selling proposition for CBI is that recipients can make their own decisions what they prioritise, and vote with their feet, or rather, their money. This is most certainly a very welcome development. From a supply chain perspective, they require a complete rethink, however (Heaslip et al., 2018). WFP and many other organisations have full-heartedly embraced CBI, with increasing percentages of their “deliveries” being ones in cash. The next question will though be, how to ensure that food is in the markets also during the pandemic. At the end of the day, if everything else fails, humanitarian organisations will still need to deliver.

References

Gibbs DN, 2009. First do no harm: Humanitarian intervention and the destruction of Yugoslavia. Vanderbilt University Press.

Heaslip G, Kovács G & Haavisto I, 2018. Innovations in humanitarian supply chains: the case of cash transfer programmes, Production Planning and Control, Vol.29 No.14, pp.1175-1190, doi: 10.1080/09537287.2018.1542172

Kovács G & Tatham P, 2010. What is special about a humanitarian logistician? A survey of logistic skills and performance. Supply Chain Forum: An International Journal, Vol.11 No.3, pp 32-41, doi: 10.1080/16258312.2010.11517238