Being seen as the endgame of the Covid-19 pandemic, India’s vaccination drive has been hailed as one of the largest vaccinations drives in the world with it being the second most populous country in the world. While there are mixed reactions from the industrial diaspora on the extent with which the vaccination is being conducted in the country, the ultimate truth remains that for a country with 1.39 billion population, there are bound to be teething challenges. Our recent webinar, ‘Vaccine Supply Chain & Challenges – India & Globally’ dwelled on the imperatives that are needed from all the quarters to ensure effective & efficient vaccination drive. Our august panelists highlighted and elaborated on the global vaccination efforts, India’s vaccination strategy, our logistical prowess and people participation that will ultimately aid in the success of the Vaccination Drive. This Cover Story brings you the excerpts of the expert panel and the humungous task that is there upon us all individuals to make it succeed – TO GET VACCINATED!
For a supply chain professional, there was never a ‘Normal” and there never will be one.
“In the 21st Century, companies do not compete, but their supply chains compete. If everything being equal (Product, Specs, Service, Price, Features), what separates organizations from each other is their Supply Chain prowess, capability, and efficiency. What we call “Globalization” had forced companies to move their supply chains across international borders making the chains more “Interconnected” but at the same time making them more “decentralized” and hence more “fragile,” emphasizes Sanjay Desai, Regional Director – Talent Development, Humana International Singapore.
Your view on status of global supply chains and the impacts that Covid-19 has had on them so far.
Corona virus has had far reaching ramifications on the world economy, supply chains/ financial stability including people health. As of mid-April 2021, we have more than 136 million cases of infections & close to 3 million deaths across the globe. There was never a worst calamity in the world (other than Spanish flu) of this magnitude. Specifically for emerging markets, this could be the worst phase as well as a gamechanger over the next 5 years. The scars of year 2020 will be etched in our memory for lifetime.
In the 21st Century, companies do not compete, but their supply chains compete. If everything being equal (Product, Specs, Service, Price, Features), what separates organizations from each other is their Supply Chain prowess, capability, and efficiency. What we call “Globalization” had forced companies to move their supply chains across international borders making the chains more “Interconnected” but at the same time making them more “decentralized” and hence more “fragile”.
Over last three decades, organizations and their supply chain are trying to find new paths, new ways to gain advantage over their competitors in the pursuit of making their products cheaper and available at greater speed to Customers at the same time. And in this penchant, Cost superseded Quality in all aspects of the Value Chain…Supply Chains became leaner and leaner over the years, leaving no room to absorb any disruptions. Eventually Corona Virus was the “Last Straw that broke the Camel’s back”.
A lot has been talked about “new normal” for supply chain in post covid period. As a Supply Chain professional of over 30 years and having run supply chains in 11 different organizations, what are your thoughts?
Personally, I do not like the word “New Normal” if this is being used purely from a supply chain point of view, may be from a colloquial and business dynamics perspective the “new normal” may make some sense. I would rather address this as BC = Before Covid and AD = After Disease for supply chain organizations.
For a supply chain professional, there was never a ‘Normal’ and there never will be one. Almost everything is dynamic in supply chain and that is the way it should be, else we will not be able to develop supply chain leaders. Businesses evolve every 3 to 4 years, so does supply chain professionals and with them the supply chain models too evolve. In supply chain,“change” is one “mantra” that drives efficiency, scale, creativity & eventually achieving better customer experience or satisfaction. As a leader, one needs to hedge working capital costs in multiple ways from time to time as the dynamics of the business demands. If you take a good look at organizations with world class supply chains, these supply chains are “tailormade” for their customers / markets/ geographies, often, you will find one common factor and that is supply chain thought leadership. These leaders have honed their ability to see into the future, they are willing to invest in people, processes, and tools (In that exact order) as a driving force. In these organizations, the senior executives/ board members understand & acknowledge the value that supply chain brings to the table.
India is called “The Pharmacy of the World”. What efforts Indian government and companies are taking to ensure that India will be able to support the huge requirements of vaccines all over the world?
India produces 20% of all pharmaceuticals consumed worldwide, making the country the largest manufacturer and supplier of drugs globally. At present, India is using two vaccines (AstraZeneca’s COVISHIELD and Bharat Biotech’s COVAXIN. Besides taking care of the domestic needs, India has already started to export vaccines to many countries like Bangladesh, Bhutan, Nepal, and Maldives as “neighbourhood first” policy. Serum Institute of India is geared up to produce 100 million doses of the AstraZeneca COVID vaccine each month. Plus, we have 5 to 6 more vaccines in the pipeline expected to be available by October / November 2021, for manufacture and domestic use. Some of these are (Zydus Cadila, Dr Reddy’s, HDT Biotech (US), and Biological E).
However, considering the scale of these manufacturing requirements, India would require huge quantities of raw materials needed to make these vaccines possible. India is working with the US to address this key factor. We must recognize the effort of Bharat Biotech and Serum Institute for working 24/7 even during shutdown periods with prior government approvals and assistance. As a supply chain professional, I strongly feel that India’s supply chain was “bent/ tested aggressively, but not broken” during the pandemic.
