The great vaccine roll-out

In summer 2020, Project investigated the race to find a COVID-19 vaccine. Amazingly, less than a year later, we chart how the UK is handling the biggest mass vaccination project ever. Rachael Pells investigates.

In a year that optimism seemed to have forgotten, something of a miracle happened at the end of 2020. Not only was the world’s first vaccine against COVID-19 ready for use, but it was ready ahead of schedule – the UK being the first western country to approve the Pfizer/BioNTech vaccine on 2 December. Suddenly the end of the pandemic felt within grasp.

But while vaccines are cause for celebration, their creation is only the first step in a complex series of operations to lead humankind out of danger. Now, project managers across multiple industries face their biggest challenge: how to get the vaccine out there and into peoples’ arms safely, successfully and at speed.

Mass vaccination

While the UK already has a workflow in place for regular vaccines, the COVID-19 programme is on an entirely different scale. And with more than 100,000 deaths recorded, it’s a race against time. The Pfizer vaccine (and those approved since) therefore requires an entirely new plan of action.

“It’s comparable to building a massive factory – it’s of a scale that is quite unusual, which presents the biggest challenge for the roll-out,” says Alex Budzier, co-founder of Oxford Global Projects and a fellow at Saïd Business School. Ordinarily, a project of this size might follow a common set of stages, he explains. “You would begin by asking: what is the policy intent? Or, in the private sector, what is the strategy we need to realise? It takes an experienced manager to determine what the project actually requires that we do – and you would start from the end user backwards.”

Overseeing the UK’s vaccination strategy is a small group of decision-makers, with many more managerial coordinators below them. At the top of the chain is the government’s designated vaccines minister, Nadhim Zahawi, who was appointed ahead of the roll-out in December. Zahawi is assisted by experts including the chief medical officer, Professor Chris Whitty, whose job is to communicate the scientific view – which will in turn influence the decision-making process regarding who is vaccinated, how and when.

But the day-to-day organisation of the project sits with Dr Emily Lawson, chief commercial officer for NHS England, who helped to coordinate the distribution of masks, gloves, gowns and aprons to hospitals at the height of the pandemic’s first wave. She is now the senior responsible officer for the vaccination programme, in charge of signing off instructions to vaccination centres.

“This programme facilitates a very complex supply chain going from a local level to the other end, where Dr Lawson will likely talk to vaccine manufacturers and even the researchers that feed into this when it comes to answering questions like: do we have to retool the vaccine to deal with new strains of the virus,” says Budzier. “Knowing how the NHS sometimes struggles with the roll-out of these programmes in what is an extremely federated system with centralised decision-making, I’m not sure how much direct control Dr Lawson will have, but it will certainly be her head on the chopping block.”

NHS advantages

That the UK has such a centralised public healthcare system can play to the project’s advantage, too. As of November 2020, the NHS oversees the equivalent of 35,395 full-time GPs working in approximately 8,500 practices. Being able to notify every practice on the latest developments and guidance at the click of a button no doubt expedites delivery and the administration involved in notifying patients for appointments.

It has also enabled the 50 NHS trusts to ready themselves for the vaccination programme. Melanie Bagot, project manager at the Mid Yorkshire Hospitals NHS Trust, explains how her team opted for lean methodologies and in particular the Toyota Way principles as a guideline when planning for their own hospital and healthcare hubs’ vaccine roll-out.

“The most effective way of getting patients through the system without any stops is through what we call ‘one piece flow’. So we’ll look at the flow of something and remove as much waste from the system as possible,” she says. Bagot’s team conducted several dry runs of the vaccination roll-out, and after receiving instruction from Lawson in November, project managers used the staff vaccination days as a wet run to measure exactly how the public vaccinations might go.

Key to making this strategy work is “empowering staff to make the changes, so that we are working with them, not telling them what to do,” says Bagot. “It’s been difficult, because everybody is learning as they go along – from a modelling perspective, the needs changed quite a lot, and the goalposts were constantly moving. But I think of it as a bit like a wedding in that you can only do so much preparation work before the big day comes. Eventually you’ve just got to go for it.”

