A look at Canada's COVID-19 vaccine supply chain
This post is inspired by this tweet:
to which, I responded:
It's kind of poetic that I'm taking tweets and writing a post about them, but here we are.
Essentially, we are doing a decent, albeit not perfect, job. But there are reasons for this:
- We have limited - if not zero - domestic vaccine production capacity (all of our vaccines are imported).
- The countries and supranational blocs that do have production capacity are limiting exports (U.S., EU) - although, this one is not impacting Canada that much. The U.S. has not exported a single dose to Canada in the regular sense, instead 'loaning' 1.5M doses of the AstraZeneca-Oxford vaccine (the U.S. has not approved it for use yet). While the EU Vaccine Export Limit has not impacted Canada, it very well could have.
- Canada is a patchwork of healthcare systems - even with our socialized healthcare, each province administers healthcare differently using the funds (primarily) provided by the Federal Government's Health Transfer. While this may not seem to be a big issue, instead of having one centralized booking platform like the NHS in the UK, our country of ten provinces and three territories has at least as many different systems. To compound this, as the provinces maintain control over healthcare, each can interpret the vaccination guidelines - ages, essential workers, etc. as they see fit, provided they meet the regulated standards for the vaccines. This could very well mean if you are in a "hotspot" in Ontario, you may be able to receive a shot if you are over 18, but it's very unlikely the same applies to those in Alberta or Saskatchewan.
Manufacturing/Production
For the purpose of this post, I'm not focusing heavily on the procurement/purchasing side of the vaccines - contracts are confidential and I would need to make too many assumptions.
We must remember that vaccines are something that literally everyone - okay, maybe like 90% of the world - want. The world's vaccine production capacity is quite significant based on estimates, but it's important to remember that we have to create vaccines out of raw materials; unlike the thoughts and prayers that magically appear during gun violence in the U.S.A., vaccines require tangible inputs and action to create the end result. This bit from this Nature piece sums it up well:
Some 413 million COVID-19 vaccine doses had been produced by the beginning of March, according to Airfinity data. The company projects that this will rise to 9.5 billion doses by the end of 2021. A larger figure was published last week in an analysis from the Global Health Innovation Center at Duke University in Durham, North Carolina. The centre’s researchers aggregated publicly announced forecasts from vaccine makers, which add up to around 12 billion doses by the end of the year.
However, Andrea Taylor, who led the research at Duke University, says these numbers are more likely to be reached by the end of 2022. “Supply chains could break down and countries could threaten to block vaccine exports,” she says — as is already happening, with India and the European Union having announced restrictions on vaccine exports.
Vaccine production can require more than 200 individual components, which are often manufactured in different countries. These include glass vials, filters, resin, tubing and disposable bags. “If any critical item falls short, then it can disrupt the entire process,” [emphasis added by TZ] said Richard Hatchett, chief executive of the Coalition for Epidemic Preparedness Innovations, a non-governmental organization headquartered in Oslo, speaking at a summit of manufacturers and policymakers earlier this month.
- by Aisling Irwin, in Nature: What it will take to vaccinate the world against COVID-19
That excerpt nails it, but essentially, vaccines are just like your phone and many other products these days that require components sourced from hundreds of locations, transported to a central manufacturing facility, then distributed to customers around the world on a precise schedule in a time where transportation is somewhat unreliable... it's impressive when you think about it honestly.
Canada's vaccines are all imported - coming mostly from the Serum Institute of India, and the rest from facilities in Europe.
To illustrate the globalized nature of supply chains especially related to COVID-19, think back to the beginning of the pandemic; tests were in short supply around the world. A major reason for that? A single manufacturer of swabs in Italy was delayed due to the outbreak in the region, which caused havoc around the world.
As a quick aside, if you're looking for more details on Canada's ability to domestically produce vaccines, John Paul Tasker at the CBC released a great piece recently, that covers the privatization of Canada's Connaught Laboratories back in the 1990s. Because, you know, it's not in the public interest to have domestic vaccine manufacturing capabilities...
I haven't even touched on the temperature requirements of some vaccines, such as the Pfizer-BioNTech COVID-19 vaccine that has to be stored at -15C to -25C. Sounds simple, doesn't it? We produce, transport and store ice cream, frozen foods, etc. all the time!
