Some thoughts on vaccination

I’ve been asked several times what I think of the government’s vaccination strategy. This is not easy to answer, because the strategy is neither transparent nor explained well. Recent events have shown also that there is conflict within even MOH in implementing it. I know that many officials within MOH are trying to do their best, but it’s also evident that they face huge internal difficulties in crafting and implementing a sensible approach.

As I have said previously, Minister Dr Sudarshini Fernandopulle and Dr Amal Harsha De Silva should be commended for clearly saying that the aim is to cover most Sri Lankans and not to rely only on free COVAX donations. But I still have concerns about what the overall goals are, plus whether risks have been properly factored into the assessment of what is an optimal strategy. I also suspect that our typical bureaucratic processes may not be fast or adaptive enough to manage the uncertainties and rapid changes in information that we are seeing.

Our vaccination strategy needs to be clear about its goals. These need to be both: (1) minimizing deaths and serious illness, and (2) minimizing transmission, since our National COVID Strategy, whose goal is Elimination, has failed to achieve its objective. If we had been able to maintain elimination (which would have required an investment in testing which we never made), then we would have had the option of delaying vaccination a little bit.

There are and will remain huge shortages in vaccine supplies through 2021–2022. Our analysis at IHP is that under the most optimistic scenarios under which all manufacturers deliver on their promised production targets, there is barely enough vaccines to cover everyone in the world by early 2022. The optimal strategy needs to take into account the significant risks of non-delivery or delayed delivery by manufacturers. The best way to mitigate this risk is what other sensible countries are doing, including other developing countries, like Malaysia. That is to pay upfront in cash so that manufacturers prioritize Sri Lankan orders in the delivery queue, order from multiple manufacturers, and order over 100% of requirements to allow for likely delays and problems.

There is another problem that some vaccines might turn out not to be so effective against future variants that we may import in future. The strategy needs to take into account the probability that new variants will be more immune resistant. This requires two types of risk mitigation: (i) border restrictions to prevent import of new variants, and (ii) purchasing vaccines which are most likely to perform well against future variants. The government appears to have given up on or is not taking seriously preventing entry of new variants, including additional cases of B117 which is already in the community—this is actually counterproductive as it will in longterm increase the cost of the optimal vaccination strategy. The second issue implies obtaining a mix of Pfizer, Moderna, Sputnik and Novavax, since available data indicate that either they perform better against known variants than other vaccines, or are likely to perform better against future variants.

The strategy also needs to properly evaluate vaccine effectiveness in real time based on emerging evidence, and not rely on WHO views which are constrained by a number of factors, including the dependency of COVAX on a limited range of vaccines, or the NMRA regulatory process which take time. It’s worth recalling here that the countries who have are furthest ahead in vaccinating their populations, such as USA and UK, did not wait on obtaining regulatory approvals before their governments spent billions in hard cash to order vaccines. In a situation like this, purchasing has to balance the costs of delay versus the risks that vaccine candidates might not obtain approval or might not work as well as projected. I also note here that relying on the WHO EUL process automatically biases against non-Western vaccines, since the WHO process has an inbuilt bias (probably inadvertent) that imposes more steps in the approval process on non-Western producers.

For a number of reasons including those above, I personally think our best strategy right now would be to take the COVAX free 20% supply of Astra-Zeneca (but not assume quick delivery), and then pay cash to order a mix of Pfizer, Moderna, Sputnik and Novavax to cover 16 million Sri Lankans, i.e., everyone else. We should also place orders without waiting to obtain NMRA or WHO approvals, if the available evidence supports the effectiveness of a vaccine.

All of the vaccines I just listed have efficacies against preventing illness of more than 90%. I would also seriously consider paying extra if that would ensure faster delivery, since analyses, including by CDC Director Prof Walensky, suggests faster deployment is more cost-effective.

16 million paid orders implies covering kids for which most vaccines are not currently certified for, but given the difficulties achieving herd immunity. I would bet on some of the vaccines being approved for kids at some point during the year. It should be noted here that against B117, most vaccines (including Astra-Zeneca) are unable to achieve herd immunity even if all adults are vaccinated—only vaccines with >90% efficacy, like the ones I mentioned earlier, have a chance of doing this.

