Provisions for Africa’s Covid-19 vaccination Campaign: The State of Cold Chain Infrastructure
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The second phase of the Covid-19 pandemic is already underway. Like the rest of the world, Africa is pinning its hopes on the anticipated imminent approval of a Covid-19 vaccine that could begin mass production by early 2021. The continent’s urgent need for vaccines emanates from a desperately weak health system. The region remains vulnerable to the potential devastation from unmitigated spread. Africa’s timely access to a vaccine will be critical to its ability to limit phase II viral spread and protect the vulnerable while avoiding further lockdown of economies as the primary means of controlling viral transmission within communities.
Africa as a region needs to urgently articulate a plan for securing vaccine for its most vulnerable populations, and for safely delivering it to African destinations from manufacturing sites outside the continent without the risk of it getting spoilt by temperature fluctuations. Africa cannot effectively deploy a Covid-19 vaccine and run an effective large-scale vaccination campaign without addressing its cold chain infrastructure gap. This is one of the most urgent infrastructure requirements for Africa’s Covid-19 vaccine deployment preparedness.
An adequate cold chain infrastructure to effectively deploy a Covid-19 vaccine
Nine of 300 candidate vaccines worldwide are in various stages of phase III clinical studies. Three are leading the race – Oxford-AstraZeneca, BioNTech-Pfizer and NIH-Moderna. Outside the West, China has two biotech companies CanSino Biologics and Sinopharm, both with phase III vaccines. Sinopharm is co-developing one of its two vaccines with the multinational Johnson & Johnson, but this trial has become the second to be suspended due to serious complications affecting one of its participants. The Gamaleya Research Institute of Russia also has a vaccine in phase III trials posited in the race to become the first to reach the market.
Whichever vaccine wins the race, its delivery anywhere in the world will face many hurdles including the availability of safety data, acceptance and finance. Each of these vaccines will require adequate cold chain facilities to be effectively deployed in vaccination campaigns. Low-middle-income countries (LMICs) will face the challenge of limited access to vaccine brought on by the limited cold chain infrastructure available for effectively deploying and managing large-scale vaccination campaigns of Covid-19 proportions. In particular, Africa has limited cold storage facilities across its airports. This elevates the risk that Covid-19 vaccine destined to some African destinations could get spoilt by temperature fluctuations en route.
Africa’s successful public health campaign against Covid-19 is not a mystery
Following a first wave of the Covid-19 pandemic that has taken more than 1 million lives worldwide, the second wave is already underway in Europe and elsewhere. Africa is widely recognized for its successful Covid-19 phase I response. According to the WHO, Africa remains one of the least affected regions in the world. This is largely explained by the fact that Africa took some basic public health interventions that have been proven to be effective at mitigating Covid-19 spread. When basic scientific facts are acknowledged, for instance, the fact that the average Sub-Saharan African country imposed more stringent containment measures more quickly than the average EU country and the United States, Africa’s Covid-19 outcomes are not a mystery. The majority of African countries adopted comprehensive contact tracing policies including at airports well before Covid-19 began spreading in Africa countries. The Africa CDC instituted a sustained, agile and responsive policy that continues to be adjusted in real time in line with emerging scientific evidence on contact tracing and isolation, which governments have tailored to their cultural and national contexts. Africa’s population is regularly sensitized to the reality of disease outbreaks like Ebola, yellow fever and lassa fever. Such awareness amongst the public created strong buy-in by African communities and widespread acceptance of the necessity of control measures. Effective communication, community by-in and public acceptance are critical ingredients in any successful public health campaign. Africa also drew on its rich previous experience with contact tracing and isolating, for instance with Ebola and tuberculosis patients. These experiences enabled African governments’ greater success at isolating high-risk contacts than other governments, including the UK’s.
These public health measures have been proven and demonstrated to significantly reduce the impact of Covid-19 spread in countries around the world. Whilst this does not rule out the possibility that other factors may have played a role, there is little data to support the proposed explanations for why and how Africa escaped the worst fate predicted. The world, it seems, is willing to accept any other explanation – genetics, the youthful population, cross protection from exposure from other pathogens, even the weather, before accepting that this was a success born of deliberate actions taken by African leaders. The willful refusal to acknowledge the facts – that the scientifically proven public health interventions that were taken into account for the public health outcomes that were observed in preference of the unproven hypothesis to explain Africa’s Covid-19 phase I outcomes – is driven by arrogance.
It would take some humility to acknowledge the basic facts. Africa mounted a robust response. It instituted concrete actions that were vigorously implemented through its multilateral institutions and government leaders working with businesses and the general population to protect its weak health systems from getting overwhelmed. These things made a critical difference in the way that the pandemic played out on the continent. However, in a world that is much more comfortable with its preferred narrative – of Africa’s perpetual failure and inability to achieve anything unless the West is holding its hand – the success of Africa’s phase I response will likely continue to be considered a mystery for some time to come.
It should however be noted that a successful phase I response does not mean similar results will be achieved in subsequent phases of the pandemic. The pandemic conditions are evolving and will be markedly different in subsequent phases. For instance, the number of Covid-19 cases in communities will be much higher making contract tracing much more challenging than during phase I. Unmitigated phase II spread of the SARS-Cov-2 virus on the African continent could create the doomsday scenarios that the region avoided during its rapid and effective phase I response.
