'Cold Chain Logistics' Could Make Vaccinating Lower-Income Countries Difficult

With recent announcements that the Pfizer and Moderna Covid-19 vaccines are 90 and 94.5 percent effective, many experts are showing a rare moment of optimism as the pandemic’s one year anniversary quickly approaches. 

They have reason to be. The effectiveness of the two vaccines is far above the FDA’s 50 percent cutoff point and they were developed at record speeds. This is partly because they both use cutting edge mRNA technology that places genetic code from the virus, rather than a piece of it, into the body to induce an immune response. Experts say that this technology also makes these vaccines cheaper, safer, and easier to produce than traditional vaccines. 

And yet, at the same time that the United States’ top infectious disease expert Dr. Anthony Fauci described the two vaccines as possible means to a quick return to relative normality, former director of the Indian Council of Research Medicine Dr. Nirmal Ganguly described them to one of India’s largest newspapers as a “logistical nightmare.” 

That’s because mRNA vaccines come with a catch: they have to be stored at low temperatures to keep delicate genetic sequences intact. 

The Moderna vaccine, for example, has to be stored at -20 degrees Celsius (-4 degrees Fahrenheit), while the Pfizer vaccine requires an even more frigid -70 degrees Celsius (-94 degrees Fahrenheit) for long term storage. For comparison, most vaccines can be stored between 2 and 8 degrees Celsius. 

In order then to move them across large distances without them spoiling, countries need an unbroken refrigerated supply chain known as a ‘cold chain.’ Maintaining a strong cold chain—especially for the Pfizer vaccine, which requires special medical-grade freezers—is already difficult for wealthy countries like the United States. But, it’s even more difficult for low and middle income countries, which can have intermittent access to electricity, large rural areas, and a lack of necessary equipment. 

When Motherboard reached out to Pfizer regarding cold chain concerns, the company pointed to a thermal shipper they had designed that could be repacked with dry ice. “Ultimately, given the unique circumstances the pandemic creates and the need for large vaccinations,” a spokesperson wrote in an email reply, “we do not anticipate for distribution or storage to be an issue.” 

But not all experts agree with Pfizer’s optimistic assessment. 

Dr. Willem Hanekom is the director of the African Health Research Institute and former chair of both the Federation of Afircan Immunology Societies and the Tuberculosis vaccine group at the Bill and Melinda Gates Foundation. He, like Dr. Ganguly, was less optimistic about the logistics. 

“My first thought when hearing the news was ‘fantastic’ and my second thought was ‘access issues,’” he told Motherboard over the phone. “The Pfizer and Biontech vaccine’s storage and transport requirements make it absolutely impossible to distribute even in a middle-income country like South Africa. There are just not enough liquid nitrogen or dry ice storage facilities outside the academic institutes here. So that was a big downer, to be honest.” 

The Moderna vaccine’s less extreme temperature requirement could make it more feasible for South Africa and other comparable countries, Hanekom said, although it would still be a challenge. But for lower-income countries, he said that he “simply has no idea how it could be distributed.”  

That’s exactly what Gavi, a global vaccine alliance and partner of the World Health Organization, is trying to figure out. As of June 2020, they have been able to procure 43,000 vaccine refrigerators for 41 lower income countries in order to improve their cold chain, a spokesperson wrote in an email to Motherboard. Besides that, they’ve also developed solar refrigerators for areas without electricity access and special ice-lined ones capable of remaining unpowered for days for those with intermittent access. 

There’s also hope that as more vaccine candidates make it past the finishing line, there may be options that have more moderate storage and transport requirements. 

“We already struggle in some places in India with vaccines that are required to be stored between 2 to 8 degrees Celsius, ” Dr. Brian Wahl, an epidemiologist based in India for the Vaccine Access Center, said to Motherboard over Zoom. “But I think early on everyone saw the development of just one vaccine as a huge win. Now, I think what I and others have realized is that the possibility of having multiple vaccines could help address issues of supply and cold chain, with some potential vaccines being more feasible in certain settings than others. That might be one of our greatest possibilities for overcoming these issues related to equity. Having all of these promising candidates in late-stage development is encouraging.” 

But before being able to distribute vaccines, low and middle income countries need to be able to get vaccines in the first place. This could be difficult, especially considering that the world’s wealthiest nations (making up just 13 percent of the global population) have already pre-ordered 51 percent of the potential doses. 

Efforts are being made though. The World Health Organization-run COVAX program aims to fairly distribute 2 billion doses of effective vaccines to participating countries. (By comparison, countries like the United Kingdom have secured an average of five doses per citizen). If entirely successful, that would mean that a country’s most vulnerable populations, as well as at risk professions like health workers, could be vaccinated, according to COVAX’s website. But so far the program—which is largely funded by national governments—has only raised $700 million of its $2 billion funding goal for 2020. 

In a statement to Motherboard, the World Health Organization wrote: “The response to this global pandemic must be collective, and leaders of countries will need to take a global view. If wealthy countries pursue a different short-term strategy and aim to secure limited supply in the coming 12-18 months to immunize broadly across their population, there will be insufficient supply for high-risk populations worldwide. […] No country is safe until all countries are safe—One world, protected.” 

It’s hard not to see the inherent injustice in the fact that some of the countries hit hardest by the pandemic and its accompanying economic fallout may also be the last to see their populations vaccinated. 

However, all the experts that Motherboard spoke to for this story maintained that the attempts by some to respond to the pandemic fairly gave them hope, and that they could spur a paradigm shift in how we look at global health in the future. 

“I would go a step further and call this hoarding of vaccines by wealthier nations not ‘vaccine nationalism,’ but rather ‘vaccine colonialism,’” Henekom said. “It's definitely a huge issue, although as someone who has worked with poverty-related disease all my life, not a surprising one. But with all that said, I’m very impressed with how the WHO and other organizations have been working together to create new models of access for low- and middle-income countries. It’s proof of concept that we can be innovative and can come up with solutions to problems together. That’s encouraging and holds great promise for future access challenges.”