I would also aggressively follow up the Russian offer to support local production of Sputnik. Russia appears to have problems in scaling-up production, which is one of the reasons why German Chancellor Merkel has offered to help Russia produce the vaccine inside the EU. This would also support the government’s goal of making Sri Lanka a pharmaceutical manufacturing hub. However, this might require the government to follow the British approach of intervening to help local private firms start local vaccine manufacture, instead of just turning to SPC, which I suspect is not a good shot for long-term, competitive export manufacturing.

I would also ask Chinese firms whether we can fill and package some of their vaccines in country, as Indonesia is doing. This is because Chinese firms face a problem in cheaply manufacturing vaccines inside China as Chinese regulators do not permit the production of vaccines in multi-dose vials, although they appear to allow firms to do this abroad, which can significantly reduce the price.

All this obviously entails money the government doesn’t currently have. However, since the economic return from going for 100% vaccination coverage with the most effective vaccines will far outweigh the costs, we should borrow if needed. Options include ADB, AIIB and World Bank. Of these the World Bank is more restrictive, as its Board under US government influence has imposed rules to discourage the use of Russian and Chinese vaccines. However, a better strategy would be to go to Parliament and ask for a tax increase to allow us to purchase the best vaccines for the nation. I am not a politician, so will leave it up to politicians to decide on that. But from a technical perspective this is what I would recommend them to do.

In future, variants may emerge that are immune resistant. This is a global problem, and in the short term this means that international travel will remain restricted through 2022, and global economic recovery constrained. I agree with international experts who argue that the only solution to this problem is global eradication of the virus. I believe this is technically feasible, but the biggest barrier is geopolitics as it would require unprecedented global cooperation. But in the absence of such global cooperation, we should aim for the best possible vaccination coverage for Sri Lankans, and adopt other policies to maximize suppression of the virus within our borders. Of course, all this suggests a vaccination strategy very similar to that of developed countries. But I have to say whilst their approach can be legitimately criticized for being selfish and also hypocritical given they are in the habit of lecturing everyone else what to do, their approach is still the most rational for any country in the absence of adequate global cooperation.

 

*Updated 24/02/21: Rearranged some text that had got mixed up. plus add some additional thoughts on purchasing non-approved vaccines.

10 thoughts on “Some thoughts on vaccination

  1. Thank you Dr. Rannan-Eliya for enlightening your readers and followers with your views and comments on the ongoing pandemic as usual. Especially in the local context when it is hard to find any analyses let alone criticism of government’s Covid19 control measures from our officials as well as other academics and healthcare professionals, except for few union leaders whose views are often stained with political allegiances they may have. I do not know the reason for this scarcity of Independent criticism whether it’s fear of persecution by the government or scarcity of thought itself among the so called specislists and experts.

    Anyways couple of things, firstly how does the available vaccines, especially the ones you have mentioned above perform against the new more virulent, hybrid variation that is said to have emerged in the US? Or has it not been spread in the community to figure that one out yet? I gathered from one of your twitter comments yhat mRNA vaccines in general are better at dealing with new variants, at least the ones we have now and also they could be tweaked and produced faster than the others. What about the other two you have mentioned: Sputnik and Novavax – what makes these vaccines better at dealing with variants including the future ones?

    You have touched upon the in country production of some of the vaccines, the Russian and the Chinese ones particularly. You also mention that doing it thrpugh the SPMC may not be the best approach perhaps alluding to possible private investment for the purpose.

    Similarly don’t you think we should open doors for the private sector to importation of vaccines to be given in the private sector, not through the government programme – that will have its own beurocratic as well as logistical challenges? Especially vaccines like Pfizer/BioNtech that require soeciallized ultra cold chain facilities for storage? Of course within a broad government designed national vaccination strategy like you have pointed put abive. I wonder why you didn’t touch upon the issue of privatization immunization programme that could not only speed up the process and also relieve some ofcthe burden off from the government?

    Finally one bigvreason that has been casually spread by the media against vaccines like Pfizer is their Cold chain requirement and hence unsuitability for a tropical and/or poor country like ours. I find no real basis in this claim, especially as evident by Malaysia’s vaccine portfolio, 50% of which is Pfizer vaccine.

    I am really disappointed by the other local professionals for not pointing the government out the erroneous views spread by their own ministers and MPs and supporting media channels except for one or two rare individuals like you.