Phase I success was however achieved at a huge cost to the people of Africa. Most African countries went into lengthy lockdowns early, sometimes even before any cases had been detected. On a continent where the majority of people survive on the informal economy, early lockdowns caused untold damage to national economies and livelihoods. Reversing the impact will likely take decades. By the World Bank’s estimate, Covid-19 could drive 43 million Africans into poverty. Further lockdowns will cripple African economies and drive millions of its people deeper into poverty to unravel decades of economic gains.
Africa needs a strategy for effectively deploying Covid-19 vaccine
Timely access to a vaccine will enable the region to avoid deterioration of a public health and economic crisis projected to sink millions of Africans into poverty. History has shown that when the world cannot produce enough vaccine as was seen during the 2009-H1N1 pandemic, the harsh reality is that poorer countries will only get access to the vaccine after the wealthy are satisfied. The global capacity to produce Covid-19 vaccine is not enough to meet the unprecedented need for it. It remains to be seen whether LMICs like those of Africa can get any vaccine at all and how much they can expect to get. How much vaccine Africa can get will depend on which vaccine technology platform successfully makes it to market, its capacity for mass production, who will be manufacturing it and how much spare stock will be available after wealthy nations are served.
Nevertheless, even if there is uncertainty as to whether a vaccine will be available to Africa, the region still needs to have a clear strategy and a well-articulated plan for securing vaccines and their safe delivery and deployment within countries. A multipronged regional strategy must at a minimum seek to secure enough vaccine to protect the most vulnerable populations. In particular, vaccination for frontline health workers and those with pre-existing conditions like diabetes, obesity and cardiovascular disease that make them more vulnerable to severe Covid-19 illness will be critical to limiting phase II impact of the Covid-19 pandemic. Africa’s Covid-19 vaccine delivery strategy must include measures to ensure that the available cold chain infrastructure is adequate. What little vaccine stock Africa can secure for its 1.3 billion people will need to be deployed optimally to achieve the most impactful and meaningful public health benefits. The risk of loss must be kept minimal. Policymakers need to make practical and easy to deploy solutions to address limited shipping capabilities in the region.
The geopolitical context is constantly evolving with new vaccine candidates emerging including from nations like China and Russia. If considered safe and effective by regulators, these vaccines will provide viable alternatives for Africa. There must also be genuine global efforts to ensure enough vaccine is produced, and that some of the vaccine produced will be reserved for the poorest people. The Serum Institute of India has been contracted to produce vaccine for LMICs. If these mechanisms work and the West does not divert these quotas for their domestic needs, these will be available for Africa. This however should not be taken for granted. Africa’s regional leaders must leave no stone unturned. The economic and public health stakes for the people of Africa are much too high.
Africa’s preparedness requires addressing cold chain infrastructure gaps
Vaccines are a high value product with a higher risk of getting spoiled when they are not kept at cold temperatures. They need to be transported and kept under refrigerated conditions at all times to maintain their integrity. Their transportation requires faster delivery options such as air cargo instead of ocean freight which takes a long time. However, the Covid-19 pandemic has stretched global supply chains and raised the need for additional capacity to transport vaccines and pandemic health products at a time when there are significantly fewer international passenger flights globally.
This limits the available options for air freight cargo. Major regional airlines like Ethiopian Airways that have been moving pandemic products onto and around the continent may not have enough capacity to handle the additional needs to transport vaccines. Africa must have a plan for ensuring that it can effectively manage the risks of spoilage which could lead to huge losses of a scarce and difficult to find Covid-19 vaccine resource. The region’s strategy must be pragmatic about how it secures vaccine for its most vulnerable with in-built contingencies for addressing the most critical anticipated supply chain challenges.
Developing criteria for priority infrastructure development
Africa has a USD 50-90 billion infrastructure gap that has been neglected and not given development priority. According to the African Development Bank Vice President for Private Sector Infrastructure and Industrialization Solomon Quaynor, African nations must re-evaluate national infrastructure development programmes and develop criteria for prioritizing the most important infrastructure projects. The IMF estimates that the damage caused by Covid-19 will cost African economies and the health sector about USD 1.2 trillion over the next three years. African governments need to put resources towards improving health infrastructure in their countries.
Last minute solutions needed to reach people with medical products and services are a critical area of investment that also require cold chain capacity. They are needed for the region’s preparedness and resilience when responding to disease outbreaks. Additional supplementary health infrastructure will help to expand Africa’s capacity for large-scale multi-nation vaccination campaigns during Covid-19 and in the future. With public funding being overstretched, policymakers should explore public-private partnerships with business leaders and international organizations to develop simple, effective and easy to execute solutions for mitigating cold chain risks.
Financing mechanisms that have been put into place to fund Africa’s Covid-19 response effort by development banks like the African Export Import Bank, the African Development Bank and others should provide the resources needed to enhance the region’s cold chain infrastructure within countries. In addition, the World Bank has been considering making USD 12 billion available for countries to buy Covid-19 vaccine using a fast-track approval process. If these funds are easily accessible under reasonable terms, they could provide an additional much-needed financial lifeline that countries could use to improve their preparedness. The World Bank and IMF funds have been criticized in the past for processes so cumbersome that they make finances inaccessible for countries. Strategic investment in improving Africa’s cold chain infrastructure for safely distributing Covid-19 vaccine around the continent would fill a public health gap and serve the needs of nations and the people of Africa beyond the Covid-19 pandemic.