Covid-19 vaccines are relatively new to the world. What differences do you see in handling requirements in relation to the vaccines (non-Covid types) of the past?
Both COVISHIELD and COVAXIN are easy to store as they require to be kept at 2-8 degree Celsius. Most vaccines commonly used in India are kept at this temperature range. This makes transport and local storage of both Covid-19 vaccines safe and easy for all parts of the country. There are two more vaccines, which are being administered globally are 1) Pfizer and 2) Moderna. Indian Government is still debating whether to allow these vaccines to be used in India. Both vaccines use mRNA technology, which involves using genetic material from the virus called mRNA, which directs the body’s cells to stimulate the immune system. This method has not been used to create a vaccine so far. While this method is simple, once you have the RNA Platform available, to manufacture on a large scale, both vaccines require stringent temperature requirements, and the range also varies considerably.
Moderna’s vaccine needs long-term storage at minus 20-degrees Celsius (minus 4 Fahrenheit), while the Pfizer vaccine requires minus 70-degree Celsius (minus 94 degrees Fahrenheit) or even lower – one of the coldest temperatures ever seen in a vaccine. Given our infrastructure especially in tier 3 and 4 cities and in rural areas, these two vaccines are not ideal to be used. However, we do have sufficient infrastructure available in our main metro and mini metro cities where we are able to store and transport (20-degrees Celsius and -70 degree Celsius).
As global economies are slowly finding their feet in a murky environment, which are the enablers of success to fight such a huge disaster? What have we (the industry) learnt from this experience to apply them?
There are many lessons that we can articulate but I prefer to talk about these top 3-4 which can be industry agnostic:
First lesson was about conducting Risk Assessment. A significant learning from Corona virus that most global and world class organizations carried is to build “Risk Assessment” right upstream in your value chain. Incorporating risk management, upstream in value chain will drive a mindset of “engineering the supply chain” v/s engineering the quarterly Balance-Sheet”.
Second lesson learnt is to increase visibility in your entire value chain like your 3rd and 4th Tier suppliers, your employees, your inventories, major customers, and their demand / supply exigencies. If you have visibility of your entire supply and demand networks, your ability to be agile as well as resilient increases many times over.
Third lesson learnt, there is a certain benefit in “collaborating” across your value chain starting from left (your customers) all the way to right (your suppliers) creating value driven collaborative strategies like demand sensing, integrated business planning, demand drive inventory planning, segregation of customers and finally a multi-source “Integrated Supply Network” of smaller supply networks across geographies.
Fourth lesson learnt is to “optimize your order management and fulfilment capabilities” to be able to fulfil your customers from anywhere to anywhere. Proactive customer engagement, adding huge value to customers P&L and speed of operations will be of prime importance as highlighted never before.
Finally, organizations realized that investment in technology, re-skilling your employees helping them to be comfortable with new tool sets and using advanced communication tools are critical success factors in future. The only way to improve in such situations, is to leverage your most valuable asset “Your People”.
We are taking help from the representatives of the community to drive immunization in rural areas.
“Believing in ‘One size doesn’t fit all’ strategy, we have observed that self-registration mechanism is pretty less in rural areas, therefore we have adopted facilitated cohort approach to increase the coverage. Strong leadership from the expert group, election model approach, learnings from Universal Immunization program, an efficient IT system and robust IEC strategy have been the strong pillars for the effective roll-out of the vaccination drive,” shares Dr. Mohan Lata, Surveillance Medical Officer at World Health Organization.
What are the key strategies in the effective roll-out of vaccines?
The Government of India is using the experience of Universal Immunization Program dovetailed with the election model approach. MoHFW develops Operational guidelines whenever there is new vaccine introduction so that uniform practices are being followed across the country. Similarly, for COVID-19 vaccination as well operational guidelines have been developed and followed across the country. As enumerated in these guidelines, a covid-19 vaccination center needs to be prepared, which should have three dedicated areas: waiting area, vaccination area and the observation area. Each vaccination center is deployed with the dedicated trained vaccination team. This team comprises of one security personnel at the entrance, one verifier who checks for the identity and is also using Co-Win portal, this is the portal developed by MoHfW, which is being used for the registration, appointment and vaccination. Then one vaccinator and the last 2 team members work in the observation room and also overall manages the session site. This dedication structure with the dedicated team is the adaptation of the election booth model. This adaptation has been taken from the election booth model.
We have also adopted some practices of universal immunization program and these practices are like development of micro-plans, information, education and communication materials and capacity building of healthcare workers on topics such as injection technique, cold chain maintenance, adverse event following immunization, four key messages and biomedical waste management. These are some of the protocols we are deploying for scaling up the vaccination drive. Along with this, the vaccination primarily is targeted for three major groups. These groups were identified by the National Expert Group on Vaccine Administration for Covid (NEGVAC). The first group was healthcare workers, then frontline workers and the priority age group which was earlier above 60 years and people above 45 years with selected comorbidities but now it is above 45 years. The list of healthcare workers was uploaded at the district level using the Co-Win portal and for every session, there was an automated generation of the due list. Beneficiaries receive messages regarding the time and place for the vaccination. The similar process was followed in the second phase as well. For the priority age group, Co-Win 2.0 which is the upgraded version of the earlier portal is being used where we no longer must upload a list of beneficiaries for registration and vaccination. The beneficiaries now can self-register themselves using Co-Win portal or Aarogya Setu app; or can also choose for on the spot registration.
