How are countries working to ensure vaccines are administered quickly with minimal waste and maximal utilization?
This snapshot looks at the policies that countries are adopting to ensure minimal waste and maximal utilization of Covid-19 vaccines, while also meeting the objectives of a quick rollout.
The information presented and analysed below comes from the COVID-19 Health System and Response Monitor (HSRM) and interviews with country experts in the network (up to 23 March 2021), ministry of health websites and news articles.
For vaccine rollout we consider the supply side and demand side.
On the supply side, there are different elements that can lead to wasted vaccine doses, these may include poor planning (ordering too many vaccines), slow or inadequate distribution, insufficient workforce, poor choice of vaccine sites, disrupted access, and delays caused by the selection of rigid priority groups (with no flexibility).
On the demand side, there may not be enough recipients because of vaccine hesitancy and barriers to booking and accessing appointments.
When vaccines supply exceeds demand, this creates waste. This is not only from wasted doses, which may be thrown out if a rigid rollout prioritisation plan is adhered to (and the related opportunity cost of not vaccinating people in ‘lower’ priority groups), but also includes waste in terms of the opportunity cost of the workforce time which could be used for providing health services.
Countries with a large and continuous supply of vaccines have adapted to make sure they are not wasted
Many countries in Europe are still facing a low supply of vaccines, other countries are expecting an increase of supply in the second or third quarter of 2021.
Other countries are getting increases in supply that they need to rollout quickly. Waste may be produced in these instances if the doses are not used up before they expire. Countries may consider offering them to people in non-priority groups who are available and willing to receive them.
In Israel, policies to address wastage of vaccine doses adapted to changing circumstances. Early in the vaccine rollout, some vaccines were being wasted at the end of the day if there were no more people from the priority groups arriving at the vaccines centre. However, when the amount of people coming to get the jab started to decline, there was an explicit decision taken by the authorities that health providers could move to the next priority group rather than waiting for everyone in the current priority group to be vaccinated. Because Israel had a large supply of vaccinations, accompanied by a large roll-out programme, there was still enough doses available for the priority groups the next day (see Figure 1).
Source: https://datadashboard.health.gov.il/COVID-19/general and HSRM
When a vaccination site in Israel had excess supply, this was communicated to the public. Civil society organisations would then pick up the communication at the individual level and amplify the message via WhatsApp groups. This resulted in people running to leftover sites to get the vaccines. When people lined up at these sites, nurses were then able to re-prioritize based on age, but this occurred informally (e.g. picking out older people from the line). Because of the excitement and increased number of younger people being vaccinated, this created a peer effect so that other people wanted to get the vaccine. Further, as some hesitant older people saw younger people in the community getting vaccinated and better evidence was emerging, some people who had previously missed appointments decided to be vaccinated. In summary, this avoidance of waste was a bottom-up initiative of the health plans together with civic society groups. Municipalities and local governments also supported these initiatives.
Furthermore, because there was excess supply in the periphery of Israel (due to hesitancy from certain population groups), people were travelling from the big cities to the outskirts to get vaccinated from this unused supply.
In other countries, top-down planning resulted in standardised procedures to minimize wastage. In England, for example, NHS England and Improvement (NHSE/I) has issued guidance that vaccination sites should have a reserve list of patients and/or health and social care workers that can be called in at short notice to receive a vaccine to avoid wastage. Patients on a reserve list should be in a cohort that is eligible to receive a vaccine, with patients outside eligible cohorts only vaccinated in very limited circumstances. In exceptional circumstances, vaccination sites can transfer vaccine doses to other sites to avoid wastage under a system of “mutual aid”.
Outside Europe, Chile is providing Russian and Chinese vaccines in a fast-paced way, using primary care systems, and administering the ‘leftover’ vaccines every day for people not in the priority groups.
Countries are expanding vaccination sites to increase access and meet demand
In Belgium, an increase in the number of vaccination centres is planned to speed up the vaccination rollout. As in other countries, the number/brand of vaccines available will also be increased (e.g. with the Johnson & Johnson vaccine in mid-April). Moreover, once logistical obstacles are reduced (i.e. when there is a wider range of vaccines and stocks, both multi-dose and single-dose vials, simple storage in the fridge), vaccination is likely to be permitted in GP practices or other decentralized centres (though discussions are ongoing). Federated entities also plan to provide for “mobile actors” capable of reaching populations that are not able to go to a vaccination centre on their own.
