Covid-vaccine distribution can take tips from how India conducts general elections

A medical worker withdraws a vaccine from a vial, Moscow | Photo: Andrey Rudakov | Bloomberg

The mother of all vaccines, or something like that, could start rolling out for the public-at-large in just a matter of months. The vaccine could be seen to bring relief … fingers-crossed … from the risk of becoming an inadvertent host of this coronavirus. Yet, it will be more appropriate if the vaccine is not perceived as a personal condom to protect individuals from Covid-19, but is seen as the mainstay of a programme to eradicate the virus.

Food for thought

There is a fine distinction between a personal prophylactic against disease and achieving population scale immunity to stop the spread of a disease. En masse, entire populations or around 65 to 70 per cent as the scientists tell, must be inoculated (and in quick-time) to rid us of Covid-19. The ultimate aim of the vaccination programme is to quickly and safely achieve herd immunity to halt the virus’s spread. That will mean conducting vaccinations on large scale and with a plan to spread the vaccine much faster than the virus can.

Suppose the approach adopted is different, so as to administer the vaccine widely but to a very small category of the population (the first responders & essential workers). While these recipients will get protected, it may beget a bigger and more dangerous risk. These small number of protected individuals, scattered piecemeal amongst the rest of the population, would still come in contact with the virus and function to expose it to the effects of the vaccine… while millions of the unprotected populace still remain available as hosts. In turn, this poses the risk of triggering an aggravated sequence of mutations in this coronavirus.

This coronavirus has already mutated more than 300 times in less than a year. Reports indicate that these mutations have not undermined the vaccines under development, so far! The biggest fear is that the vaccine may prove ineffective against a future strain of the virus. Therefore, to have a fighting chance against this pandemic, the deployment of the vaccine should be extensive and expansive. Strategically, the vaccine is to be used like a weapon of mass destruction against Covid-19, and not merely like a bullet proof jacket for some.

Also read: Govt begins prep for Covid vaccine drive, asks states to set up 3-tier system for rollout

Deployment strategy

Just as the pandemic took centre-stage and even before the first lockdown in India, was when in a thought piece on preparing to deliver the vaccine, it was first mooted that a coronavirus inoculation exercise be approached the way we address nationwide elections. For elections, many thousands of booths are set-up across the country so that every eligible voter has the opportunity; in India, the entire nation is covered in phases and within months. The Covid-19 vaccination programme can be conducted along similar lines — the key agenda being, to follow a predetermined timeline for complete geographical coverage, with no person left without. In this case, the result to count upon is the ousting of the viral spread.

The strategy behind Covid-19 eradication efforts requires adopting tactics to deploy the vaccine like a cluster bomb. Pick up a geography, vaccinate 65 per cent of the population post-haste, shift to the next region, repeat until the whole country is done. India could conduct this simultaneously in multiple blocks, until entire districts and states can achieve herd immunity by way of vaccination. The task can be achieved within weeks, like is ably demonstrated during national elections.

In India, the magic ratio of 65 amounts to approximately 880 million people — not unsurmountable for India, a country that holds national elections that cater for more than 900 million eligible voters. A piecemeal vaccination programme where millions of unvaccinated hosts remain available to the virus, or allowing the vaccinated to freely travel into a viral area, may lead to the failure of the new vaccine; and another round of lockdowns and vaccine development.

However, just freeing a sub-continent from the spread of Covid-19 will not be sufficient, until all continents are equally free. Hopefully, the rest of the world will also pursue a mass cluster-based vaccination approach.

International effort to spread the vaccine faster than the coronavirus is needed. 

Also read: ICMR data shows BCG vaccine raises immune response in elderly, could protect against Covid

Deployment tactics

Vaccinating 65 per cent of a population is expected to rid it of this virus. Unable to find sufficient viable hosts to reproduce and spread, the ‘R naught’ of the virus will drop close to zero. Strict anti-Covid protocol would still be needed as the protection from the vaccine will kick in after a couple of days. Even after, those protected should not travel out into non-vaccinated regions – to minimise exposing the virus to the vaccinated while it still has other viable hosts to mutate and play its own war games.

To evaluate more about administering the vaccine in a population cluster within weeks, let us work with a few assumptions. A vaccine giver could administer a dose every five minutes and work 10 hours a day; s/he can inoculate 120 others every day. Two vaccine givers per vaccination site can serve 5000 people in 21 days. This example means, that Delhi with 20 million residents will require 4000 vaccination sites with 8000 vaccinators, if the exercise is to be completed in 3 weeks.

These sites cannot be the hospitals as they are still overloaded with the pandemic work load. Instead, empty movie halls, schools, malls, even local pizzerias or pharmaceutical shops can be enlisted for the purpose. Other such possibilities are also suggested in another article. More the number of dispersed sites, the better, to avoid crowding… that will still remain a big NO NO! Going to get a vaccine shot should not result in catching the virus.