As you know health is a State subject, we have undertaken some targeted approach like campaign for women on women’s day, mobilization of pensioners, inclusion of Panchayati Raj representatives, retired government people etc. As one size does not fit all, we have also observed that the self registration mechanism is less in rural areas. Therefore, we have adopted facilitated cohort approach which included mass mobilization and on-the-spot registration cum vaccination of the beneficiaries.
Strong leadership from Expert groups, Election model approach, learnings from Universal Immunization Program, efficient IT system and robust IEC have been strong pillars for effective rollout and implementation for COVID-19 vaccination.
Is the current vaccination drive as successful as any other immunization drives that India has been doing over the years?
Usually in mass vaccination drives, we introduce vaccines at one go for the selected regions. But for Covid-19 vaccination, we have broken down the drive into phased manner. I believe we are keeping up pace with the planned roll-out and achieving the target. For elderly age group, different approaches have been deployed for the effective roll-out and implementation. Learnings from past vaccination drives and UIP is helping us.
How has supply chain been maintained from the vaccination drive? Has the government of India formed any public private partnership or any secondary distribution mechanism?
Supply in India includes delivery of the vaccines from Government Medical Store Depots (GMSDs). In total, we have 4 GMSDs in the country – Karnal, Mumbai, Chennai, and Kolkata. From GMSDs, the vaccines come to state vaccine stores followed by the Regional Vaccine Stores or Divisional Vaccine Stores. From there, the vaccines are delivered to District Vaccine Stores. From these district vaccines stores, the vaccines reach to Cold Chain Points and these are usually situated at Block level i.e., community health centers or primary health centers. During this entire cycle of supply, the cold chain of the vaccine is maintained through usage of the insulated vaccine vans and cold boxes. From these cold chain points to the session sites situated at the last mile, the vaccines are sent on the same day i.e., the vaccination day in the vaccine carriers. These vaccine carriers are usually accompanied by the conditioned ice packs in order to maintain the ambient temperature of +2 to +8 degrees. To track the entire system of supply chain, we have electronic vaccine intelligence Network (EVIN) system. This helps in temperature monitoring and tracking of stock of vaccines and expiry date. The concept of FIFO is used to avoid vaccine wastage. For any unopened vaccine vial at the sessions site, we maintain the reverse cold chain using the same prescribed conditions. Covid-19 vaccination is also done at the private hospitals, so GoI has also acknowledged that if these private hospitals have sufficient capacity for storage or they can function as cold chain points, they can stock vaccines for their own consumption. This is the kind of PPP model the government is following as far as Covid-19 vaccination is concerned.
What is the role of NEGVAC?
A National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) has been established, which provides guidance on all aspects of COVID-19 vaccination including prioritization of population groups, procurement and inventory management, vaccine selection, vaccine delivery and tracking mechanism, etc. NEGVAC is chaired by Member (Health), NITI Aayog and cochaired by Secretary (H&FW). NEGVAC has representation of Secretaries from Ministry of External Affairs, Department of Expenditure, Dept. of Biotechnology, Dept. of Health Research, Dept. of Pharmaceuticals, Ministry of Electronics and Information Technology, representative from five State governments and technical experts. The government is utilizing the experience of elections and universal immunization program and ensure that there will be no compromise on scientific and regulatory norms and other Standard Operating Procedures (SOPs). The group also ascertains equitable distribution of vaccines to other nations. The group also provides guidelines on the vaccine candidates’ selection, procurement mechanisms, prioritization of population group, financial resources requirement of vaccine procurement and logistics. The group guides the MoHFW on the vaccine safety, AEFI, and guides the department on creating awareness regarding the vaccination drive.
How are you motivating people to come out and get vaccinated?
One size does not fit all. Strategies could be different for everyone be it state or a district. We are taking help from the people who are the representatives of the community. These practices have been replicated from the experience of previous vaccination drives. We are reaching out to panchayat level elderly people to motivate others by taking the vaccine jab. This is one strategy we are following in the rural areas. Likewise, teachers can be the role models for parents so that they can come forward for vaccination. We are using FAQs developed by MoHFW to give answers to the doubts and queries of people. As mentioned earlier, strong advocacy and interdepartmental coordination is our key of successful implementation.
What are the lessons learnt from the vaccination drive? What are the opportunities that it has presented?
This largest vaccination drive is effective through concerted and tireless efforts of the health workers, along with the gaiety inter-sector and inter-department coordination. For any mass drive to be effective, a definite structure with demarcation of roles and responsibilities is vital, which was done through the guidance of NEGVAC and development of operational guidelines. IT and IEC are the two pivots for this vaccination drive which are also the opportunities to see forward. The strengthening of IT component of immunization system and robust IEC (like FAQs for citizens, regularly busting fake news) is yielding good results.
In our war against the Covid 19 pandemic, the battle is now.
“We will win the battle against Covid eventually. Establishing a secure supply of vaccines, augmenting disease surveillance and scaling up social mobilization will be key to how soon we win the battle.” asserts Dr. Raj Shankar Ghosh, Senior Advisor – Vaccine Delivery, Bill & Melinda Gates Foundation.