Italian regions have organized for large venues to be used as Covid-19 vaccination sites, including community hospitals, public grounds, sport halls, barracks and airport terminals. This first phase of rollout has been coordinated by the Extraordinary Commissioner, the Regions and the Department of Civil Protection, also mobilizing the armed forces and Red Cross volunteers. The Ministry of Defence is converting drive-throughs previously used for swab testing into vaccinations sites. The national goal is to reach an administration capacity of half a million doses per day by April 2021 and to also use local level resources such as GPs, paediatricians and pharmacies.
In Germany, there has been a move to decentralize vaccination sites from big municipal centres to GP practices.
In Spain, there are plans to use mass vaccination points, such as sports centres, when there are more vaccines available. This will enable more people to arrive at the same time and wait while maintaining a safe distance. So far, vaccination is taking place in health centres, but if there is a substantial number of vaccines arriving in the country, mass vaccination points will be needed to speed up the vaccination efforts in the population.
In Latvia, state and municipal medical institutions, as well as private facilities (e.g. family doctor practices) are being used as vaccination sites. If necessary, vaccination could be also provided in pharmacies and in non-medical facilities.
The location of where vaccines are administered is relevant. Among some priority groups, there is high vaccination rates as the campaigns have been rolled out in the places where they live or work. For example, there are high vaccination rates among those in the military, people living in nursing homes and some other institutional settings for adults, and for health care workers particularly when vaccines are administered in hospitals. Although in health care setting, some hesitancy has been observed. For example in the UK, differences in vaccines update among health care workers has been observed related to ethnicity.
Other countries with vaccines supply have introduced mobile vaccination units to make it easier for people to attend vaccine appointments
Efforts to minimise barriers to access can help improve vaccines uptake. For example, in Israel, mobile units from Magen David Adom (the emergency care services) brought mobile vaccination sites to universities, yeshivas, malls, and busy commercial streets. The advantage was that they could vaccinate people from any health plan, and they would come back exactly 3 weeks later to administer the second dose. University rectors supported the initiative with letters and reminders.
Romania has also organized mobile vaccination centres and mobile vaccination teams to enhance access for essential workers. The Romanian legislation also allows for drive-through vaccination centres and in family physician offices, but these are not yet functional.
Mobile vaccination centres are also used in Estonia. The planning and provision of vaccines is highly decentralized, down to the provider level. Estonian vaccine providers (primary care providers that have undergone training) are required to draw up a target vaccination plan for their clinics; assess the need for Covid-19 vaccine on a weekly basis according to the plan; and order the required amount of vaccine from the Health Board. They also invite target group representatives and individuals to be vaccinated and inform the State Agency of Medicines about side effects caused by immunization.
Some countries are permitting a wider range of health workers to administer COVID-19 vaccines
For information on which health professionals and other people are allowed to administering Covid-19 vaccines in European countries, please see the recent HSRM policy snapshot (published on 24 March 2021).
Box 1 provides an example from Canada on how the province of Ontario initially rolled out the Oxford- AstraZeneca vaccine.
|Box 1. Example of a flexible approach to vaccines administration|
The province of Ontario (Canada) implemented a flexible approach when they gained access to an initial shipment of the Oxford-AstraZeneca vaccine. There was recommendation made by the National Advisory Committee on Immunizations (NACI) to not give this vaccine to those aged 65+. When Ontario received an initial shipment of the Oxford/AZ vaccine, the province’s task force decided that due to the limited supply, the doses would be targeted toward residents aged 60 to 64 both through a pharmacy pilot project and in GP surgeries. Eligible residents were able to book an appointment at a pharmacy, and doctors contacted people directly to book appointments. This occurred before an online booking platform for those aged 80+ was developed.
Since then, the recommendation has changed to include those aged 65+. However, there is concern that some people may now be hesitant to receive the Oxford/AZ vaccine because of the change in priority groups, concerns that the vaccine is inferior, information on the shipment expiring and a belief that the government is trying to use the doses quickly, and reported blood clots in other countries. Towards combatting hesitancy in Canada, Quebec’s health minister took the jab on camera and there are plans for Ontario’s Health Minster to follow suit.