In the UK, NHS policy leaders have organised users into 10 priority groups, ensuring the oldest and most vulnerable (care home residents and their carers) are vaccinated first, followed by the over-80s and frontline health workers. There are several reasons why the UK is following this approach, explains Peter English, a consultant in communicable disease control and former chair of the British Medical Association’s public health medicine committee: “There are broadly two strategies: one is to protect the people who might be seriously ill if they get it, and the other is to vaccinate the people most likely to spread it.”

Supply, supply, supply

Largely, the decision comes down to the supply chain. On paper, quantity should not be an issue: the British government negotiated several months ago to pre-order 40 million doses of the Pfizer vaccine and 315 million doses of competing vaccines. But they take time to produce, and pharmaceutical companies are under pressure to distribute products fairly across the globe.

“If we could vaccinate the whole of the population in three or four weeks and that was going to prevent spread, starting with the workforce would be a good strategy. The reality is, the vaccine is trickling in. The trickle is going to become more of a stream, but never a flood,” says English. While the motivation behind the vaccination programme is to prevent illness and death, there is the hope that it will also slow transmission (as indicated by preliminary research published in February).

With end users prioritised, the next step is to line up resources – that is, the nurses and practitioners who administer the jabs – and determine what they might require. “That is then translated into the next step, which is the physical deliverables,” says Budzier. Supplies must be gathered and distributed across every corner of the country, from syringes to the chairs that people will sit on, to determining and allocating the buildings where the vaccinations will be given.

At the centre is the supply chain, and Amy Shortman, director of product marketing at logistics company Overhaul, is quick to point out that manufacturers are well aware of the challenges involved and well placed to address them. “It’s not a massive shock to our industry, because we’ve been moving medicinal products on dry ice for many years,” she explains. “But the difference here is the value and quantity of the product needed, so risks are elevated; while the clinical trials were happening, they were also planning the massive increase in manufacturing that was going to be required.”

With clinical testing complete, the biggest burden falls on project managers tasked with planning and preparing the distribution, she explains. “This means looking at freight capacity and the lanes via which the products are moving.” While other vaccines like seasonal flu drugs can be transported by ocean freight, the COVID-19 vaccine is both fragile and more urgent, and must go by air. “With a reduction in passenger flights, suppliers needed to make sure they could secure cargo space on aircraft,” Shortman says.

It’s common for vaccines to be kept cold – most need to be stored and transported at 2–8°C. But for the Pfizer vaccine to be delivered most effectively, its ingredients need to be kept extremely cold at -70°C. The Moderna vaccine must also be kept frozen at -20°C.

To make things trickier, the Pfizer vaccine does not arrive ready for use: it is transported in demi-jugs, several litres in size, ready for UK manufacturers to organise into the individual vials sent out to GP practices – a stage called ‘fill and finish’.

“COVID-19 vaccines have to move from the point of manufacture or the point of harvest all the way to the consumer’s arm in a continuous, seamless chain with temperature control,” explains Toby Peters, a professor at the University of Birmingham and expert on the cold economy. “In countries where it’s not manufactured, it will need to land at an airport at the correct temperature and move to a big warehouse.”

A high-risk endeavour

Tracking and tracing is also used to protect the precious cargo from theft and tampering. “When you think about the relatively small volume being deployed, this is a high-value item,” says Peters. “That becomes highly complicated and challenging, particularly in rural communities with poor infrastructure.”

The technology available to suppliers to ensure the vaccine is kept safe and trackable is as high-tech as you would expect for a high-risk industry. AI can be used to ensure the product is traceable and temperature controlled. And yet, despite this, the UK’s vaccine roll-out was slow to start, with the government coming under fire.

“The problem is, vaccines are biological products and every batch must be tested,” explains English. “The biosecurity risks are enormous – if you find something that shouldn’t be there, that entire batch has to be discarded.” When doing things as fast as possible, that is inevitable, he adds: “The alternative is delaying everything and not doing it until you have a stockpile. The right thing to do when we’re talking about saving lives is to go as fast as possible and accept that there will be glitches from time to time.”

