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COVID-19, a virus orders of magnitude smaller than a particle of dust, has turned daily
life on earth into something deeply unfamiliar.
In the ten or so months since it first emerged, the virus has settled at a steady clip of
killing 5,000 people per day, or nearly a million total, currently.
It has played havoc with the world economy, plunging the globe into the worst economic
crisis since World War Two.
It has interrupted an era of mounting globalization, and pushed us into a more insular, nationalistic
state.
The effects of this virus are truly all encompassing and consistently dreadful, but time has bestowed
upon us a reward for our patience.
We are potentially nearing the beginning of the end, meaning we could now be at the end
of the middle.
That end of this virus will take far longer than the beginning—we’re likely far from
halfway through the pandemic in terms of time—but the slow decline in dreadfulness is potentially
on the horizon.
That’s because a vaccine is coming.
There was previously a period of doubt on whether an effective vaccine could be developed,
it’s never a sure shot, but all indications currently suggest, given the unprecedented
extent of scientific effort, that it is indeed coming.
The only and paramount question is when.
Right now, in September, 2020, all attention is focused on the late-October, early-November
timeframe.
That’s the earliest possible moment when any of the frontrunner vaccines, from major
manufacturers including AstraZeneca, Pfizer, and Moderna, could enter regulatory review.
If all the data confidently point to the vaccine exhibiting an acceptable level of safety and
effectiveness, it is possible that one of these will then be granted emergency use authorization
by the American FDA, or its equivalent by other major national regulators.
It’s worth noting that this is far from a sure-shot, but experts do say that having
a vaccine in 2020 is a less-than-long-shot possibility.
However, it is almost certain that you will not be injected by a COVID-19 vaccine in the
year 2020.
It is possible, but for the average person, when you actually get a dose of a COVID vaccine
has much less to do with when it’s approved, and more with how fast it is manufactured
and distributed.
The full effects of the pandemic—health, social, and economic—will not end until
a critical mass of people are vaccinated.
That means that when we get back to normal life has much more to do with when the last
person is vaccinated, rather than the first.
This is why some have said that the fast distribution of a vaccine will be an even greater challenge
than the development itself.
This process, this challenge of getting the majority of the world's population vaccinated,
can quite legitimately be described as the most daunting and consequential single logistical
challenge ever.
The stakes have never been higher, but the challenge has also never been greater.
Let's look at why.
First and foremost, it's a scale problem.
Shipping and administering one vaccine to one person is not difficult, but shipping
and administering five billion vaccines to five billion people is.
That’s because there just isn't enough room in our world's logistics network, as it is
now, to do that.
Making it even tougher, there’s more chance than not, based on the current leading candidates,
that the first major vaccine to be approved will require two doses administered 21 or
28 days apart.
That doubles the challenge.
Distributing ten or more billion doses of a vaccine would be difficult enough in normal
times, but these are far from normal times.
With international travel all but nonexistent—currently sitting at more than 90% down—passenger
airlines have dramatically cut back their international route networks.
Now, this is an issue because traditionally, some 50% of pharmaceuticals are shipped in
the belly-hold of passenger aircraft, rather than on dedicated freighters, as this can
help get them closer to their final destination faster.
With limited passenger service, overall cargo capacity is down about 30%, while cargo demand
is only about 15% down, meaning there is already a supply crunch.
This has led to existing dedicated freighter aircraft being used more, additional dedicated
freighters coming into service, but still, due to constrained supply, a dramatic increase
in shipping costs.
Even already, before the COVID vaccine comes into the global logistics network, pharmaceutical
manufacturers have had to come up with new techniques to ship their goods including,
for example, flying their product to where shipping rates are cheaper and trucking them
to their final destination or charteri ng private planes.
Of course, the world already experienced a massive logistics challenge this year with
the distribution of personal protective equipment, and shippers were able to scale up for that
reasonably successfully, but there’s one simple reason why it won’t be so easy this
time around: the cold chain.
Vaccines are temperature-sensitive.
Most all of them have to be stored in a highly precise, climate controlled environment in
order to stay safe and effective.
So, the cold chain is the supply chain suited to shipping goods that need to be kept cold
or frozen, such as meat, chemicals, and pharmaceuticals.
Of course, the difficulty with the cold chain is that everything used has to be specialized—the
origin warehouse, the truck, the plane, the en-route warehouse, and the final destination
each need to have the equipment to keep the goods at the specified temperature or the
goods have to be shipped in packaging that keeps them at the specified temperature.
Both options are complicated and complication compounded by other complication is what makes
a true logistical challenge.
It doesn’t end there, though.
One of the leading vaccine candidates, Pfizer’s BNT162b2, must be stored and transported at
around -90 °F, or -68 °C. That is far, far colder than the requirements of most vaccines,
which can ship either at refrigerated temperatures or a wider range of freezing temperatures.
A thermal requirement such as this is a whole different ball-game, and it means that they'll
be able to use only a subset of cold chain infrastructure, which is already a subset
of the overall logistics infrastructure.
Beyond the issue of actually getting such a vaccine to a distribution site, most hospitals
don't even have facilities to keep a vaccine at such a temperature, let alone clinics or
pharmacies, meaning that even finding places that can receive this vaccine is a challenge.
Part of the reason why this obstacle has come up is that traditionally, vaccines are thoroughly
tested to determine what sort of storage and shipping conditions they can endure while
still staying safe and effective, but with the breakneck pace of development for these
COVID-19 vaccines, there likely will not have been enough time to conduct these tests before
distribution, meaning they'll have to keep the standards at what's already proven.
