Every year, during World Immunisation Week (24 to 30 April) we reflect on the millions of lives saved every year through one of world’s most successful and cost-effective health interventions – immunisation. Who could have predicted (with the possible exception of Bill Gates and a few others) that during this year’s observance, we would be living under circumstances formerly reserved for the pages of science fiction because of a rapidly spreading and highly contagious coronavirus against which we have no immunity and no vaccine?
But, here we are, doing our best to adapt to our changing circumstances and to understand what this could all mean for the future of our healthcare system and economy. And, in the meantime, scientists around the globe are working furiously on a vaccine that will – hopefully soon – bring an end to the economic turmoil and loss of life.
While there is rightly much talk of ‘flattening the curve’, it is equally important to start thinking about how to capacitate the supply chain to ensure that we get ahead and stay ahead of the next curve. Because, even if a Covid-19 vaccine was to be produced and approved within the next 18-24 months, we’d still need to roll it out on a massive, hitherto unprecedented scale.
There is also a very real risk of spikes in the curves of other entirely preventable diseases.
One of the lesser known impacts of the Covid-19 pandemic is its effect on existing routine vaccination programmes for diseases such as measles, mumps and polio. The global lockdown, including the closure of schools, means that such programmes are effectively on hold.
A notable voice has been the World Health Organisation (WHO) director-general Dr Tedros Adhanom Ghebreyesus: “While the world strives to develop a new vaccine for Covid-19 at record speed, we must not risk losing the fight to protect everyone, everywhere, against vaccine-preventable diseases. These diseases will come roaring back if we do not vaccinate.”
One only has to look to the Democratic Republic of Congo (DRC) to see how this displacement effect could play out. In an effort to contain the Ebola virus in 2018, restrictions on movement in that country caused a halt in the DRC’s vaccination programme. The result was the worst measles outbreak ever seen with over 300 000 reported cases, in which 6000 children succumbed – more than double the Ebola death toll of 2277 as reported by the WHO.
No doubt with the DRC’s experience in mind, the former head of SA’s National Institute for Communicable Diseases (NICD) Prof Shabhir Madhi last week raised particular concerns about how few measles vaccinations have been given in the past month. We will - sooner rather than later - face the challenge of catching up with these delayed vaccinations in addition to rolling out the Covid-19 vaccine.
Ordinarily, vaccines can take two to three years – sometimes up to 10 years – to develop. With the biggest brains and billions of dollars focused on Covid-19, there is some hope that a Covid-19 vaccine could be developed in as little as 12-18 months. And if the Covid-19 vaccine is the key to getting ahead of the virus and bringing the pandemic under control, one of our primary goals in the next 12 months must surely be to ensure that we fully capacitate and empower all role-players along the supply chain.
In our work across 74 countries spanning five continents supporting several non-governmental organisations and governments with established vaccination programmes, it has become abundantly apparent that central to effective immuniation is a well capacitated and effectively managed cold chain. Otherwise, the practical deficiencies in basic temperature control risk upending efforts to prevent the spread of Covid-19 and other diseases. What does this entail?
The cold chain is described by the WHO as “a system of storing and transporting vaccines at recommended temperatures from the point of manufacture to the point of use.” If the cold chain is broken at any point along its journey from the manufacturer to the end user, the potency of a vaccine may be compromised. In the worst case, mainly as a result of accidental freezing, it may be rendered entirely ineffective.
We firstly need enough fridges and freezers to store the enormous volumes of vaccines that will need to be produced for the global population. This includes large cold storage facilities at the national and regional distribution depots, in the refrigerated containers and temperature-controlled vehicles that carry the vaccines, at the hospitals and local clinics that store and dispense them and in many cases, the cooler boxes that carry the vaccines into remote villages and schools.
Unfortunately, there are many impediments to ensuring a well-maintained cold chain. Medical-grade refrigerators are not cheap and funding is already being stretched to near breaking point. Even when there is funding available, too often the procurement processes to acquire them are long and cumbersome. So, government and healthcare organisations are being required to make the absolute most of the assets they have.
It is worth noting that the same fridges that carry and store vaccines often also store insulin which too is temperature sensitive. The relevance of this cannot be overstated as underlying health conditions like diabetes are intrinsically linked to the Covid-19 mortality rate.
The Internet-of-Things (IoT) and solutions like remote temperature monitoring and control devices monitor the cold chain in real time and ensure the proper functioning of the equipment from the point of manufacture to the end user, preserving the efficacy of these lifesaving vaccines.
Global organisations like UNICEF, the International Committee of the Red Cross and the Pan American Health Organisation have already adopted the technology. Philanthropic institutions like the Gates Foundation, the Clinton Health Access Initiative and Gavi Alliance do an incredible job of bridging the gap between the limited resources of developing countries and the high costs involved in cold chain management. But these institutions are no substitute for effective national planning and preparedness. The time to think global, act local is now!
As the world enters into a new phased approach to lifting the lockdown and more businesses begin to re-emerge, so too will governments have to enter a new phase that broadens their focus from simply containing the virus and flattening the curve, to building systems to get ahead of this curve and the others that will inevitably come. When Covid-19 arrived, it exposed the unpreparedness of the global healthcare system. Clear, efficient cold chain and temperature management will give global public health responses the shot in the arm so critically needed to deal with preventable viral infections.
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