Which are the factors that are critical for vaccination planning perspective? Which are the roles that you see technology can play in this?
Before answering this question, let me take you three decades back. I was working for an NGO delivering Primary Health care in one of the desert districts of India in Rajasthan. One day when we were planning on improving coverage in far flung villages in the district, a health worker told us that planning for vaccination basically required a 3P fulcrum.
Empowered People. People who are aware of the vaccine. People who are trained to vaccinate. And people who will mobilize the population for vaccination.
The 3P fulcrum is relevant in routine immunization or large campaigns like Polio eradication or adult vaccinations like Covid vaccination.
As we plan for scaling up vaccination coverage in routine program and campaigns, we must answer the following questions:
What is the production capacity of vaccines currently being used in the program? What is the committed supply to India? We can only do as much as the product supply to our program is.
Are centers evenly distributed? Numbers & equity. Map the centers. Find out vacant spots. Are both public and private sectors being effectively utilized?
How many trained people do we have? Have we engaged the full potential of health care workers in both public and private sectors to vaccinate our people?
India and many other countries in the region have prepared early for Covid vaccination program. Following 3 P principle. (i) Committed vaccine availability. Domestic and global supply. (ii) Covid-vaccination appropriate delivery infrastructure available in public and private sectors. (iii) Trained manpower available in public and private sectors. Completed their training through a mix of online and face to face trainings and demonstrations. Prioritized population based on local clinical and epidemiological data. Now let me address how India planned its Covid vaccination program. Before I come to planning, let me tell you an anecdote.
About 20 years back in a district in Jharkhand State where I was in-charge of India’s National Polio Surveillance Program, there was one district which was a poor performer for many rounds. A new district magistrate joined the district a few months prior to Pulse Polio program. In just about 2 months vaccination coverage improved. I went to meet him and asked him what has changed in the last 2 months. He told me that there were gaps in the program, and he had met the gaps with the GAP strategy. The GAP strategy is: Governance; Accountability and Planning. If we have a strong governance, if we have clear roles and responsibilities and make people accountable for their activities, and if we have a good micro plan in place, then a program is destined to succeed. In India for Covid vaccination program, we have seen governance executed well by the NEGVAC committee which is a high level inter-departmental committee formed at the apex reporting to the highest authority in the Country. Principal accountability lies only with few people – at Central level, State land at district level. At district level District Magistrate is overall in-charge of the program coordinating all locally available resources for implementation. Micro-planning has been done by frontline workers at Primary health centers. As they have done for other programs like Mission Indradhanush and National Immunization Days.
There is a 4th P – Partners. Partnership in vaccine delivery has always been strong in India. With Covid vaccination new partners like World Bank and ADB have come forward to support vaccine delivery in South Asia Region. Existing partners in India include WHO, UNICEF, UNDP, JSI, PATH, GAVI, CHAI, the Technical Support Units in the States and BMGF to name a few.
Is there any technology case study to manage the entire value chain in a cost effective and secure manner?
For every successful technology, primarily in healthcare, there have been four attributes that we have to acknowledge:
Technology was developed because there was a demand. There was a problem or an aspiration that present solutions could not solve and therefore there was a need to design and introduce a new technology solution.
Technology must adapt to current health systems. This means it can be scaled up in the system with efficiency, speed, and minimal investment.
Technology needs to be affordable for the government to scale up in public health programs.
Technology must be user-friendly. One example that I would like to quote here is of Vaccine Vial Monitors (VVMs). A VVM is a label containing a heat sensitive material which is placed on a vaccine vial to register cumulative heat exposure over time. The combined effects of time and temperature cause the inner square of the VVM to darken, gradually and irreversibly. A direct relationship exists between the rate of colour change and temperature:
The lower the temperature, the slower the colour change.
The higher the temperature, the faster the colour change.
The VVM is a circle with a small square inside it. It can be printed on a product label, attached to the vaccine vial or tube, or attached to the neck of an ampoule.
VVM is the only tool among all time temperature indicators that is available at any time in the process of distribution and at the time a vaccine is administered indicating whether the vaccine has been exposed to excessive heat over time and whether it is likely to have been damaged.
VVM along with the expiry date on the vial clearly indicates to health workers whether a vaccine can be used at any given point of time.
I was a primary health officer about 25 years back. In the vaccination program that my PHC implemented, one of the rigorous and mandatory tasks was to ship back random vaccine vials from our remote primary health center to a centralized laboratory in Kasauli in Himachal Pradesh. This whole process was both costly and complex. From across India, everyone had to send back random vaccine samples in reverse cold chain for the Central Research Institute laboratory at Kasauli to check efficacy and the potency and the cold chain status of the vaccine. By the time the PHC would receive the status report back from Kasauli, the vaccine would have been administered.
In 1995 India launched Pulse Polio program. A nationwide vaccination campaign with Oral Polio vaccine. In such campaigns a clear understanding of cold chain status of the vaccine would be critical to the quality of the program. There was no way one could understand whether cold chain had been effectively maintained during supply of the vaccine. Therefore, a technology was introduced in the form of vaccine vial monitor. This boosted confidence not only for vaccinators but also for general public. It was so easy to distinguish the two colors that parents themselves could understand whether the vaccine being delivered to their children was of good quality. A good technology in public health programs should be easily interpreted.