So, to reiterate, already, a likely vaccine will only be able to be shipped through a
subset of a subset of a subset of an already strained logistics network, to a subset of
sites, and it'll need to happen many billions of times, but even the solutions to these
challenges present additional challenges.
Pfizer, for example, knowing that the unique distribution requirements of their vaccine
could limit its commercial success, has developed a partial solution.
It’s essentially a highly specialized stand-alone box that can, with the use of dry ice, keep
the vaccine at the required temperature for up to ten days.
This means that, hypothetically, the vaccine could be shipped through a more traditional
logistics network, however, this box has highly specific requirements.
For one, upon arrival, it can only be opened twice per day, not more than one-minute at
a time, in order to keep the vaccines at the required temperature.
That means that a distribution site would need to accurately predict how many doses
they would need in a given day before that day—if they take out too little, they’d
be slowing the process by not vaccinating everyone they can, but if they take out too
much, they’d have potentially life-saving vaccines go to waste at the end of the day.
Also, this box can only carry vaccines in multiples of a thousand, and keep in mind
that it only keeps cold for ten days.
So, how, for example, do you go about getting the vaccine to a clinic that can only vaccinate
fifty people in a day—like a rural clinic in a small town.
Even if shipping was instantaneous, they could only vaccinate five-hundred people in ten-days,
meaning half their vaccines would go bad.
Pfizer is apparently developing a smaller temperature-controlled box to solve this problem,
but that means adding a whole other type of distribution, which increases complexity,
which slows the process down.
In its scenario planning, the American CDC mapped out a distribution process for if both
Pfizer and Moderna’s vaccines are approved and, if this happened, the Pfizer vaccine
would be directed to only large distribution sites that would either have the facilities
for ultra-cold storage, or the capacity to vaccine enough people that the short shelf-life
of these vaccines wouldn't be an issue.
Then, the Moderna vaccine, which only requires traditional freezer temperatures, would be
directed to smaller sites with less advanced facilities.
This would certainly create a scenario in the US, and likely elsewhere, where the Pfizer
vaccine would be primarily distributed to people in cities, while the Moderna vaccine
would be the vaccine of choice for rural areas.
Another challenge that needs to be confronted is the order of operations for distribution.
The Coronavirus affects different people in different ways.
This means that if we want a vaccine to save the the most number of lives possible, the
first person in line should be that who is most susceptible to COVID-19, and the last
person in line should be that who is least susceptible.
One set of research modeled two scenarios—the first where, of the first 3 billion doses
available, 50 high-income countries buy up 2 billion of them.
The second was where the first 3 billion doses were distributed to countries proportionally
based on their population, regardless of wealth.
In this model, twice as many people died overall with the first scenario—the wealthy countries
first scenario—than the equitable, proportional approach.
However, for vaccination purposes, it is the least wealthy countries, arguably those that
need the vaccine most, that are toughest to distribute to.
Poor countries tend to have limited cold chain infrastructure, let alone normal logistics
infrastructure, and fragmented, poorly-funded healthcare systems.
Distributing and administering a complex vaccine like Pfizer’s will already be tough enough
in the wealthy countries like the United States, but just imagine how difficult it will be
to get a vaccine from distributor to someone’s arm in rural Democratic Republic of the Congo,
for example, in ten days, while keeping it at -90 °F.
How soon a COVID vaccine is administered will quite directly correlate to how many lives
are saved.
Every day of delay will, with certainty, lead to more death and despair.
The manufacturers are working as fast as they can, they are already producing millions of
doses of their vaccines before they’re approved so they can be distributed as fast as possible,
and regulatory agencies have been preparing for months for an unprecedentedly fast review
process, so it is now truly down to every member of the global logistics network to
save lives.
Of course, many of those that will be involved, especially once we get to wide-scale distribution,
will be companies, not governments or nonprofits, and for them, this presents a massive business
opportunity—in addition to the positive public relations potential.
UPS, for example, has built two freezer farms in Louisville, Kentucky, and Venlo, Netherlands,
near their hubs, which can each hold 48,000 doses and can go down to the temperatures
required for the Pfizer vaccine.
DHL and FedEx too are reportedly massively upscaling their cold-chain infrastructure
to be able to handle some of the surge in demand, while other lesser known logistics
companies are too.
Ultimately, though, its tough to find someone in-the-know who doesn’t admit that shipping
will be a bottleneck.
We already know it’s not going to go perfectly, so right now, it’s about doing as much work
as possible to make sure the process goes as well as it can be.
This will come down to making sure that as much planning work as possible is done now,
before the vaccine is approved, so that distribution can happen as fast as possible when that does
happen.
Now is the time to figure out how and where the vaccine will be distributed.
If you are a healthy, relatively young person thinking selfishly, you should care tremendously
about the distribution process, because you are at the back of the line.
When you get your shot, when you get to start letting your guard down, has everything to
do with how fast everyone in front of you gets theirs, and how fast they get theirs
will also impact how many of them will die.
We know this process will not be perfect, and it wouldn't be reasonable to ask for perfect
given the complexity of the challenge, but if we truly put every effort into planning
and preparing for this now, and create a system that orders people by need, rather than wealth,
we can at least know, at the end of this, that no lives could have been saved if only
the vaccine got to them faster.
For our collective consciousness, looking back far in the future, this moment will be
defined not by when we get to go back to concerts or parties or the gym, but rather by how many
lives we saved when confronting what is hopefully the greatest global challenge of this generation.
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