If one were to vaccinate eight million over six months, it would mean over 50,000 persons a day an impossible task with existing facilities. For this reason, many temporary vaccination centers are being built in Germany.
While in our article “WARP SPEED?” of the 16 Dec, we applauded the efforts and successes in bringing forward the arrival of the first vaccines, we also expressed reservations about the wave of optimism that rose on the new of the approval of the first vaccine released by Pfizer/BioNTech and the impending one by Moderna. We pointed out that, the Operation Warp Speed bulletins released by the Administration in August and September, revealed an insufficient attention to the vaccine distribution.
In particular, we pointed out that, under the constraints of cold chain conditions, the dispensing of vaccines would be terribly slow. We quoted CDC Director Dr Robert Redfield’s comments that, whereas deliveries from factory to local state distribution centers had been planned, no thought had been devoted as to how to distribute vaccines at the state level, and that at least 6 billion dollars would be necessary to get the nation prepared.
Dr Redfield made these comments on September 15th, almost three months before the approval of the first vaccine for emergency use. The statements ran against Trump’s philosophy which tries to put responsibility on States, rather than on the Federal Government. When things do not work, it makes it easier to blame the Governors. We witnessed earlier this year the use of this attitude when states had to compete for the supply of PPE and suffer a dearth of testing kits. As illustrated in the screen shot from CNN, we are witnessing the same phenomena. After overly optimistic promises, reality settles in and exposes the problems in achieving a rapid vaccination rate.
We, in Greece, should urgently turn our mind to dispense efficiently and rapidly the vaccines, so as not only protect a majority of individuals, but eliminate the propagation of this virus that becomes more contagious by the day.
While preparing the previous article, we became wary of this problem and tried to imagine a cold chain vaccination center at the, presently unused, old Athens airport. This vast open space would enable the creation of a state-of-the-art vaccination center accessible from many different entry points by large flows of vehicles. This of course would be a temporary installation that could be dismantled after the pandemic end.
Imagine a central circular building of approximately 8-10 meters’ diameter that would be connected in a star fashion to a series of vaccination huts similar to the pay toll gates of our motorways, except much larger, possibly refurbished shipping containers, where the patients could be observed after vaccination. The core building would not only contain the refrigeration equipment to store the vaccines, but would also function as a control center, to monitor the initial registering, the pre- vaccination checklist of the patient’s conditions and the recording of the actual vaccination. Additionally, there would be emergency rooms and doctors in attendance in case of complications.
Before entering the vaccinations huts, while waiting in the queue in their vehicles, the patients would be registered and controlled through a precheck and the information relayed to the central operation block through portable electronic means.
Imagine five arms of a star with five gates with their associated huts for each arm. If one assumes a vaccination time of 20-30 min, to ensure no adverse reaction, one would vaccinate about 50-75 people per hour. This means that if the center were operating 12 hours a day only 600 to 900 people could be vaccinated in one day. Operation Scientists and Doctors might find a way to accelerate the process by having several people vaccinated in batch.
If, for instance, 5 people were vaccinated at a time within the space of the container the daily throughput could approximate 5000 people. One could even think out an alternative scenario with bringing people in a succession of buses with a limited number of people following adequate social distancing criteria to further increase throughput of the system.
This is a purely theoretical model and one that would probably make most doctors freak out in horror at this amateurish vaccination chain. However, it illustrates the magnitude of the task when administering vaccines that must be kept at extremely low temperatures.
To eradicate this pandemic, a sufficiently large number of the population (70-75%) must be inoculated to achieve herd immunity, which for Greece is close to 8 million people. There are only 280 hospitals in Greece, most of which are small to very small by international standards.
As illustrated by the imaginary center described above, the constraints to an efficient vaccination center for a refrigerated vaccine are amongst other criteria: rapid dispensing, efficient access, adequate medical controls, and social distancing. Each in itself is manageable but taken together they represent, given the enormous number of people to be vaccinated the gargantuan task ahead of us and for that matter for of all the nations of the world.
It is the access to facilities that strike us as the biggest stumbling block. Even the largest and most efficient hospitals in Athens are devoid of large parking facilities and their access is limited because of surrounding buildings and narrow roads. Further these establishments must cater for daily health problems and cannot be dedicated to vaccination only. Although it would be presumptuous to estimate the daily vaccination capacity of a large facility to dispense those refrigerated vaccines, a daily figure in the low hundred would seem appropriate.
If one were to vaccinate eight million over six months, it would mean over 50,000 persons a day an impossible task with existing facilities. For this reason, many temporary vaccination centers are being built in Germany and these would be a far better model for the Greek authorities to follow than the back of an envelope sketch produced by Koumoundouros.
It is unlikely that we will be able to vaccinate a sufficient number to achieve herd immunity within even one year. An even more complex issue is that whereas we know that the new mRNA vaccines are very efficacious (in the order of 95%) we do not know how long the antibodies the are generating will last it could be only 12 months if one believes the most conservative experts, which would then further complicate the task, as people would have to be revaccinated before the whole vaccination queue has been completed.
It would therefore appear that the new vaccines are only a stop gap measure which will enable the vaccination of the most critical workers in the front line such as our doctors, nurses, police and fire fighters, and the people most at risk such as the elderly and people with underlying conditions.
Fortunately, many other vaccines developed with more traditional technologies are also in the process of completing their clinical trials and are likely to be approved in the first half of 2021. Because of governmental support, these later arrivals have also been developed at a much more rapid speed than would have been possible under normal commercial conditions. Not only are they less expensive but they can be kept at a normal refrigerated temperature. This facilitates the distribution and the dispensing at least 10-fold, compared with vaccines requiring ultra-cold chain storage.
Pharmacies can hold them and make them available to local doctors and the whole process is spread out making it rapidly accessible, just like a normal flue vaccine would be. It is too early to speculate about their efficaciousness and duration, but the pundits talk about 70% and five years which is a much more interesting proposition. The Oxford/Astra Zeneca vaccine which has just been approved in the UK appears to be an excellent candidate subject of course to the approval of our medical authorities.
But others are coming including Johnson & Johnson and please do not smile, Chinese (Sinovac) and Russian (Sputnik V) vaccines. Although one can debate the ethics of dispensing such vaccines before the completion of the 3rd clinical trial phase to large sections of the population such as the army or front-line workers, the data that will soon be available will include a much larger sample than that offered by Western third phase trials.
So, Koumoundouros is optimistic about 2021 with some serious reservations. The mRNA vaccines have not yet proven that a person contaminated although protected cannot infect a third party. This means that social distancing, mask-wearing, and all the other inconveniences associated with this virus may be with us throughout this year. As more traditional vaccines emerge the burden will be less, but we must remain vigilant over this year and hope that better therapeutics and economical rapid tests emerge.
5 January 2021