Author: Maurizio Arseni
Laura Murphy contributed to reporting.
The 1976 vaccination campaign in the US was against an influenza that experts believed could rival the 1918 strain but never ended up causing disaster. Poor and rushed government decision-making led to the unnecessary vaccination of about 45 million citizens. The vaccination campaign ended only when the vaccine started to have adverse and widespread side effects. According to some experts, the lack of citizens' trust towards vaccines and the consequent high vaccine hesitancy rate inside American society is rooted in this episode.
Trust and transparency will also determine the success of the COVID-19 vaccination campaign. Vaccines have gone through the authorities' rigorous approval process before being distributed, and the first available data shows that they are safe and effective. However, what may erode citizens' trust is the lack of transparency in the technology deployed by countries to support equitable and transparent vaccine allocation and distribution.
As the pandemic rages worldwide, countries are rushing to vaccinate their population. The magnitude of the challenge is immense. In the United Kingdom alone, the government offered vaccination slots to 16 million people by mid-February. In the United States, the Biden administration has committed to administering 100 million vaccines over the first three months of the year. According to Science Magazine, it is "still unclear what percentage of a population needs to be vaccinated or recovered from COVID-19 before herd immunity kicks in,” though “early predictions were between 60% and 70% and then rose as high as 90%”-- the caveat being that these predictions were“based on modeling or even guesswork."
Global collaboration among governments and the private sector has been crucial in creating COVID-19 vaccines. At the current stage of vaccination efforts, synergies among manufacturers, distributors, and frontline healthcare workers are equally important in maintaining quality throughout the entire vaccine distribution chain, including the “last mile:” vaccination center to post-vaccination monitoring. Failure to maintain appropriate temperatures as well as vaccine administration guidelines that leave room for interpretation can lead to significant numbers of doses of vaccines lost in these last decisive steps.
Childhood vaccine programs, the millions of doses of vaccines given in 2009 to fight the spread of H1N1 (swine flu), and annual influenza vaccinations across countries illustrate a similar theme: public health systems have frequently been running immunization programs that target a large part of the population, even if the yield could and should be higher.
However, delivering COVID-19 vaccines poses unique challenges. To achieve "herd immunity" against a raging pandemic that actively demands widespread prevention measures, an estimated 10-14 billion doses of vaccines need to be produced and administered in a short period of time. By comparison, the global capacity for production and distribution of the vaccine for seasonal flu, an annual and endemic bug that we have come to expect in populations, only reaches 1.48 billion doses. Matt Hancock, the UK Health Secretary described the COVID-19 vaccine distribution effort as "the biggest civilian project in history." Given the large scale of the vaccination program, public health institutions, healthcare providers, transportation networks, and storage facilities need to join forces in novel ways. Technology can aid this coordination.
There are 10 types of COVID-19 vaccines currently available on the market. They are all different, but they all require two doses administered within an interval of 3-4 weeks to be effective, adding an additional challenge to the last-mile issue. With only 1 dose, none of the vaccines will be effective. While on average 3 different types of vaccines are currently available in many countries, they are not interchangeable and demand different administration schedules. Johnson & Johnson developed the world’s first single-dose COVID-19 vaccine. Recently approved by the FDA, it could increase supply and speed up US immunization.
In the US, the federal government decided to create a centralized data repository for immunization data. This Immunization Information System (IIS) will coordinate the COVID-19 vaccine distribution and ensure that people receive their follow-up dose even if they leave their state of residency.
The Centers for Disease Control and Prevention (CDC) asked states to sign a data use agreement to allow sharing personally identifiable information (PII) from local registries with the federal government, raising important privacy and security concerns that could deter many individuals from getting vaccinated. The CDC reassured that even if the information includes names and other identifiable information, it will be anonymized in a data clearinghouse before authorities at the federal, state, and local levels analyze the data.
Yet, public health experts warn that the privacy and security concerns raised by the CDC’s request might deter many communities, such as immigrant communities, from getting vaccinated in the first place. Dr. Alex Radunsky, Director of Global Health and Policy at the Institute of Technology and Global Health, believes that centralizing control of health data is not the right approach but rather that “technology solutions are here that do protect patient privacy while making data available for public health decision making.”
Current vax-tech used in the US to meet the last mile challenge
The US Department of Health and Human Services, in collaboration with data mining firm Palantir, has developed Tiberius, "a cutting-edge data platform to collect, correlate, and visualize data across the entire operation." It allows states and federal agencies to view health care providers registered on VTrcks, the CDC’s digital platform that integrates all the vaccine supply chain from purchasing and ordering as well as the distribution to health care providers. They can also use Tiberius to allocate vaccine doses within their jurisdictions.
