Dr. Nadeem Jan (TI)
With dozens of viable candidates pushing through clinical trials, it is possible that a COVID-19 vaccine could be available in Pakistan as early as 1st or second quarter of next year. Once Pakistan gets its due share from the global supply chain, we could encounter another mega challenge, that is spread across the vaccine supply and demand chain.
Health system preparedness – or lack thereof – could spell trouble for the country’s COVID-19 response efforts. Without a comprehensive vaccination strategy in place, there could be bumps in vaccinating communities, especially the vulnerable population.
For an optimum utilization of the forthcoming RNA vaccine, we must enact changes in DNA of our health system.
To address this pragmatically this author developed a – V8 Model of vaccine preparedness– for safe and effective utilization of this precious entity. The V8 model encompasses A to z of the vaccine supply and value chain and may be modified contextually as required.
The plan is a sum of 8 Vs along the critical pathway that would galvanize efforts for an effective vaccine utilization, described in detail below:
V 1: The Vision. i.e. The Vaccine Road Map: The 1st and foremost in any vaccine program is the strategic road map for the vaccine that cuts through the procurement supply chain, implementation, and surveillance. Right at the outset COVID-19 has witnessed political divisions, disinformation- infodemia- and confusion. To avoid this NCOC should take lead and craft a vaccine road map that is unanimously agreed by all stake holders and political leadership. A shared vison and narrative would lay the foundation of a successful vaccination program and guides the rest of the operations.
V2. Venues for Coordination: Pakistan has established a strong coordination network of NCOC at the center and that is best suited to oversee, coordinate and manage the vaccine supply. A similar arrangement at the district level would be helpful in management of the vaccine on the ground. The Polio program network of Provincial, district, and UC level could be a better option with some additional modifications as required. Apart from this mega structure, technical platforms for various component of vaccination value chain must be functionalized right from the word go.
V3. The Vaccine: More than three vaccine candidates are in the pipeline, one by Pfizer, the other Moderna and the 3rd one is the AstraZeneca, each has a different value. The efficacy of Moderna and Pfizer one has proved to be over 90 % but the cost and the peculiar cold chain preconditions at ultra-cold temperature makes it an entity of last resort. The Astra Zeneca is cheap and can be transported in the normal cold chain, but its efficacy has been in the range of 70 to 90 %. Pakistan is part of the Chinese vaccine trial -developed by CanSinoBio and the Beijing Institute of Biotechnology – and this engagement entitles it for an early , cost effective and timely supply of this vaccine once it pass through the stage 3 trial. The choice of vaccine to be procured by Pakistan is not yet announced but it should at the minimum safe, cost effective, less taxing on cold chain, available at scale and easy to administer. Apart from direct procurement Pakistan should also tap the COVAX facility for subsidized/ free vaccine delivery – COVAX has shortlisted 92 Low, middle income countries for Corona vaccine support – and Pakistan stands every chance of availing that facility.
V4. The Vehicle for transportation i.e. the Cold Chain: Installing ultra-cold chain for the Pfizer vaccine makes it a low priority choice. Even if we are bidding for a vaccine with normal cold chain requirement we still must assess, capacitate, and make our cold china system more robust to cope up with the heavy requirement of Corona vaccine. The country will need a distribution plan that ensures the vaccine is safely and efficiently transported to communities across the country. Seemingly government alone wouldn’t be able to cater for the entire needs of the cold chain and an arrangement with private sector needs to be evolved – public private partnership- for the vaccine supply and storage. Health ministry in consultation with NCOC should embark upon developing mechanism and SOPs for this arrangement well in advance of the vaccine provision.