To organise the schedule, each person in the target population can receive an appointment which they could confirm by making an online payment. If they abide with the schedule, this money (or a share) can be refunded in full. But if they ignore and crowd in before their due date, then the deposit will not be refunded. This could help coerce some discipline and prevent unplanned crowding, while easing a bit of the cash flow for the exchequer. It is here, that the high risk individuals within the target region can be allocated priority, since the entire cluster will be vaccinated in a short while in any case.

Also read: Facilitating easy loans, trials abroad — India looks at options to make Covid vaccine cheaper

Monitoring the vaccine

The vaccine will need to be monitored all through its transit until it is dosed. Any exposure to inclement conditions and broken vials should be captured at each stage where the vaccine exchanges custody — key facets will be temperature-time-shock while in transit, besides the usual batch-wise details. There are enough sensors and loggers that the blockchain can use for such record-keeping. To build-in systemic checks, these ledgers could also match doses given with the usage of syringes, swabs, any diluents, etc. A planned reverse logistics for medical waste & disposal will also benefit from such records.

Connecting the vaccine

A lot of talk has surfaced, in my opinion wrongly conceived, on creating more dedicated cold stores and reefer vehicles for the primary movement of the vaccine. Those suggesting this will find handy to review the involved capacities. WHO has published guidelines on vaccine packaging and storage, and a handbook to calculate the amount of space required.

In the case of the coronavirus vaccine let us assume that each dose is 0.5 ml and assess some of the logistics requirements. A cubic metre of space equals 1 million millilitres or can hold 2 million doses. However, the vaccine will not come in large casks but in small vials, maybe 4 doses to each and in secondary packaging.

Let us continue with the example of 4 doses per 2 ml vial, and also assume each vial of the vaccine will occupy 20 ml (twenty cubic cms) of space in the cold-chain. A twenty footer reefer container has a capacity of 28 cubic metres and can therefore transport 5.6 million packaged doses. Less than 4 such reefer containers can hold a supply of 20 million doses… the entire population of Delhi. Around 250 such containers to supply 1.35 billion doses, which at aggregate level will require a total space of 6750 cubic metres – occupy a total footprint of 3,688 square metres if stowed to a height of 6 feet.

Even if each dose is 1 ml, twice the initial assumption of 0.5 ml, then these aggregate numbers will double, or could even be quadrupled. But then, this supply will also not happen all at once; will be staggered over time. So, space is not a problem for bulk haulage or in storage. The real concern is after breaking bulk at the receiving depots. The situation will vary in different geographies (about 140 countries have a population of less than 20 million, with around 70 with less than 5 million).

If the vial size and packaging is redesigned by the vaccine makers, to suit the expected scale of operations, then the space requirement can be further optimised. In the current scenario, as long as daily demand is assured, the supply could be in more optimally designed packages, and in larger doses per vial say 50 or more. It could make the stowage more efficient and add to overall economics – though the risk could also increase. In all, the primary supply and storage at vaccine depots involves very manageable capacities. Disposable syringes and other supplies will be the items that will actually demand more volume in transport and storage, but these should be manageable outside the cold-chain. Rest assured, the complexity in first- and mid-mile logistics can be handled provided the exercise is planned well in advance.

Also read: Cadila to boost Covid vaccine production capacity by 70% if it passes human trials

Plan the last-mile

The key supply chain challenge, especially in a country the size of India, will be the last-mile distribution and ensuring a vaccine holding systems at each vaccination site. These could be active or passive cooled technologies or a combination thereof. Portable solar cooled units will also help. In regions where temperatures fall below 2° Celsius, the holding space may require heating. It is here, where much detailing of implementation and planning is needed. If the vaccinations are undertaken in phases to achieve cluster based total coverage like during elections, the last-mile equipment could also be shifted to other locations as this activity progresses.

Such planning will need to orientate with the supply chain model, whether the vaccine supply and medical waste pickup will happen every second day, or weekly, etc. The type of vaccine, temperature required and usable life are other factors to consider. Further details and discussions will only lengthen this post more; and I already wonder how many had the patience to even read this one, and persevere so far along.

Meanwhile, we should trust the planners who are tasked this job and ward off the coronavirus as best we can. And keep hoping the virus will stay vulnerable to the vaccine… I also wish that this damn virus will take a right turn and mutate into a friendly benign form.

Until then, stay safe – stand clear of Crowds, wear a Mask, keep Clean.

PS — the above largely considers vaccines in the -20° or 2° to 8° Celsius range. The available projected production of the vaccine under cryogenic care, indicates volumes that primarily target demand from North America and Europe. The vaccine at -70°C will require many thousands of specialised insulated boxes designed for dry ice capability, from the vaccine manufacturer until terminal depots. Even then, the last stage at vaccinators’ site will be at 2-8°C. Luckily, such insulated boxes can also double to service the needs at these higher temperature ranges.

The author is the former CEO of the National Centre for Cold Chain Development. Views are personal.

This article first appeared on LinkedIn.