Billions of COVID-19 vaccines, one problem: Who will deliver them?

When the Bill & Melinda Gates Foundation needed support for its domestic COVID-19 vaccination programs in the United States, one of the organizations the foundation tapped was Seattle-based VillageReach, a longtime vaccine delivery partner in sub-Saharan Africa.

VillageReach, which focuses on last mile health care delivery, seconded two staff members to Seattle's King County to help start local vaccine operations. The organization’s staff welcomed the chance to help with the health crisis at home. They have also drawn lessons from a relatively early experience with the vaccine rollout in the U.S., hoping it might benefit their programs and partners abroad.

“We're able to learn a lot firsthand about some of the challenges with delivery, some of the workforce surge needs that are required to be able to scale up vaccine delivery in really quick timeframes,” said Jessica Crawford, director of VillageReach’s global technical team.

One of the most apparent lessons has been that as the world embarks on the biggest vaccination program in public health history under an extremely rapid timeframe, simply getting vaccines to countries is only the beginning of the challenge.

In King County, vaccination campaigns required more health care workers and support personnel than was immediately available. And for countries facing daunting resource constraints, it is unclear where that workforce and funding will come from.

“We see this tremendous amount of investment that has gone into the production and the procurement of vaccines, but we haven't seen commensurate investment into the systems that are necessary to deliver that vaccine or to get that vaccine into the arms of people,” Crawford said.

“That was true here in the U.S., and we're seeing that true globally,” she said.

The workforce gap

Newly released findings from the World Bank add detail to these concerns.

Vaccine readiness assessments in 128 low- and middle-income countries found that while 85% of countries have national vaccination plans, “only 30% have developed processes to train the large number of vaccinators who will be needed.”

Countries are required to submit National Deployment and Vaccination Plans to receive shipments from COVAX, the global vaccine distribution facility established in mid-2020. According to slides from a Feb. 17 ministers of health briefing by the World Health Organization’s Regional Office for Africa, which was shared with Devex, the review committee approved all 37 of the NDVPs that it received.

"Countries have had to submit detailed readiness and delivery plans before receiving vaccines, showing they were able to begin rolling out vaccines in a swift and effective way,” a spokesperson for Gavi, the Vaccine Alliance, wrote to Devex.

“COVAX and its partners continue to work with governments to address any challenges that may arise so that health systems are ready for widespread deployment as further doses become available," the spokesperson added.

The World Bank plans to deploy $12 billion to help countries purchase and distribute vaccines, tests, and treatments. And the readiness assessments are meant to inform how these funds are distributed.

Some countries are struggling to cover the operational costs while waiting for World Bank funding to be approved, said David Bryden, director of the Frontline Health Workers Coalition.

“The implication to me is that Gavi is providing the vaccines even to countries that are still struggling to put together the budget to ... actually provide the vaccinations,” Bryden said.

The World Bank’s assessment found that while countries appear to have gaps in their readiness for COVID-19 vaccination campaigns, “most have prepared well enough in most of the essential areas to begin inoculating their populations as soon as vaccines become available.”

Another level

COVID-19 vaccination poses a challenge above and beyond what countries have faced before — even those that have proven adept at large-scale childhood immunization campaigns. Routine vaccines are administered gradually as children are born, which is very different from vaccinating large numbers of adults in a short timeframe.

The World Bank’s analysis found that “the existence of well-functioning child immunization systems is not a strong predictor of country readiness to deliver COVID-19 vaccines.”

There is also potential that COVID-19 vaccination will have to happen annually due to the nature of the virus and how it mutates, Bryden said.

The COVAX Facility has set a goal of vaccinating 2 billion people by the end of 2021, but its coverage plans would only reach 28% of the population in participating countries under the best-case scenario. To reach herd immunity against COVID-19, countries will have to scale up their immunization plans significantly beyond that.

Seattle’s vaccination plans initially leaned heavily on existing health care providers and networks, but it quickly became clear that the county needed additional access points, Crawford said. They created mass vaccination sites outside of existing clinics and mobilized people from student networks, the National Guard, and the Public Health Reserve Corps.

“There is existing capacity that is available, but it needs to be mobilized,” she said.

Crawford estimated that to avoid bottlenecks, every vaccinator administering doses requires an average of five support staff responsible for tasks including registration, client assistance, and managing equipment — though those needs vary depending on vaccination strategies.

“The current health workforce alone is not large enough to handle the undertaking of this magnitude,” said Crawford, who is also a member of the COVAX working group on supply and logistics.

“That's true in any normal year, and it's especially true in a year when the health workforce is tired, fatigued, and burnt out and currently responding to a pandemic,” she said.

The fallout from those pressures is coming into clearer view.

According to Bryden, 84 countries have reported health worker strikes since the COVID-19 pandemic began. In addition, health workers are reporting the increasing prevalence of depression, anxiety, insomnia, and burnout, causing increasing absence from work.

“We want countries to be ambitious and bold with the plans that they're putting forward,” Bryden said. “But then that begs the question of, ok, well, where's that additional support going to come from?”