Transportation
Ice cream aside (but not too far away, it's too good), there are only a few companies that are able to transport goods requiring the cold chain (the cold-temperature supply chain) in volume great enough to handle this increase in demand. FedEx is one, and a significant one, with around 90 cold chain facilities in the world, but even they needed to do significant planning to ensure speed and reliability of distribution. UPS, another major transportation operator, built two new freezer facilities in the U.S. and the Netherlands to ready themselves for the uptake in demand. K+N, and other pharmaceutical companies have distribution networks as well.
Let's say everything up to this point has gone smoothly; manufacturing is humming at full capacity (which, has not happened because of facility issues, and the, uh, never ending pursuit of profit above all else, denying the relaxation of Intellectual Property Rights, but more on this later). The next thing that needs to happen is the distribution of vaccines from wherever they land in Canada, such as Montreal or Toronto. This is where the easy tough work begins domestically.
Canada is a great nation (by some, but not all, measures). We have perceptions of ourselves as friendly, kind people. That being said, there are security precautions that must be followed when transporting high-value, high-risk goods. For the most part, these precautions are built into the supply chain logistics systems that Canada is relying on. Nonetheless, it adds an additional dimension to distribution.
Now to what I'm sure at least one person reading this is thinking: Canada is also huge (geographically speaking), so that's got to have something to do with it. You would be correct. But, let's hold up here: 2/3 of Canadians live within 100kms of the US-Canada border, or put another way, 2/3 of Canadians live in about 4% of Canada's land mass (StatsCan). Much of that area is connected by major highways, (inter)national airports, and other methods of access. For those that are not in regions serviced by major highways or other infrastructure, that means more handling of vaccines required, shifting deliveries into smaller vehicles or airplanes (or snowmobiles) to get it to smaller, inaccessible locations.
Delivery
Phew, the vaccine doses have made it. Produced, shipped and delivered to a point of provincial distribution or to their final destination to be put into arms. If the former, the provincial health authority has to either contract out a further logistics supplier, or deliver doses to points of injection themselves. At the point of injection, not only are there the aforementioned concerns regarding security, but storage is important at this point as well. I know I would hate to see vaccine doses be wasted because someone forgot to set a freezer a degree lower.
Let's freeze on the storage for a second (pun most definitely intended): while some of the vaccines can be stored in a regular freezer, some require lower temperatures. Large regions (Saskatoon, Calgary, Toronto, etc.) have access to these facilities, whether it be for commercial uses (food distribution, logistics cold chain facilities, etc.) or academic uses (universities, etc.), and a limited amount of direct healthcare-related storage. Not an issue for large regions - I'm sure places are happy to give up extra storage for vaccines. It still wouldn't be enough though: Canada had to procure (read: purchase) 100 ultra-cold freezers to ensure storage capabilities country-wide, to ensure temperatures and assist locations with storage.
Here's where the fun begins: vaccines can start going into arms.
The Pfizer-BioNTech vaccine is approved in Canada for ages 16+. Canada has roughly 31 million individuals above 16 years old. That is 62 million appointments, walk-in injections, or drive-thru stabs (2 dose regime for Pfizer-BioNTech, Moderna, AstraZeneca-Oxford) that are required to get the population - above 16 years old - fully vaccinated. That's no small feat - that requires booking systems to be functional, call centers to be opened, staff to be available, and much more. It also requires health professionals, dealing with rising cases around the country, to be available to actually inject patients.
Thankfully, it being a pandemic and all, means the provinces are not short on locations they are able to set up clinics, thanks to little to no events occurring.
Canada's Position
I hope that, thus far, reading this post has made you more aware of the magnitude of variables that are required to distribute vaccines to Canadians. With that, let's talk about how we stack up.
First of all, stop comparing us with the United States. The U.S. has domestic manufacturing capacity and fiscal capacity that we can never compare to. If we desperately want to evaluate our position relative to the U.S., this excerpt does a great job:
"I mean, it's a gift and a curse that we've had reasonable control of our [Canada] COVID-19 pandemic throughout the last few months," he said. "But the reality is there's estimates of 25 per cent of Americans being infected at some point or another.
