What’s the Hold-up With COVID Vaccinations? Don’t Hold Your Breath…a 2021 Prediction

Welcome to 2021!  At the beginning of each year, I typically put together some predictions about what to expect in the supply chain world in the next year.  Umm…. I didn’t do so well in 2020….  About the only predictions I think I did okay on were the continued movement towards localized supply chains, and the continued onslaught of counterfeiting.  Both of these trends were driven not by current events, but by the sudden and massive impact of COVID-19 on global supply chains.   Localization is underway as we start to see organizations moving more towards local production in manufacturing networks with localized suppliers (to avoid being shut down), and shortages of PPE continues to occur, which results in counterfeiting activity on the rise.

One prediction that I know is already underway, that we discussed in detail on our recent webinar:  vaccine delays are going to continue to occur.  In our webinar, Professor Finkenstadt and I discussed how multiple bottlenecks are occurring in all stages of the vaccine production supply chain.  One of these areas was in cold chain capabilities.  Using data from the Homeland Infrastructure Foundation, we identified what the public refrigerated warehouse map actually looks like. Major urban centers, especially the Northeast and Midwest, are in pretty good shape. But then you have this huge gap in the center of the country – the Dakotas, Montana, Wyoming, New Mexico, parts of West Texas – where there isn’t a lot of cold storage capacity.

Well, we will use dry ice, which is easy to get, right?  Hold on.  Dry ice is generally made by pumping (injecting) liquid carbon dioxide into holding tanks, where it is frozen to sub-zero temperature of about (-)109F- (-)112F making it a compressed ice state CO2.  The problem here is the CO2.  Dry Ice is manufactured in close proximity to oil and ammonia refineries. Given the COVID-19 pandemic situation, oil prices have dropped which has caused reduction in CO2 productions as overall oil production went down. This had a negative impact on the vaccine supply chain given the immediate dry ice requirement for transportation of COVID-19 vaccine.  In the United States amid lockdown, 34 out of 45 ethanol plants that sell CO2 have either been closed entirely or have cut short their production.  So not only is there a dry ice shortage, but transporting this stuff also has its challenges.  Packaging of Dry Ice in containers with inadequate ventilation can cause the entire shipment to blow up due to increased built up pressure and the inability of released gasses to dissipate.  During transportation, dry ice placed in a confined region can lead to decreases in oxygen level in the surrounding area, making it difficult to breathe.  o Direct human contact can lead to frostbite, where the skin cells freeze and are damaged subsequently. Therefore, only experienced personals are advised to handle distribution when dry ice is involved. Yikes!  This is a major issue, as the government has asked the regulators to allow for more dry ice transportation than advised given the COVID-19 vaccine transportation across the world.  Remember, we need to get 60 to 70 percent of the country (and the world) vaccinated and can’t leave out rural communities.

Oh yeah – if you’re hoping to get one of the mRNA vaccines, which promise to be 95% effective – you may also be waiting awhile.  There is increasing evidence, as we predicted in our webinar, of severe material shortages occurring in the manufacturing process. Manufacturing plant personnel described challenges in obtaining reagents and certain chemicals, as well as glass vials, syringes and other hardware. They also cited a shortage of “fill and finish” facilities where vaccine doses are loaded into sterile containers and a dearth of workers with the specialized skills needed to run mRNA production processes. Such resource scarcities, GAO concluded, could lead to production backlogs.   In addition, manufacturers need better access to a rare substance called vaccinia capping enzyme (VCE), which helps keep the mRNA from degrading and gives it a deceptively human appearance to prevent cells’ protein-making machinery from rejecting it. One expert calculated that making the 10 pounds of VCE needed to generate 100 million mRNA vaccine doses would overwhelm the limited capacity of bioreactors (containers used to carry out biochemical reactions).

To date, there also seems to be a bottleneck once the vaccines are reaching the state.  Out of the 20 million or so doses of the vaccine distributed, only 4.3 million have been administered, which is less than 1.3% of the US population.  So what gives?  Many of the problems seem to be at the local level – that is, once the product arrives at the state.  A recent article posted by Dan Stanton and Phil Palin note that several causes are implicated: lack of funding, Christmas distractions, fatigue among public health professionals (more), health care providers being seriously overextended, stockpiling for rollout this week to Long-Term Care facilities, lagging throughput data, and much more.  This makes a lot of sense.  If you think about it, states and healthcare providers are already overwhelmed, and turnover among healthcare workers have never been greater.  Many hospitals and states are also overwhelmed with demand for testing, as students return to college and schools, and have testing requirements prior to being admitted.  And increasing shortages of supplies and qualified testing personnel, as reported by the College ofAmerican Pathologists, suggests that the bottlenecks for both vaccinations and clinical testing are at a breaking point.  “Lab staff have been working full throttle since March. I think that is often lost on people. They kind of assumed that when cases were low with COVID-19, that maybe the lab staff got a break.  Well, that wasn’t the case.” says a clinical pathologist at the University of Minnesota.  An article in the New York Times also emphasized the burnout rates of testing lab people.  While this may not be the same group of people doing the vaccinations, hospitals are also overwhelmed with the deluge of new cases coming into ICU’s, and physician offices are generally overbooked with new cases.  Long term care facilities are struggling to keep personnel who can keep up with the testing requirements imposed on them, and the pharmacies (CVS and Walgreen) supposed to be administering the vaccines at these facilities are also overwhelmed with specimen collection for COVID testing, and challenges with scheduling.

At the end of the day, this is a capacity constrained scheduling problem.  As pointed out by Dan and Phil, “Recognizing, measuring, and actively managing throughput at each vaccination venue is crucial. Developing capacity and organizing vaccination processes to achieve explicit numerical throughputs — and adapting as necessary — will be fundamental to achieving system-wide success. Part of this is effective Queue Management (similar to what we have studied with post-disaster operations at fuel racks). Queuing tens-of-thousands of humans in the midst of a pandemic is more complicated than hundreds of post-hurricane tanker trucks.”

To summarize, there is not yet a whole-community strategy for COVID-19 vaccinations.  You can’t use the same, single approach for every situation. Just like “selling” the vaccine requires a community-engagement plan with local leaders and religious communities, you need a customized deployment plan to administer vaccines, that takes into account the serious capacity problems that exist at state, county, and local level. Each state needs to consult with the localitiies, and seek to work with them for a plan.

The other resource that has not yet been tapped into is the military.  The National Guard have medics – perhaps not enough to vaccinate a whole state, but enough to get started.  Vaccination protocol training should be taken up quickly- the military excels at scaling up and executing in an emergency, and have the logistical planning capabilities for deploying resources in an agile manner.  I believe this should be the next resource tapped into at the state level, and each state should begin having discussions with their local National Guard to coordinate and find a way to get this done. Even with Biden coming in and promising 100M vaccinations in 100 days – I have my doubts.  This is a very complicated problem, one that requires scheduling, coordination, and detailed logistics planning…. something the federal government is not great at doing, as we saw with the COVID response in 2020.

This vaccine won’t administer itself.  The bottom line?  I don’t think we will be able to surmount the challenges that lie ahead in a timely manner.  By May perhaps we will get to 30% of the population vaccinated.  By September, perhaps 60%, maybe approaching herd immunity.  But 100%?  I think early 2022 is a realistic goal…and it may only get as high as 80% if we’re lucky, even then..