How should governments allocate Covid-19 vaccines? 

The difficulty of discovering a vaccine is eclipsed only by the difficulty of getting it to people.

Vaccine discovery for SARS-CoV-2 is moving with breathtaking speed and precision. Unprecedented investments to open clinical trial sites and preorder untested vaccines shaved years off the discovery process.

As of early November 2020, only 10 months since the virus’s genome was first sequenced, Pfizer and BioNTech as well as Moderna reported promising data about their vaccine candidates. Nine additional candidates are in phase-3 efficacy trials.

With new vaccines on the horizon, governments face the next stage of pandemic problem-solving: how to allocate, distribute, and verify vaccine doses and ensure the vaccines translate to vaccinated populations.

The same level of precision, investment, and collaboration must apply to developing a vaccine delivery strategy as has been invested in developing the vaccine itself.

As clinicians and researchers, we have studied health care delivery for over a decade. Prior pandemics taught us that our inability to quickly vaccinate at-risk populations and end transmission was due to “implementation bottlenecks,” a term used to describe the challenges of getting life-saving supplies or medications to populations.

In this post, we describe key considerations for an equitable vaccine delivery strategy and the bottlenecks to avoid.

To generate demand for vaccines, first understand your population

Efforts to end the Covid-19 pandemic will fail if too few people accept a vaccine. Public trust in vaccines was declining worldwide even before the pandemic, so Covid-19 vaccine acceptance is not a given.

The challenge is not only about acceptance — it’s about encouraging healthy people to seek an intervention, which requires generating demand.

To generate demand for Covid-19 vaccines, targeted research studies to understand a population’s attitudes and concerns can provide a springboard for action. Once we understand community perceptions, we can tailor communication strategies.

Multiple actors play a role in generating demand. Public health authorities and government leaders can provide clear messaging consistent with science and be transparent and detailed when describing approval processes.

Vaccine industry leaders must publicly assert independence from political pressures and ensure representation in clinical trials. Public figures such as celebrities and social media influencers can get vaccinated, highlight accurate information, and counter misinformation and disinformation. Businesses and employers can support their workforce to get vaccinated.

The impact of grassroots leaders, trusted community members, and the health workforce can be profound.

During a recent measles outbreak among the Orthodox Jewish community in New York, for example, a group of Orthodox Jewish nurses facilitated community discussions, helped parents identify misinformation, and partnered with health care workers to build community trust in the measles vaccine and increase vaccination rates.

There are many examples like this one that, over time, help create a receptive environment for safe and effective vaccines.

To allocate scarce supply, look to real-time, local data

When a vaccine is approved and comes to market, the initial supply will be limited. Unfortunately, market forces and private rewards often determine the allocation of scarce health resources. To suppress transmission and minimise disease burden for the hardest-hit populations, Covid-19 allocation must be equitable — not reserved for the privileged.

We can learn from the bottlenecks of the 2009 H1N1 outbreak. Early, limited supplies of H1N1 vaccine were purchased by high-income countries and not allocated to countries with high rates of transmission. This not only exacerbated inequalities but also failed to stomp out the pandemic.

Models show that an 80%-effective Covid-19 vaccine distributed in proportion to population could prevent 61% of global deaths. If it were distributed to high-income countries first, it could prevent only 31% of deaths.

Under the WHO’s ACT Accelerator, a global collaboration to ensure equitable access to Covid-19 tests, treatment, and vaccines, participating countries would receive enough doses to cover 20% of the population.

After that, allocation depends on country-level risk assessments and population vulnerability. More than 186 countries have opted into the effort, called COVAX, but the United States, Russia, and India have so far held out and there is still an estimated US$5 billion shortage

Global collaboration and political will are essential for allocation decisions during a pandemic. In practice, however, local leaders and implementing partners need more than guidelines. They need region-specific data about their populations to efficiently and equitably allocate the vaccine supply as it trickles in.

To address this bottleneck in the U.S., our team at Ariadne Labs, a health systems innovation center at Harvard, drew from the expertise of the nation’s top third-party researchers, epidemiologists, data scientists, and medical professionals to build a tool called the Vaccine Allocation Planner for COVID-19.

The tool aims to provide state and county decision-makers with localised data on available vaccine doses, priority populations, and regional vulnerabilities to plan for equitable vaccine distribution, based on the Framework for Equitable Allocation of Covid-19 Vaccine by the National Academies of Sciences, Engineering, and Medicine (NASEM).

As the tool evolves, it can be adapted to settings outside the U.S. to aid in allocation decision-making and to track vaccine distribution.

To distribute vaccines and verify coverage, invest in information systems

Billions of vaccine doses will need to be distributed for the global population to end the Covid-19 pandemic. The goal of supply chains — getting the right product at the right temperature to the right person at the right time — requires airtight coordination across both physical and digital infrastructure.

Early investments have enabled vaccine front-runners to plan for vaccine deployment and source ancillary materials such as vials and stoppers, despite shortages.

The physical aspects of the supply chain — transportation and cold storage, for example — will need to operate at scale and be entrusted to expert manufacturers, supply chain logisticians, and organisations well-versed in “last-mile distribution” challenges.

One key challenge for governments will be ensuring that information systems are robust enough to process real-time data and granular enough to forecast needs in any given region.

Seamless communication channels across the supply chain are vital in both the initial phase of distribution and in the longer term as more people are vaccinated and the vaccine portfolio diversifies.

The digital infrastructure serves another critical purpose: verifying vaccine coverage to fine-tune immunisation targets. Considering the geographic spread of at-risk populations, vaccine verification systems that are secure, portable, and interoperable are necessary to track progress and dosing and allocate vaccines accordingly.

Governments are writing the playbook for a complete paradigm shift in vaccine development and delivery. The decisions made today will impact population health now and for generations to come. 

This blog post is adapted from a longer article published in Health Affairs in November 2020, which was written with support from Iman Ahmad, Laura Submaranian, Keri Wachter, and Ami Karlage.

It was published on Apolitical, the global network for public servants. You can find it here. For more like this, see Apolitical’s government innovation newsfeed.