A second example of an effective technology would be the Co-Win platform that has been launched for Covid vaccination. It was clear in early stages of planning that in order to address this large cohort of the adult population, the program had to have a very systematic pathway from registration to tracking to recording of any adverse impact to certification process. And all of these needed to be delivered through a single window application. Based on principles of a successful existing supply chain technology in Routine immunization, eVIN technology, an application was developed for this purpose. This application is CoWIN technology. A technology that registers all beneficiaries, tracks them, records all serious adverse events and on completion of the vaccination schedule provides a certificate that records the individual’s Covid vaccination program.
What are the lessons learnt from the vaccination drive? What are the opportunities that it has presented?
In my career spanning 30 years in public health, there have been 3 defining moments attached to three vaccination programs. These programs taught me some fundamentals of vaccination like a teacher patiently.
Pulse polio taught me the intricacies of partnerships in vaccination programs.
Japanese Encephalitis vaccination taught me the intricacies of planning a campaign & the pathway from a public health problem to policy to program.
Rota vaccination taught me the value of meticulous evidence collation for an effective vaccination program.
My debt to these 3 programs is lifelong.
Coming back to the current scenario, one thing that we need to be very clear is that the world is ultimately one big village. One of the things that I am very proud of is the Vaccine Maitri initiative of Government of India as they opened up its vaccine supply for its neighbors and other Low- and Middle-Income Countries across the globe. This initiative truly manifests everything that the spirit of India stands for in its recognition of every life having equal value. Vaccine Maitri that has served more than 80 countries worldwide is truly a very bright colored feather in India’s shining cap.
The second lesson that we need to look at is the importance of social mobilization in the program. When the vaccination program began, we felt that there would be a massive vaccine eagerness. However, when the vaccination program rolled out, a few were hesitant to accept the vaccine. Initial coverage took time to accelerate. There were multiple appeals from Health Ministry and other Ministries, leading medical professionals as well as from various leaders of the society. Soon the coverage picked up and now we are seeing 3-4 million doses being delivered every day.
Third thing we need to keep in mind is that technology is a very good solution, but we need to be prepared for back-up plan. If sometimes technology solutions perform below expectations albeit temporarily, we can quickly have an alternate plan in place. There always needs to be a mitigation plan. For example, when Covid vaccination program was launched in India, at some places media reported that the Co-Win app was not working to its full potential. The States however did not allow that to slow down the program. They immediately took help of Google sheet and captured data. Within a short time CoWIN was functioning at its full potential and the States adopted CoWIN application fully. Such mitigation plans are very important for large scale programs.
Countries will have to prioritize three things presently. The 3 Ss.
• Supply security of Vaccines
• Social mobilization
The three are self-explanatory.
Vaccination must reach maximum number of people both in terms of eligibility criteria by age and coverage. To do that, the world needs to have enough vaccines. To have enough vaccines, production must be ramped up. And vaccines must be distributed equitably, so that no Nation, no segment of population is deprived of benefit of vaccines.
Surveillance both in terms of reporting, testing and action following availability of relevant data is critical to identify hot spots of transmission. Immediate action – both in terms of preventing transmission and protecting the population with vaccines must be deployed immediately.
Effective Social mobilization is imperative to achieve victory against the virus. Social mobilization will ensure that more and more people adopt Covid appropriate public health practices and extend their arm for vaccination.
India and the world will win the battle against the virus eventually. The speed to victory will depend on the speed and extent to which we embrace the 3S tools.
Technology has been playing the role of an enabler in solving infrastructure problems.
“While the world was focused on Covid-19 vaccines, we turned our sights on another key problem: proper storage and delivery. We built and delivered efficient medical coolers & freezers that precisely cool and store vaccines for days, even without regular power. Because if there is anything better than keeping India safe, it’s to keep India safer,” asserts Jaishankar Natarajan, Associate Vice President, Head New Business Development – Appliances Division, Godrej & Boyce Mfg. Co. Ltd.
What challenges do you see with respect to wide geographies that India possesses in terms of vaccine delivery?
There are many challenges that we face in the urban, peri-urban and the rural areas. The first challenge is scale. The entire immunization program if you look at the scale at which it was operating was meant to cater to around 27 million population. For COVID vaccinations its over 10 times this figure. It is mind boggling scale, which needed to be immediately deployed. That is the kind of pace we are talking about. Government is going to co-opt many more centers which are hospital facilities, healthcare centers, which are currently available for various other activities into this vaccination program. Establishing protocols, ensuring the same rigor and procedures to follow in all these co-opted healthcare spaces is of paramount importance.