    Hope you will continue the good work you do and would be able to “talk” some sense into the rest of those officials and experts involved in the process.

    • The answer to one of your queries is in your question…I think one of the factors that discourages high quality critical comment is in fact the practice in Sri Lanka of refusing to address the substance of what people say, and instead casting aspersions on the messenger for either having financial motivations or being politically aligned. I’ve been subject to both. I think it would be better to keep motivations in mind, but also engage with what people are saying.

      On COVID, whatever else you might think of the GMOA, and I certainly do think they are quite wrong some times, the fact is that on the fundamentals they’ve been absolutely right from Day 1. Unfortunately, the habit of questioning their motives instead of dealing with what they say has been hugely damaging for the country.

      • Thank you Dr. Rannan-Eliya for taking the time and trouble to respond in detail.

        On what’s stated in your first para of the response. I do agree that it could be one reason but I don’t think it’s just that or the main reason.

        Having said that we are talking about professionals, experts, specialists in their respective fields. They should not.be discouraged by such petty reasons in giving their professional opinions. It is part of their duty to tell the truth as per their professional expertise to whom ever such truths are relevant, in this case concerning its a public health matter – to the public as well!

        I know that you have been subjected to such unreasonable accusations but I don’t see that you have stopped being critical. I guess it’s a kind of present day occupational hazzard, not that I agree or accept that things should be the way they are.

        I however fully agree that you have been too kind! I think you somewhere made a comment to that end. probably on twitter.

        I’ll get to the GMOA bit and about unions in general in a second reply.

      • GMOA

        Let me start at the outset by saying I am no big fan of unions whether they be GMOA or otherwise. Wait! I think it should be the other way around. That is: Unions are not a big fan of me!

        But having said that I do not deny their importance in general, that is either wrt to Coivd19 management or other plethora of issues they make a voice about. I wholeheartedly agree with you that GMOA’s role and the voice during this pandemic has been absolutely commendable and they have despite being a union been very scientific and technical about what they say and recommend putting most other professional and so called professional associations imho into shame! I also agree that they are quite wrong sometimes.

        However my reference to unions in my initial comment wasn’t aimed specifically at the GMOA. I m sure you have noticed that since the onset of this pandemic a number of unions have come up voicing their opinions, both in the health sector and other sectors too. GMOA, the unions of the nurses, the PHIs, the MLTs are notable in the health sector. In addition teachers unions, bus drivers (or is it owners?) associations, canteen owners etc etc from other non health sector unions and associations have all chipped in their fare share of criticism an sometimes wrath on the issue. whether they be right or wrong, they in my opinion all are valid and have a place. Like you said to which I too agree they require engagement based on science and reason and not political gimmicks and what not. Definitely not by authority that stifle healthy debate and discussion nor by force at times in the form of extra – judicial even; occasions of the use of which in the local context are not too difficult to find.

        That said all unions are political. You can not deny that. They at times are directly associated with political parties – sometimes openly at other times not so openly. Even if they are not linked to political parties their voices, opinions. positions eventually become ‘political’ if you know what I mean. Because they are organized groups of people with large membership that could influence the governing bodies whether the latter like it or not. Given their primary duty is to their membership and technically being trade unions they do not have to strictly be scientific in they dealings.

        In addition in my limited opinion most people in the society, the so called influential people that have the so called soft power disregard them as trade unionists! Basically they are “Union Karayo” and their voices thus automatically become null and void! I can remember a Chief Editor of one of the leading business magazine locally, whose friend request I made the mistake of accepting on facebook without knowoing him personally, mocked GMOAs opinion. When I offered my two cents on his posts on Covid19 that did not agree the “Positive” view he had, it seemed his feelings were hurt! I was basically the prick that pricked the happy bubble he liven in with his friends. Then I had one of the leading Physician and an ex-prof whose name I do not want to drop here, but well known and connected to Sri Lankan medical fraternity but now live and work in the UK condemned the GMOA and their voice! He of course questioned the mandate the GMOA has to make public statements and give press interviews on matters that do not fall within issues of employment of their membership with the administration. I shall see if I can trace the exact comment he made and post here sometime for you to see how the unions and GMOA are looked down upon.

        Given the above context in my opinion, the absence of critical voices of professionals who are experts and specialists in their chosen fields becomes rather deafening! and does not seem to help!