Every Thursday, the pharmaceutical companies producing the vaccines communicate to Operation Warp Speed, (the U.S. public-private COVID-19 partnership for vaccine production and distribution whose program name was recently removed by the Biden administration) the number of doses available in the coming week. Tiberius runs algorithms fed by factors like demographic, employment, and public health data to assign the highest number of doses to the states that need it the most based on their total population, not on the number of people in high-risk groups. States finalize the orders on Saturday and deliveries arrive on Monday.
It is, however, impossible to know the exact details of variables that the Tiberius algorithm considers to determine vaccine allocation. “Proprietary health data systems are a black box. If they cannot be evaluated in public view, why should we trust them to develop and deploy technologies that address inequality within society?” asks Dr. Radunsky. According to him, “Despite unequal access to vaccination, prompt rollout will take pressure off of hospital capacity."
The CDC rolled out Vaccine Administration Management System (VAMS), the centralized federally administered online vaccine management platform, for local and state public health officials to manage vaccine distribution and speed-up vaccine administration.
The platform can be accessed by healthcare providers to make vaccination appointments available to the general public to support scheduling and tracking vaccination administration. It also provides real-time access to local and state public health organizations to support and monitor the vaccine administration and allow to plan inventory management of vaccines’ stock.
Citizens who are registered by their employer can utilize the platform to locate and schedule vaccination appointments; answer pre-screening questionnaires before booking the appointment, and receive text reminders for appointments and second dose administration.
The CDC is also using the Vaccine Adverse Events Reporting System (VAERS): a platform available since 1990 for healthcare providers to report any side-effects that may occur to their patients after receiving a vaccine. For the first time, individuals can self-report side effects through V-Safe via a smartphone-based texting system. After enrolling in the system, the user receives daily messages the week after the first and second dose to check if she has had any side effects and to find out if the vaccine interfered with her daily activities. Reminders are sent once a week for the six weeks following each dose. If severe symptom patterns are emerging from the logged messages, experts at the CDC can advance an investigation to determine the safety of the COVID-19 vaccine that was administered.
Why vax-techs are failing to meet the last-mile challenge
The US government strategy for vaccine distribution is built around the idea that states would use a single-scheduling tech infrastructure. So far, the centralized infrastructure proposed by the federal government has hindered the nation’s COVID-19 vaccination campaign, slowing down the pace of getting shots into citizens’ arms.
VAMS, the 44 million dollar system developed by Deloitte for the CDC, was so poorly designed that only 10 out of 50 States decided to adopt it. They are now reporting random appointment cancellations and unreliable registrations, leaving many Americans struggling to know when and where they can get vaccinated. In many states, platforms designed to book vaccination appointments do not have enough computing power to handle the high-user traffic. State vaccine registries have had challenges communicating with each other, making it difficult to share data about vaccinated individuals across different platforms.
Existing Innovative Open Source Solutions for vaccines distribution
“If the US is willing to learn from other countries, we can build a more efficient health information system,” according to Dr. Radunsky. Around the world, there are many tools used to support vaccine delivery efforts. In some cases, countries are testing new registration or decision support systems starting from open source systems or, as exemplified by some European countries, readapting existing immunization systems.
Two examples of open source solutions are the DIVOC and DHIS2 initiatives. DIVOC--Digital Infrastructure for Vaccination and Open Certification--enables countries to orchestrate large-scale vaccinations using open-source digital infrastructure as a public good. It uses flexible and extendable software that allows multiple systems to plug-in, helping countries to coordinate vaccines, facilities, workers, rollout areas digitally. It also allows large-scale vaccination and certification of vaccine administration by issuing a digital certificate. The project was initiated in India by eGov, a foundation offering an open, citizen-centric, technology platform to help improve the quality of services and promote inclusive governance in urban areas.
In 2017, the WHO and the international health community organized a collaboration, led by the University of Oslo’s Global Health Information System Program (HISP), to develop DHIS2, a digital health data toolkit. DHIS2 is the world's largest health management information system and, being an open-source technology contributing to the achievement of the UN’s Sustainable Development Goals, it is also considered a Digital Public Good. HISP updated the platform with a COVID-19 vaccine toolkit to support vaccine delivery and post-vaccine monitoring, allowing countries to rapidly add COVID-19 vaccine tracking to the existing vaccine recording system.
Currently, 45 countries are using DHIS2 as an information management system to track immunization. Of these countries, 36 have already integrated the DHIS2 Covid-19 surveillance solution. Based on the same data standards, the platform allows for the integration of global data, the introduction of tailor-made solutions, and the coordination of local expertise for a national roll-out.
“A system that is open source will continue to respond to the needs of the community,” says Dr. Radunsky. It can be rapidly deployed and adapted to both the infrastructure and regulatory environment of each country; it has already been tested; and most importantly, since it is accessible to all, it promotes continuous innovation and trust within public opinion.