Cold chain is a big challenge. The scale of vaccine movement between the urban set up would require large depot to depot transfer either through mobile, refrigerator vans or through temperature-controlled cartons, which are currently being developed and scaled up in the country. It is not available at a scale which is required. There are last mile challenges as well, in terms of delivering and distributing vaccines, which needs to be undertaken at a large scale. Large amount of planning of where exactly the vaccines are required and how fast it needs to be delivered daily needs to be done a continuous basis to understand and deliver the coverage we are looking at. This is about urban side. The rural side has got several challenges in terms of physical infrastructure not being available. Instead of people coming to hospitals, there is a need to set up camps closer to villages and then motivate people to visit the camps. Availability of healthcare workers, mobile cold chain solutions and ensuring that the right kind of solution is available so that you have large coverage possible in each of the outreach programs is of paramount importance.
COVID-19 vaccines are extremely temperature sensitive. Under- or over cooling can affect vaccine potency, leading to compromising its efficacy. This has a direct implication on citizen health and as well cost overrun of the vaccination program. Given the huge economic implication of the vaccination drive, any wastage or inefficiency in the vaccination process due to logistical issues related to cold chain must be avoided. Our medical refrigerators are designed to deliver such precision cooling despite power cuts and have qualified tough international WHO PQS certification standards. Currently, to meet the increasing demand, we have enhanced our production capacity of these specialized products by 250%.
Will we be able to keep pace with the infrastructure development and the quick roll-out that is needed for the vaccine?
Technology has been playing the role of an enabler in solving infrastructure problems. Let me give you an example, Continuous Power availability & to a large extent when available, the quality is inconsistent in peri urban and rural areas.
Outside of India, it is a major challenge in most of the African countries. So, when we came into picture 5 years back, we did due diligence in understanding the issue with the supply of power. We came across several challenges. Firstly, there were power deficient areas. In those areas, we attempted the adoption of alternate energy sources such as solar.
The second challenge was where power was available, the quality of power was lacking in terms of voltage capacity, surge protection, huge amounts of spikes, etc.
We found out something very unique that wherever the stabilizers were given separately along with the equipment for running cold chain, we found that either the stabilizers were defunct, or they had been taken off for general use for other purposes. We came up with a solution to provide in-built voltage stabilizers within the unit itself. We made it very powerful to withstand the surges of voltage of 2-4kv and ensure that the product reliability is taken care of in such adverse quality conditions. In case of non-availability of power, we devised solutions which are not dependent on battery because the battery itself reduces the life of the equipment. We developed equipment which can run directly on solar power. A lot of technology innovations happened in that area. In many rural areas, service intervention is extremely challenging.
In case, something does go wrong, one needs to have the ability to acknowledge that there is something wrong, and it quickly needs fixing. Remote diagnostics need to be built in. Second is to reach to the equipment itself and fix the issue so that vaccine storage or supply does not get hampered. We had to come out with solutions which had hold over time of maintaining the required temperature within the equipment of about 2-8 degrees for over 3-4 days and in some cases where accessibility is very remote, we ensured that technology provides solutions that our refrigerators can maintain the desired temperature without any power and can remain stabilized for over 15-16 days. These are the interventions which led to lot of innovations in the equipment. There is one more example of us deploying such solutions for delivering vaccines across Brahamputra riverbanks. So, accessibility to several villages went up because of such deployment.
There is a feeling that India has not stepped up the gear on the vaccination drive. What interventions had to be quickly taken to bolster capacities for an active response?
When we talk about infrastructure for COVID response, we need to also look at the manufacturers’ infrastructure who have designed the entire plant to serve certain capacity requirement. This requirement has suddenly gone up 10X. While we have seen this coming last year, we have pre-empted by proactively investing in developing extra tools, augmenting machinery well in time, etc., to cater to this surge in demand. We also went back to our suppliers to get their toolings in place. There are several aspects of reaching the vaccine to the last mile and I feel that we still need to catch up on that front. Having said that, there are companies who are willing to come up with temperature controlled cold boxes, quickly deploy them to ensure that distribution does not get hampered, there are mobile solutions coming up, which will enable smooth last mile delivery. Pace of augment would need to be reviewed by the concerned authorities.
As India takes the immunization drive to the hinterland, there will be a big challenge—to store vaccines and deliver them. We are trying a concept called Mobile Clinic. We ran a similar program in Assam, called Boat Clinic where our refrigerators were mounted on boats and they moved from island to island. Once on the field, they come back only after a week or so. The equipment should hold the precise temperature for a week or 10 days. We have taken the same concept in the Covid-19 immunization drive.
We did a pilot in Maharashtra with a 25-litre refrigerator in a van and our R&D team took the van to the hinterland of Maharashtra and ran it successfully for three days consecutively without any electric supply. We are now ready to offer the mobile van solution to various health organizations and governments to take forward the entire immunization program across the country.
Godrej is also running a training program to educate healthcare workers on proper use and maintenance of their equipment, temperature monitoring and troubleshooting. It has already trained 600 frontline workers. The company has an extended network of 680 service centres across the country and 5,000 feet-on-street technicians.
What are the possibilities of deploying the current distribution network for vaccine distribution? What kind of technology augmentation we require?
From the tracing point of view, whether there have been any breaches. There are several interventions which are being put in place. From distribution point of view, RFID tracking, remote monitoring of cold chain temperature of each box is maintained. It is relayed as the vehicle moves along the journey. Any breach is recorded. There are protocols in place such as how many hours of breach is acceptable, what kind of breaches are allowed. From a point of view of taking a call if any compromise has happened during the vaccine movement, that can be ascertained and has already been put in place. Most of the distribution chains have already deployed such technology.
