Opinion: Why a strong cold chain is more critical than ever to defeat COVID-19

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A vaccination campaign against influenza virus in Sao Paulo. Photo by: BW Press

Today, thanks to modern air travel, the mobility of populations is greater than it has ever been in history, such that viruses can spread in hours rather than months. However, improved capabilities for disease surveillance and breakthroughs in genetic sequencing mean we can also detect and understand pandemic disease with speed and accuracy. This gives us the tools to manufacture and deliver lifesaving vaccines at a global scale.

As a result, highly lethal influenza virus, polio, measles, and other viral outbreaks have been brought under control or effectively eliminated. History has proven the power of vaccines. Thanks to national governments and the work of transnational organizations such as UNICEF, Gavi, Médecins Sans Frontières, the World Health Organization, and the Bill & Melinda Gates Foundation, immunization against potential pandemics reaches more than 80% of children worldwide and saves 2 million to 3 million lives each year. The eventual discovery of a vaccine will undoubtedly arm the world with a powerful tool to defeat the SARS-CoV-2 virus.

The power of loggers

To identify the exposure of vaccines to high or low temperatures, health workers rely on data loggers. These small units act as guardian angels that accompany the vaccines along their journey and ensure that the cold chain is respected under all circumstances. They allow health care providers to digitally keep track of unacceptable excursions outside WHO-recommended temperatures between 2 and 8 degrees Celsius. Thanks to this technology, parents know that their children are safely protected against deadly infections.

At a national level, government officials can keep a close eye on the performance of the cold chain. Combined with a remote temperature monitoring device, the logger provides not only a real-time visualization of the temperature data but also a GPS location of the equipment over Google Maps. In unstable countries such as Nigeria or Afghanistan, the technology prevents putting lives at risk for unnecessary maintenance work.

However, history has also shown us that a vaccine in itself is not a panacea. Its development will be the beginning of a long fight against a virus that has spread at a breakneck speed across more than 150 countries. To win the fight, we will need to immunize 60% to 70% of all individuals. This will not only require massive manufacturing and logistic capabilities but also strong cold-chain systems.

Innovations can help crack the challenge. Recently, Gavi CEO Seth Berkley, Harvard Medical School’s Rebecca Weintraub, and the Center for Global Development’s Prashant Yadav urged the world to ensure delivery systems are ready to manage the safe — but also rapid — distribution of billions of doses of temperature-sensitive vaccines. Governments, nongovernmental organizations, and private companies are mobilizing.

Why an unbroken cold chain is important

Vaccines travel far and wide from the time they are manufactured until the time they are administered. As most are temperature-sensitive, their transport and storage require constant refrigeration along the entire supply chain. Once exposed to hot or freezing temperatures, vaccines lose their potency and must be immediately discarded to prevent the risk of giving children and the elderly a potentially ineffective and unsafe antigen.

In 2017, the improper storage of a measles vaccine in South Sudan contaminated 15 children under the age of 5, who subsequently died of severe sepsis and toxicity. A few years later, it was discovered that refrigeration equipment distributed globally and manufactured by a reputable company was freezing the vaccines instead of keeping them at 2 to 8 degrees Celsius. In a similar incident, an Asian manufacturer removed its devices from the market after seeing a breakdown in performance and the freezing of vaccines.

Solutions for transporting and storing vaccines in tropical weather conditions have existed since 1979, when Electrolux cracked the challenge. The company, currently known as B Medical Systems, had developed the first refrigerators able to maintain stable temperatures despite frequent power cuts and a transport box that kept vaccines cool during lengthy journeys in rural areas at extreme temperatures.

New, innovative technologies and advanced features have emerged since then. Today, there are vaccine refrigerators resistant to abrupt voltage spikes and solar-powered cold-chain equipment. In the most off-grid areas of the world, and in countries such as Afghanistan that are engulfed in instability, solar energy is more reliable than an electricity supply. Frequently, the sun is strong enough to keep vaccines cool and safe, to charge phones, and to power lighting through harvesting systems.

Health Center Kits: the solution that makes electricity mobile in remote, off-grid areas. Video by: B Medical Systems via YouTube

Despite these technological innovations, vaccines are still being wasted because of temperature control and related logistics. The problem is that many health centers in low- and middle-income countries don’t have adequate vaccine cold-chain systems.

Knowing that the cold chain is the largest factor inhibiting successful immunization for all, Gavi has adopted a strategy that, notably, consists of strengthening vaccine cold-chain systems in LMICs. Since its launch in 2000, Gavi has helped to vaccinate more than 760 million children in the poorest countries across the world, preventing over 13 million deaths.

Boosting the immunization coverage in the Democratic Republic of the Congo was one of its most ambitious goals. Tremendous efforts to deploy thousands of solar-powered vaccine refrigerators in the country’s most vulnerable provinces have halved child mortality over the past two decades.

In Nigeria — whose government has devoted considerable efforts to reinforce its cold chain in the past 15 years — there are over 19,000 pieces of vaccine cold-chain equipment, including 5,000 solar direct drive refrigerators. Research revealed that about 250 SDD refrigerators would save over 6,000 lives in the country and prevent over 37,700 cases of illness in the next decade. In addition to the social value, each cold-chain unit would also contribute to boosting Nigeria’s economic growth, resulting in over $4.4 million per unit in just a decade for an initial investment of $7,000. Healthier people live longer lives and are more productive in the workplace.

How a vaccine refrigerator saves lives in Nigeria: the story of Dr. Archibong at Kuchigoro Health Clinic in Abuja. Video by: B Medical Systems via YouTube

Gavi also created the Cold Chain Equipment Optimisation Platform in 2016 and, through this, committed $250 million toward strengthening immunization coverage and equity in LMICs by improving their cold chains. Only equipment that passed a set of performance, quality, and safety tests by WHO has been deployed in ill-equipped health facilities. When lives are at stake, reliability is key; it is essential that the vaccine cold chain works perfectly at all times. To reach a further 300 million children from 2021 to 2025 and save an additional 7 million to 8 million lives, Gavi has set up a new, ambitious plan worth $7.4 billion. Now more than ever, the world needs to double down on immunization and come together to offer every child a healthy life.

A strategic weapon to defeat COVID-19

No country is immune from the new coronavirus. There is a high chance that the virus will settle in the most vulnerable countries and cause calamities. Due to their weakened health care systems, financial fragility, and malnutrition, an outbreak could rapidly overwhelm their health and economic systems. Sub-Saharan Africa has about 1 doctor for every 5,000 people, compared with 1 per 300 in Europe. In countries with per-person incomes below $1,000 annually, two-thirds of the population lives in the countryside, where the closest health center may be several hours away on foot.

Introducing lockdowns, social distancing, and other preventive measures is insufficient in densely populated countries. How can you self-isolate if you live in overcrowded slums? How can you wash your hands regularly if your household is not equipped with piped water?

The coronavirus has been testing governments’ abilities to act quickly and collectively. While the world is waiting for a vaccine, it is high time that the world joins forces in arming the most vulnerable countries with the reliable cold-chain equipment needed to bring the pandemic under control.

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About the author

  • Raja Rao

    Raja Rao is the director of cold-chain strategy and markets at B Medical Systems. He has over 20 years of experience in global health and development. He provided leadership and support to global coalitions of partners such as UNICEF, WHO, and Gavi and supported UNICEF in creating market-based procurement strategies. He supported the launch, rollout, and scale-up of the eVIN vaccine management information system.