V5. The Vaccinator: The backbone of the effort are the people who would be directly involved with vaccinating the communities at large i.e. the Health workers. The Pakistan EPI program targets. children under 5 years but for this target population too, the program have encountered gaps of trained human resource both qualitative and quantitively. Now with a vaccine for which all age groups qualify, this gigantic task would strain the system and for that ample human resource planning should be carefully orchestrated, plan at the minimum should include posting, essential training, deployment, monitoring and effective utilization. As a transitional strategy the government can envisage the utilization of large human resource of polio & EPI program which can be adequately trained and utilized for a quick win win. The health system leaders will also need to prepare COVID-19 vaccine documentation guidelines for each cadre for an effective vaccine administration, monitoring & reporting.
V6: Vaccinattee, The end line beneficiary:
No matter which vaccine is approved, initial quantities will be limited. In an environment of scarcity, an equitable prioritization plan is necessary to define the segments of the population that should get vaccine first. There is widespread agreement that frontline healthcare workers caring for the most vulnerable patients need to be at the front of the line.
But which population is next? And at what point do we start vaccinating beyond healthcare workers and start reaching those most vulnerable persons themselves?
In the early days of vaccination, a clear national plan will be required to maximize the impact and save the greatest number of lives – with a secondary goal of ensuring that public understands rational choices and does not feel unfairly deprived.
Rather than taking the “peanut butter approach” and spreading vaccines equally, the country will need a more dynamic allocation strategy. The government should allocate vaccines in greater proportion to emerging hotspots, stopping the spread in communities where science shows its metastasizing. Secondary prioritization should be given to areas with higher percentages of priority vaccination candidates, like those aged 65 and people with predisposing conditions. Not only is this method more equitable, it’s also more effective, as it ensures that burning fires are put out first.
The national level policy and framework should clearly identify, map the high-risk groups and areas, get it approved from NCOC and disseminate that widely to avoid any confusion or unrest.
V7: Verification: Accurate and Methodical Patient Tracking & surveillance
In the case of the COVID-19 vaccines, nearly all require administration of two doses within a prescribed window of time. Not only do the providers need to ensure that all patients return and receive their second dose within the time window, but they must ensure patients receive the same vaccine they did on the first visit.
Historic adherence to multi-dose vaccine regimes is low, historically more than 30 percent drop out. Failure to receive the second dose essentially means that the first dose was wasted – something that we can ill afford during this time of scarcity.
To overcome these challenges, patients and the vaccine they receive will need to be linked together – in an electronic health record – and providers will need automated technologies to guide immediate follow-up in the event of a missed second appointment; would be good to develop a mobile app for this.
V 8: Vaccine hesitancy:
Resistance to vaccination has gained momentum during the last couple of years in the west and East like. The anti vaxxers have boycotted Measles vaccination for unscientific reasons and same has been witnessed in our polio vaccination campaigns. Launching a new vaccine and that too associated with skepticism wouldn’t be a smooth transaction.
Peculiar problem of the COVID-19 is that information about this pandemic has been coming out in dribs and drabs and this has created space for misinformation to thrive.
Prof Heidi Larson head of the “Vaccine Confidence Project “at the London School of Hygiene and Tropical Medicine has shown concerns about the impact misinformation appears to be having on people’s intention to take coronavirus vaccines.
Her team research about vaccine confidence in the UK and US informs that 54% of the study population said they definitely would be vaccinated. But it dropped down further by six percent when inaccurate claims about vaccine safety emerged.
All this call for a well-tailored comms strategy that could allay fears and win hearts and minds of the skeptics that would help not only Corona vaccination but larger vaccination interests of the other vaccine preventable diseases.
Like most facets of this pandemic, the administration of the COVID-19 vaccine will likely be anything but straightforward.
The efficient implementation of a well thought out national vaccination plan could extricate us from the rough waters that have engulfed us since March 2020 and position us on the path to resilience.
Welcome 2021! the year of hope.
Dr. Nadeem Jan (Tamgha I Imtiaz) is a decorated health & polio expert, who has an illustrious career with UN, USAID, World Bank, Gates Foundation and Governments of Pakistan, Somalia, Kenya, Ethiopia, South Sudan, Afghanistan, and Philippines.
He can be reached at Nadeemjan77@hotmail.com