In terms of storage, there are close to around 1 lakh units and several more have been deployed recently. The Central Government has connected all of these devices in their EVIN portal, which constantly monitors temperature. Each of the devices have their own dataloggers to ensure alternate set of data is available at any point in time. This also ensures that local level data monitoring is also not compromised. The area where we still lag is in the last mile delivery. Currently vaccine carriers are cold boxes which currently don’t have any mechanism by which we can ascertain the last 8-9 hours of journey of vaccine is able to sustain itself in terms of temperature. There have been devices which have now developed across the globe to address the challenge, which used remote monitoring mechanisms to ensure that even the last mile is covered.
WHO is putting together a testing and governance protocol to ensure these devices are certified. Once those devices hit the market, we can confidently say that the entire journey from the pharma company till the last mile is completely monitored and reviewed and the vaccine efficacy is ascertained without any breaches.
What are the remedial plans in place if any temperature exertion is reported during the last mile transport? How do we analyze whether the product has lost its efficacy or not?
Till now, one of the standard practices that government followed for breaches, include vaccine vial stickers. These tend to discolour or become black if it is exposed beyond a certain time over 8 or 10 degrees. That is one very good indication whether the vaccine vial has been breached over a longer period of time. But on the freezing side, the sticker doesn’t work. In that case, the medical practitioners need to shake and check for cloud formation of liquid to detect breach. Bulk of the problem in the supply chain, as per our experience, is that lot of vaccines are actually freezing rather than breaching on the higher temperature side. Of late, there are real time monitoring solutions being deployed in terms of cloud-based visualization of what’s happening on a real-time basis. During every outreach program, the district supervisor will be able to see what exactly is happening to the cold box during movement. This is more at a pilot stage. I am sure conversion will gain pace given the scale at which we need to deliver the vaccines.
These solutions are applicable across the length and the breadth of the country. In fact, we are providing global sim cards by way of which it can be deployed in Africa also and can be monitored from here.
What is Vaccine Vial wastage roughly and at what stages it may occur and how to control that?
One is vaccine wastage because of temperature breach. The second is when a vaccine vial has been opened and the entire vial doses could not be administered. While returning the vial to stock, a proper protocol needs to be ensured. If this is not maintained, then the vial could go wasted. Then there are some wastages when vaccines are returned, and reverse logistics scenarios aren’t up to the mark. Planning can be one major issue which can iron out these challenges. Deployment of digital technology to track & monitor and ensure proper planning tools, so CoWin platform itself is being used to ensure that you have only that many doses’ vaccines delivered basis the requirement so that it is evenly distributed, and it is available everywhere. Now there are no pockets of high dosages and the pockets of scarcity.
So those aspects can be well managed by the deployment of technology and I think we are in the right direction of ascertaining that. Government of India has laid out clear guidelines and protocols on how vials should be used and how they should be maintained back into the cold chain when it isn’t fully used. There is always difference between planning and practice, which needs to be followed to ensure that what we set out to do is accomplished.
What are the lessons learnt from the vaccination drive in terms of logistics? What are the opportunities that it has presented?
Technology deployment to overcome infrastructure barriers to facilitate wider outreach.
Training to standardize practices across states/ vaccination centers.
Building scale to meet Covid vaccination coverage plans.
Planning & Distribution to reduce wastage and ensure vaccine availability at all centers.
We need to continue to promote local pharma manufacturing instead of flying vaccines from far off countries.
“India is one of the largest vaccines producers in the world. Almost 2 out of 3 children globally receive vaccines made in India. The supply chain and quality control standards are already well laid in the country. What needs to happen is that the countries outside India need to come up with more localized solutions. We are witnessing increased joint ventures in this direction lately. Having the ability to produce vaccines locally offers many advantages and is the right way to go,” states Michael Culme-Seymour, Vice President and Managing Director APAC at Roambee, Former Consultant to the World Health Organization.
Is there any specific success formula in terms of the roll-out that other nations can emulate?
As we know that first country to roll-out vaccination was the US and, in my view, it was orchestrated in a very organized manner. The credit for this goes to public private partnership. I remember watching the interview process at the Senate hearing where UPS and FedEx had to present their strategies on the effective delivery mechanism that they have planned for the vaccine. Does the packaging work? Do the temperature monitors work? On the international community, Israel and the UK picked up speed, however quickly things in Europe the roll out has not been so successful. The reason for this was more inclined towards political disagreements coupled with delays from Pfizer and AstraZeneca. Efficacy questions were being raised on the AstraZeneca. This hampered the confidence of populace to come out and get vaccinated.
I believe the logistics industry has played its part well in reaching the vaccines to the last mile in the most secure manner. Countries have stepped up their vaccinations drive, and the kind of euphoria being witnessed during the arrival of the vaccines is tremendous confidence booster. India is sourcing within India and it seems to work well where most countries have to fly their vaccines from other nations.
Moreover, it was pleasing to see the action that COVAX and UNICEF took. UNICEF (tasked with the largest delivery of COVAX to 20% of the world population) coordinates the logistics of 2 billion vaccines against all kinds of diseases every year, and that this is really nothing new! The infrastructure is there, the science is there. They are experts in managing this having very qualified partners with the logistics industry supporting them.
