In COVID-19 vaccine race, rollouts are sometimes an afterthought

The population in war-torn Yemen has paid a heavy price during the COVID-19 pandemic, partly due to its battered health system.

“I don’t think there is a home without COVID-19 — [there are] lots of deaths,” said Rajaa Ahmad Ali Massaad, the nation’s first female anesthetist.

At Aden Hospital, where she works, about 260 nurses and doctors have contracted the disease and at least three of them died, she said, adding that, “Yemen is definitely not ready for another COVID wave.”

Vaccines were supposed to be a lifeline for countries. Scientists developed them at record speed, the COVAX Facility was created to ensure equity in vaccine access, and roughly 42 million doses have been distributed through the global initiative. Yemen received 360,000 doses at the end of March but has yet to report administering any.

Other countries have also experienced delays and challenges in rolling out vaccination campaigns. Liberia received 96,000 doses in early March, but it has only reported administering about 400. South Sudan received 132,000 doses near the end of that month but has reported administering about 1,400.

Health experts say that funding and planning for in-country rollouts have, in some cases, been an afterthought. Now, there is minimal support and training for the health workers expected to administer vaccines. This, coupled with vaccine hesitancy and logistical challenges, has resulted in slow deployments.

“When we are budgeting, we are not thinking beyond the purchase of the vaccines. We need to think of the whole program — from purchase to the delivery — what it would cost us and what needs to be put in place for that to happen,” said Joachim Osur, technical director at Amref Health Africa.

Unused vaccines are problematic for a number of reasons. They have a limited life span, and the longer that populations go unvaccinated, the higher the odds that the coronavirus will mutate in ways that make it resistant to existing vaccines.

“The vaccines that we are receiving often have a short shelf life,” said Alinafe Kasiya, Malawi country director at VillageReach. “And so, the challenge has been: What do we do to make sure we are using these vaccines in record time?” The country’s health minister said this week that more than 16,000 doses provided from the African Union will be destroyed due to expiry, after receiving the doses only three weeks ago.

When the African Union gives countries vaccines, it expects them to roll them out quickly, said Dr. John Nkengasong, director at the Africa Centres for Disease Control and Prevention, during a press briefing on Thursday.

“We are in a very, very dire situation of access to vaccines and availability of vaccines. I make an appeal to all countries — if you have your vaccines, use them. Use them up quickly," he said.  

Some countries that had slow starts to their vaccination campaigns did not have delivery or supply chain mechanisms in place or funded when they received doses, said Emily Janoch, director for knowledge management and learning at CARE USA.

“In some cases, they found that the plans they had on paper wouldn't work but didn't have a quick way to pivot to a new plan,” she said.

Unpaid and unvaccinated

CARE estimates that for every $1 invested in vaccine doses, $5 is needed for delivery. Countries should allocate half of that amount for equipping, paying, and supporting front-line workers to ensure they are kept safe during rollouts.

Women account for 70% of the health workforce globally — and half of this work is unpaid, as many health systems in countries with limited resources are kept afloat by volunteer or underpaid community health workers.

“Much of the work goes unpaid because it is considered to be ‘women's work,’ which tends to be undervalued in economies overall. The assumption is that this is an extension of women's social expectations to be nurturing and caregivers for the sick," Janoch said.

The cost estimates around rollouts often fail to include health worker salaries “because we assume they're already paid, which we know isn't true,” she said. And in most estimates, community health workers aren’t listed.

Janoch added that the “lack of payment for health workers leads to slower rollout, as there is a lower motivation to work in a high-risk environments and health workers who are underpaid do not have the financial resources to take on additional costs they face in COVID-19 — like additional burdens of child care, children's education, or caring for sick family members."

Meanwhile, Rwanda and other countries that have long invested in health workers were able to administer their vaccine doses quickly. “There are some countries that were able to literally start the day they got vaccines,” Janoch said.

Vaccine hesitancy and logistics

Negative reports and misinformation about vaccines are stunting rollouts in some countries.

While unusual blood clots may be “very rare side effects” of AstraZeneca’s vaccine — the main one distributed under the COVAX Facility — health institutions such as the World Health Organization and Africa CDC still recommend its use, saying the lifesaving benefits far outweigh the low risk. However, reports about the vaccine’s potential side effects, as well as its questionable efficacy against the virus variant originally found in South Africa, have led many to question its safety and usefulness.

The Democratic Republic of Congo and Cameroon paused deployment of the AstraZeneca vaccine when European countries halted distribution over the rare blood clots. DRC has not administered any doses of COVID-19 vaccines to date, but plans to start on April 19, and Cameroon has only administered about 500.

WHO has also documented vaccine hesitancy among groups prioritized for immunization and an eagerness for inoculation among low-priority groups, including people who are relatively young and healthy. Kenya, for example, initially had low turnout for immunization among priority groups, so the government broadened access, Osur said.

“We have concentrated so much on purchasing the vaccine and bringing it into the country, and we have not done much in community education and sensitizing communities to have the vaccine,” he said.

While urban centers are targeted first for vaccine rollouts in most countries, distribution in rural areas will create logistical challenges, Kasiya said.

“I think the logistical challenges become enormous in terms of making sure that we have the vaccines in the right places, that we have the right people trained and enough people trained to administer the vaccines and we are also handling the vaccines in the right way in terms of the cold chain,” he said. “As we get more vaccines, I think those challenges will become more pronounced.”

Kawa Tong, health and nutrition manager for CARE in South Sudan, said she is worried about vaccines reaching rural parts of the country over the next few months because the rainy season has started.