    • Private sector involvement – We need to be very specific about we mean. Many rich countries do use private doctors to give jabs, but the COVID vaccine remains publicly funded. Right now no major producer sells COVID vaccines to private buyers – all sales are to govt or international buyers. Importation exclusively private sector is not an option right now, On top of that because all vaccines only have EUL authorization, firms require legal indemnity against adverse effects claims. Govt can do this through legislation, but private sector cannot do this itself, so it will need govt support of some kind.

      • Thanks for putting the concerns related to getting the private sector involved into perspective. Yes, we may have to be very specific but that does not mean it’s impossible. Especially seeing the article you posted on twitter on Pfizer’s highly unreasonable additional indemnity claims. But I am sure all that could be worked out and agreed upon.

        On the flip side the article shows that countries like Brazil and even Argentina have been negotiating with Pfizer…. for how long now… since mid last year? to obtain their vaccine!

        Meanwhile what did our ministers were doing? They were making speeches in the parliament why we do not need the vaccine yet! I can remember at least two ministers – Namal Rajapakse and Vasudeva Nanayakkara making very strong statements saying we do not need the vaccine still. I wonder from where do these ministers draw their expertise from!?

        I am sure we could close the stable gate once the horse has bolted, like we always do, by appointing a presidential committee to investigate why the vaccines were not ordered in adequate amounts well in advance like most other countries have done if the situation get worsened and we need a scapegoat to put the blame on instead of the actual people who are responsible! . Then we could make more speeches in the parliament on the hundred thousand page report the committee produce!!! *Sigh*

        In my opinion we need ministers who could ACT and act on a TIMELY fashion- not ones who could just make speeches in the parliament!

  2. Few more concerns noticed:

    * Your suggested four vaccines only has one Russian vaccine and none Chinese, yet you say the World Bank may not be supportive of buying Russian and Chinese vaccines. But we could still buy the others with their support I guess.

    * I wonder if the government would go for a tax raise. One of the key things that the President did soon after getting elected was to give a tax break to the rich. This according to their political opponents is the main reason for economic fallout not just Covid19. It is also an openly talked fact that to compensate the tax break some of the top benefactors would fund campaign activities of SLPP, particularly that of an allied group, supposedly made of intellectuals. Given this appears to be the govt strategy, I doubt their willingness to raise taxes anytime soon.

    * You also suggest we should let the Chinese manufacture their vaccines here. But there’s no Chinese vaccine in the four vaccine portfolio you have recommended. Wouldn’t it be a good idea to have one?

    * Last but not least on an earlier blog or a twitter post may be, I think you recommended one Chinese vaccine with good efficacy and also one jab (compared to most others ypu need two). You highlighted the importance of one jab vaccines in contexts of poor compliance in getting the second dose which may be relevant to some local communities. Hence I feel it would be good to have one such one-jab vaccines in the portfolio. Preferably the Chinese one as then you could simultaneously explore the possibility of letting them manufacture their vaccines here. It could be specifically reserved for communities that would likely default getting the second dose.

    * So including One-jab Chines and OAZ from Covax we could go for a 6 vaccine portfolio.

    • My comments are based on currently available information that I am aware of. China has the largest vaccine development portfolio in the world – the most candidates plus it covers all the different vaccine technologies, including mRNA. So I am sure some of these will turn out to be good, but currently we don’t have good enough data to assess their leading candidates or what we know suggests they are not in the 90%+ efficacy range.

      From a risk diversification perspective which aims at maximizing probability of getting doses fast, I would like Malaysia consider adding some Chinese vaccines too, but my first preference is for the others mentioned.

    • To be fair to the government, only the JVP manifesto called for tax increases. Both the UNP/SJB and SLPP/SLFP ran on platforms calling for large tax cuts. When in power, both political groupings have also consistently cut taxes since the 1980s. The last UNP government cut taxes hugely in its first budget, despite running on a campaign pledge to increase education spending, which of course doomed that promise. Intellectuals of course said nothing – leading me to agree that perhaps most of our intellectuals do need more education to understand that you can’t increase spending without increasing taxes…..

      If we want more taxes—and I do—then we have to hold our whole political establishment to account, and both political parties. Both are as culpable as the other.

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