COVAX is something that has never been tried before. COVAX is the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator. The ACT Accelerator is a ground-breaking global collaboration to accelerate the development, production, and equitable access to COVID-19 tests, treatments, and vaccines. COVAX is co-led by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI) and WHO. Its aim is to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world. It is a monumental effort. I believe we have to got off to a good start, but there is a long way to go.
What else do you think we need to do so that the campaign becomes successful?
I think we need to be realistic that Covid would be around for many years. The Covid-19 vaccine may later be combined with the annual normal influenza vaccination. We need to consider looking at the long-term aspects and not just the one-off mass vaccination that we are witnessing currently. For example, if you are using a school for vaccination purpose, it’s not sustainable. We need to start looking at different locations with a fixed infrastructure. The focus has really been on vaccines, but there are lot of ancillaries around the entire vaccination drive, which need to work in tandem. I feel most of those aspects are still untouched such as PPE kits, disposal of biomedical waste, so on and so forth.
It’s very important for governments and private actors to think these through in its entirety. Logistically a lot of these supplies are going by sea freight. For every pallet of vaccine, there is at least 5-10 pallets of ancillary supply. It is voluminous and has a high value. We do have an issue with the global sea freight right now with the disproportionate amount of sea containers not being available.
Finally, I think waste management is vital. Medical waste needs to be disposed in a professional way. The process is normally managed through incineration and must adhered to strict WHO guidelines. We also need to draw our attention on the rise of counterfeit vaccines, which is one of the largest challenges we are facing right now. Fake vaccines and fake pharmaceuticals have been in the market for the past 20 years. We must make sure that the public and private partnership ensures the safe storage and transportation of all pharmaceuticals to protect patient safety. That requires serialization of the vaccines, combined with the digitalization of logistics. In short, we need to build a sustainable supply chain around vaccines.
What level of governance do we really require in terms of manufacturing, transportation and also deploying it on the tier III & IV cities?
India is one of the largest vaccine producers in the world. Almost 2 out of 3 children receive vaccines made in India. The supply chain and quality control standards are already well laid in the country. What needs to happen is that the countries outside India need to come up with more localized solutions.
We are witnessing increased joint ventures in this direction lately. Having the ability to produce vaccines offers many advantages and is the right way to go. Governments have to make sure that the corners are not cut because here we are talking about patients’ safety. I also think there is going to be a demand in direct to patient services to help reduce the stress on the medical centers and hospitals. There are already massive backlogs of people who require urgent medical assistance. We have to think about permanent vaccination centers. This must be managed and governed by the Ministry of Health together with private partnerships.
What do you have to say on the pricing of the vaccines globally?
Let’s not talk about the profit margins of pharmaceutical companies. Right now, our focus should be to make sure that every human being has the equitable access to vaccines around the globe. That is what Gavi, WHO, COVAX and other global associations have been doing. We have to continue in that direction as we can’t be held hostage because of pricing hike or political interferences.
We have seen the kind of pressure the export ban by certain countries on PPEs had created. Similarly, as the vaccine was being produced, the EU threatened to stop exports to make sure their population gets vaccines. That can’t happen. No country should politicize vaccine distribution. Lot of financing mechanisms are in place for countries who can’t afford to buy vaccines from the other countries. We need private donations and co-operations need to hold hands and come forward to vaccinate a particular country’s population who are deprived of vaccines owing to financing issues.
What is QUAD and is India going to be one of the major beneficiaries here?
QUAD is an alliance between Australia, India, Japan and the US. QUAD can play an important role in four key areas going forward: maritime security, supply chain security, technology and diplomacy. The latest announcement is that the QUAD has decided as a group that that they will produce 1 billion doses of vaccines in India at the Biological E facility in Hyderabad and this is this is not only a massive boost for India but it's great for the region. This this is a very good demonstration of what private public partnership can do on other regional level. We need to become less dependent on the super nations for pharma supply chains. India has proven that it has the ability to produce world-class pharma products for the global supplies, so I think QUAD has made a strategically important decision here.
What are the lessons learnt from the vaccination drive? What are the opportunities that it has presented?
The pandemic has created other bottlenecks that should be addressed: the fact that while the world was focused on Covid-19, there were many other diseases out there not being treated as they should, due to lack of staff, infrastructure, and lock-down regulations. In addition to the medical knock-on effect, there was the economic one for so many industries reliant on free movement of people and goods. Three challenges are also worth mentioning:
1) Local manufacture of vaccines: the closer to home, vaccines can be made available, the better,
2) Counterfeit: from fake Covid-19 test results to fake vaccines – a robust blockchain solution needs to be in place to ensure authenticity and trustworthiness. The end-user should be able to check via an encrypted confirmation of the vaccine via their smartphone, that do have the bonafide product.
3) The growing issue of bio-medical waste through the increase in PPE, needles, and other Covid-19 related refuse: not all locations have the facilities for incineration, and could the logistics therefore play a part in removing and helping to destroy this waste?
I think these are the three key questions that need to be resolved at the earliest.