Peters believes that government ministers most likely overlooked or didn’t fully appreciate the scale of the project required to organise a cold chain for the Pfizer vaccine once on UK soil – resulting in the delays seen at the end of 2020. “The day we started designing the vaccine, we should have started to design the cold chains to deliver it, because it was obvious we would need one,” he says.

Given that the Pfizer vaccine is produced in Belgium, many feared Brexit might have an impact on getting the supplies through the border. And yet, Shortman says, those involved in the vaccine supply chain “haven’t really noticed any issues. My opinion is that’s because distribution… has been very much within the public domain, ie the NHS. It’s been very efficient in their hands because they are used to doing this on a yearly basis with the flu.”

There are also contingency plans in place: vaccines are placed in the same high-priority category as life-dependent medicines and insulin, ensuring that should a hold-up occur as a result of the UK border with Europe, military planes can be deployed to pick up the supplies instead.

Creative thinking needed

Back at home, creative thinking is required to make the physical space available to vaccinate at such a large scale. Alongside GP practices and other healthcare centres, seven NHS Vaccine Centres have been set up in buildings such as Millennium Point in Birmingham and the London Excel Centre. Other local centres approved for use include football stadia, supermarket car parks, empty department stores and even cathedrals.

To help ready some of these centres, the military have been called in. In England, a Vaccine Quick Reaction Force has been set up with the army, made up of medically trained personnel. The force comprises 42 teams, which will support each of the seven regions that the NHS runs. Trained volunteers from both St John Ambulance and the NHS Volunteer Responder scheme will also be on hand – more than 80,000 of whom had completed the clinical training by January.

Army personnel helped to assist Bagot’s team set up a large vaccination centre at Navigation Walk in Wakefield, which she says had the added benefit of both teams being able to share information on successful approaches. “We learned a lot from the army because they had already been working in some of the other mass vaccination sites in Leeds and Newcastle,” she explains.

What’s increasingly clear is that this is a project that will take several years, not months. The Pfizer vaccine so far does not guarantee long-term immunity, and it’s likely that future rounds of vaccination will be required once the first one is complete. For these reasons, Budzier believes it’s crucial that project managers don’t drop the ball once the initial targets are reached. “One thing we see often in big projects like this is that the big figures – getting to two million vaccines a week for example – can drive very short-term thinking,” he cautions. “Once we’ve achieved mass vaccination, and businesses want their airport or their football stadium back, we have to realise that this is not a one-off event… this is not just getting someone to the moon and back, this is establishing a regular tourism to the moon for the time being.”

Industry observers view this as an opportunity to build a stronger, more resilient vaccination programme that can be utilised in the long term. Cold chains, for example, once designed, can provide a blueprint for future pandemics, and future COVID-19 vaccines could be incorporated into the annual flu jab planning. “Realistically, we’ve still got another two to three years of this initial roll-out from a global point of view, and stability around future planning is really critical,” says Shortman. “But if we’re going to be living with this virus for a long time – and the likelihood is we will be – we’re pretty well set up for it.”

Planning ahead for the next pandemic

When the government’s Vaccine Task Force was created in April 2020, it had three objectives: secure access to the most promising vaccines for UK citizens as quickly as possible; make provisions for international distribution for fair access across continents; and establish a longer-term vaccine strategy.

To ensure that we are better prepared for future health crises of this scale, three permanent sites for long-term vaccine manufacturing have been set up across the country. This commitment to funding epidemic-preparedness is a big step, and puts the UK in a stronger position. But an equally important part of protecting the UK population’s health is to support similar projects in the developing world.

Jenny Ottenhoff, senior programme director for the ONE charity, explains: “Leaders need to understand that their responsibility to their citizens hinges on how the world responds to COVID-19 and not just on how they respond within their borders.”

Ensuring fairer distribution of the available vaccines across lower-income countries is not only ethical, but will also help us overcome the virus faster. “There’s pretty solid evidence to show the impact of the pandemic will continue so long as the virus is continuing unchecked in less developed corners of the world,” says Ottenhoff.

Fortunately, the UK is leading the way. A ‘vaccine access test’ devised by ONE to measure distribution fairness takes into account financial contributions, policies and multilateral leadership. The UK and South Africa rank top.

by Rachel Pells