African nations gear up for an influx of COVID-19 vaccines

Following a several-month dry spell of COVID-19 vaccines, countries across the African continent are now finally receiving shipments in the millions of doses. In July, African countries received more doses than the entire months of April through June combined.

The World Health Organization Regional Office for Africa is aiming to have 30% of the continent’s population vaccinated by the end of the year. To reach that goal, COVAX aims to ship 620 million doses to African nations, which would account for about 23% of the continent’s population.

Separately, the African Union has made Johnson & Johnson doses available to countries for purchase, and it plans to ship nearly 50 million by the end of the year, which will account for about 3.6% of the continent’s population. This still falls short of the end-of-year goal.

With this increase in supply, health experts are concerned about rollouts — as countries juggle different types of vaccines, logistical challenges, and a sporadic supply of vaccines.

Juggling doses

Dr. Phionah Atuhebwe, new vaccines introduction officer at WHO Africa regional office, said the agency is concerned about the confusion around the introduction of multiple types of COVID-19 vaccines, with different requirements around the number of doses needed, the handling required, and the length of time between doses.

“One of our biggest concerns right now [is] the multiple products and countries having issues with delivering the multiple products,” Atuhebwe said. “It's going to be very complex.”

Governments now must choose where to allocate different doses — and these choices have consequences, Atuhebwe said. When making these decisions, countries need to have justifications, such as allocating the Pfizer vaccine in a capital city, because of the ultra-cold chain requirements, and sending J&J to a part of the country that requires longer travel hours.

Countries should avoid allocating different types of vaccines in the same location, Atuhebwe said. Confusion could arise if people are told that one dose is enough for them, but a neighbor is told they need two doses. Or a person is told to come back for a second dose after a certain number of weeks, while a relative is told to come for a second dose at an earlier date. It could also be logistically confusing for health workers to handle different vaccines at the same time.

Having only one type of vaccine in a region is also helpful in monitoring adverse health outcomes, Atuhebwe said.

“If someone has an adverse event following immunization, we'll know that in this particular district, for sure, this was the vaccine that this person got,” she said.

Decisions around where to allocate vaccines can also be political. For example, if a government chose to give a certain vaccine to a part of the country that is a stronghold of a political opposition group, and someone has an adverse reaction to the vaccine, it could raise tensions, Atuhebwe said.

“That is something very difficult to manage because the government chose to give this vaccine to the northern part of the country, where there's opposition,” she said.

And once that decision is made, governments need to properly communicate this to communities.

“People must understand why they are receiving Johnson & Johnson versus Pfizer,” Atuhebwe said, adding that health workers need to be properly trained on distributing this information.  

A ‘drip, drip’ campaign

Though global supplies of vaccines have loosened up, African countries are still receiving them in a “drip, drip” manner which makes these vaccination campaigns unlike other vaccination campaigns many countries have experienced, said Jens Pedersen, humanitarian adviser for Médecins Sans Frontières in South Africa.

Instead of visiting a community once to vaccinate all children under 5 fully, as has been the case during most other vaccination campaigns for other diseases, health workers might be forced to return to a community several times, administering COVID-19 doses based on age and vulnerabilities to severe illness, as the doses trickle in.

And many countries are still working to identify who these priority groups are so the correct number of doses can be rolled out to different parts of a country, Atuhebwe said. Many governments have difficulty targeting older populations because they hadn’t previously been targeted for vaccination campaigns, and there are also challenges around identifying people with comorbidities, she said.

“The elderly people, where shall we find them?” she asked. “Many people don't even know if they have hypertension or diabetes.”

Countries are also in the process of building up cold chain capacities for the incoming vaccines, particularly the ultra-cold chain used to store the Pfizer vaccine. The United States pledged to donate 500 million doses of the Pfizer vaccine to low- and lower-middle-income countries. But it’s still unclear how many of these will go to African nations.

There are 15 African countries with the required ultra-cold chain storage facilities needed for the Pfizer vaccine at the national level, according to Atuhebwe. The Democratic Republic of Congo already has that capacity at the sub-national level, and the government is working to further expand this.

Kenya, Lesotho, Madagascar, Mozambique, and Uganda have procured ultra-cold chain equipment and are awaiting delivery. Guinea, Liberia, Sierra Leone, Uganda, and South Sudan have limited capacity but this needs to be upgraded before receiving the Pfizer vaccine.

The Pfizer vaccine also requires the use of a low dead-volume syringe in order to get six doses out of the vial rather than five, said Hayley Andersen, an associate at the Tony Blair Institute for Global Change. But there are a limited number of manufacturers globally that produce these syringes, raising concerns that if countries can’t access these syringes, then a shipment of Pfizer vaccines may have fewer doses than were projected.

“It's very possible that an allocation of six is being counted when Pfizer doses are received, but actually only five are getting extracted from each vial,” Andersen said.

Countries also need to stock up on personal protective equipment for those embarking on vaccination campaigns, build up information technology systems for tracking the vaccines and those already immunized, strengthen systems around quality assurance and safety monitoring, ensure adequate electricity in areas distributing vaccines, and employ enough people, she added.

WHO is advising countries to have detailed, evidence-based micro plans to guide their national rollouts in the coming months.  

And these plans need to be well-funded, Andersen said, adding that this should go beyond loans, which comprise much of the financing many countries have been offered.

“Above all, to address all these implementation challenges, really the biggest aspect is funding. Countries need funding. And I think, really, they need grants. There's some hesitation around just taking on more loans,” she said.

Update, Sept. 9, 2021: This article has been updated to clarify that the source for a quote is  Hayley Andersen, an associate at the Tony Blair Institute for Global Change.