"In Canada, the figure is probably closer to the 10 per cent range, so we are nowhere near a population-based herd immunity."
- Dr. Zain Chagla, an infectious disease physician and associate professor of medicine at McMaster University in Hamilton, in this CBC article.
Let's take a look at Canada based on this great table created by Trevor Tombe, a professor in the Economics Department at the University of Calgary, and a fantastic follow on twitter:
Given that Canada's deliveries of Pfizer-BioNTech doses is accelerating beginning the first week of May, those rankings should (hypothetically) stay on track or get better. Personally, I take solace in the last column of the table, Daily Doses per Capita. Canada is 2nd (presumably behind the U.S.) in terms of the G7, G20, and Countries with 10M+ Population. And, I'll offer a hypothesis for why we're not higher in terms of the World: we refuse to use vaccines developed by certain nations due to geopolitical situations - China, Cuba, or Russia (okay, I don't think we ever said as much, but let's make the inference).
We, in Canada, are very quick to complain about being the 'last in line', simply because we are not... first? I mean let's be real: being 2nd, or even 57th, is not last when there are 190+ countries in the world.
Intellectual Property
The countries that are last? Majority, or developing, world countries who cannot afford the prices that vaccine manufacturers are demanding (and demand they can), relying on ill-funded initiatives such as COVAX. These majority world countries, or "shit-hole countries" as some have put it, are relying on intergovernmental organizations such as the WHO for equitable access to vaccines, provided they don't reduce multinational pharmaceutical company profits.
You may ask yourself, "If we have the capacity in these majority world countries to produce vaccines, why don't we?" Profit. Protecting the profits of multinational pharmaceutical companies, even when there is a moral impetus not to. South Africa and India (important) asked the World Trade Organization to waive intellectual property rights on COVID-19 related patents, to which they were denied. The vote shaped out as follows (source unknown - likely Bloomberg, another map can be found here):
Canada is 'lucky' in that its history as a country, it has been a rich, powerful friend of other rich powerful countries. This grants it the ability to devastate poorer countries and peoples to the benefit of itself.
As I noted above, India is important in all this. Not only is it dealing with a brutal outbreak of COVID-19 for a magnitude of reasons, but it also has the world's largest vaccine manufacturer, capable of producing >100M doses of vaccine a month. Relaxing IP restrictions would allow capable facilities, provided they have access to the raw materials, to produce safe, effective vaccines at even greater rates.
Now, to be completely fair and 'both sides' this argument for/against relaxing IP restrictions, here's an article that gives you the companies' side.
And in total, here's a really great Al Jazeera piece that dives in to the issue in greater detail.
Summary
Supply chains are tough, fragile beasts; vaccine supply chains that could help the world in ending a miserable pandemic, whose main goods are desired by everyone in the world... that's even more difficult. Canada is in a privileged position, being able to afford the most doses per person in the world, hedging our bets well. These COVID-19 vaccines require safe, clean manufacturing with hundreds of inputs, cold chain transportation and storage, sophisticated technology to book appointments and track doses administered, and much more... all during a pandemic.
Can we take a moment to appreciate what we have accomplished, science and supply chain wise, in the past year? Incredibly effective and safe vaccines were developed, manufactured, and we've now got over a billion doses administered in the world since the beginning of this pandemic, which was just over a year ago. Yes, we've made mistakes (lots of them). Yes, there are always things that can be done more efficiently and effectively. But there are very few people who would have said this to have been possible. In March of 2020, Dr. Fauci of the U.S. NIH said it would be 12-18 months before a vaccine would be developed and ready to be administered. A whole nine months after that statement, the first vaccines were administered. That is incredible. 13 months after that statement, a billion doses have been administered.
Relax your need for instant gratification. Follow public health measures. Listen to the scientists and experts. Thank your delivery people, and be okay with vaccine doses going to those working in distribution centers and shipping facilities. They're doing a lot.
If you want more information as to the science behind the COVID-19 vaccines, my cousin, a BSc student at McMaster, has a great podcast called I don't know much:
https://anchor.fm/s/58a96598/podcast/rss