Efforts to combat vaccine hesitancy have been undertaken to increase uptake
Many countries have taken action to address vaccine hesitancy among their populations. Two examples from Belgium and the UK are considered in Boxes 2 and 3. A forthcoming policy snapshot will examine issues around vaccines hesitancy further.
|Box 2. Combatting vaccine hesitancy in the UK|
In the UK in December 2020, 78% of adults surveyed reported they would be either ‘very likely’ or ‘fairly likely’ to have the Covid-19 vaccine if offered and the proportion reporting this increased with age. Of the adults who said they would be unlikely to have the Covid-19 vaccine if offered, the most reported reasons why not were: feeling worried about the side effects, about the long-term effects on their health, and wanting to wait to see how well the vaccine works. However, by the end of February 94% of adults were prepared to get vaccinated against Covid-19.
Much greater vaccine hesitancy was observed among people from some ethnic minorities including black, Bangladeshi, and Pakistani populations compared with people from a white ethnic background. In terms of actual vaccination uptake as evidenced by data from mid-February 2021, 86% of white people had been vaccinated in the 70-79 age group (and not living in care homes) compared with lower proportions in other ethnic groups (55% of black people, 68% of people with mixed heritage, and 73% of people from South Asian backgrounds). Moreover, white people were almost twice as likely to have been vaccinated as black people among the over-80s in England. Efforts are underway to provide targeted, accurate and factual information in culturally appropriate ways to specifically reach these groups. Ministers have pledged a fund worth more than £23 million to try to supress the spread of misinformation about the vaccine and a video has been aired on television showing celebrities encouraging their communities to take the jab. In addition, vaccination sites have been established in places of worship such as mosques to try and increase access and acceptability.
|Box 3. Combatting vaccine hesitancy in Belgium|
Specific efforts to promote the Covid-19 vaccine are directed at specific target groups. These initiatives have been developed in collaboration with associations active in the field (including intercultural actions, help for refugees, etc.) to define the form and content of the messages (e.g., there is a strong concern that the vaccine could hamper fertility in the African community).
The federal website on vaccination offers general information sheets in 38 languages as well as videos in French sign language. Further initiatives are planned for blind people. Additionally, the federated entities have developed communication materials focussed on specific targets, for instance Covid Breakers for those aged 18-25 in Brussels.
Many European countries are still facing a low supply of vaccines so waste is not yet a concern. Yet in countries such as Israel and the UK, where there is adequate and continuous supply of vaccines for the priority groups, there has been flexibility in extending the rollout to the next priority group to reduce wastage. Procedures to share vaccine doses among providers with different levels of demand is important to manage supply and reduce wastage. Moreover, putting in place procedures to ensure health providers/vaccination sites are able to reach out locally to the population is important to ensure people receive unused doses at short notice. However, special considerations need to be made to ensure hard to reach/marginalised groups can attend vaccine appointments.
Expanding the range of available vaccination sites is important to increase accessibility. Furthermore, increasing the type of health workers that can administer vaccines is a key strategy to speed-up rollout. Also having flexibility in the approach is important such that there is a need to adapt to challenges on an ongoing basis, including reassessing supply, coverage of priority groups, and reassuring the population that vaccines are safe. Figure 2 shows strategies to reduce vaccines wastage.
Figure 2. Strategies to reduce vaccine wastage: supply and demand actions
Similar to the pandemic response, flexibility is needed in the vaccines rollout particularly as supply changes. This includes a reassessment of needs on a constant basis, recent examples include:
- Denmark revised its vaccination plan following delays with supply of the vaccine. From February 2021, this plan is revised on a weekly base to be adapted to the pressing needs and challenges.
- Spain updated its vaccination strategy in February 2021 mainly to adapt to the low supply of vaccines.
To reduce vaccine hesitancy, countries should invest in campaigns to promote vaccine uptake with communication that is i) tailored to alleviate the relevant concerns and ii) reach marginalised groups that may have lower uptake.
Sherry Merkur and Ruth Waitzberg