Une pharmacienne ouvre un congélateur pour préparer des doses de vaccin Pfizer/BioNTech, le 8 janvier 2021 à Bordeaux. Mehdi Fedouach / AFP

The slow start of vaccination is not a logistical problem

Destinations

What is therefore at issue here is the fact that upstream, the government has not sufficiently integrated the logistical constraints, and that downstream, it has not succeeded in explaining to the general public why the vaccine logistics started more slowly than in our neighbors, and in particular in Germany.
In short, it is not so much a logistical problem, but a strategy and marketing problem!

1st step: the design of the vaccine strategy

To understand this, we have to start from the starting point, which is the development of the vaccine strategy. In the second half of 2020, the Haute Autorité de Santé instructs a working group to make recommendations.
Composed of several doctors and a sociologist, this one reviews the medical literature to develop your strategy.

While it is known by definition that the quantities of doses will initially be limited, the main challenge is to determine who to vaccinate first. For this, the experts are based on two prioritization criteria: “the risk of developing a severe form of Covid-19 and the risk of exposure to the virus”. This leads them to propose a strategy based on five successive phases.

According to them, the first should target residents and staff of accommodation establishments for dependent elderly people (Ehpad), which represents around one million people. The second phase then plans to extend the vaccination to those over 75, to people aged 65 to 74, as well as to some caregivers.
Finally, three other phases are planned in order to gradually extend the vaccination, which should be concluded with the population least at risk: those over 18 without comorbidity. In general, this phasing responds to an objective explicitly formulated by the experts, which is to use vaccination first to reduce severe forms and reduce the pressure on hospitalizations.

At this point, it can be noted that no logistical consideration seems to have been taken into account by the experts, who rely on a strict medical view. The term is thus mentioned only once, and again, to emphasize that clusters have been able to develop in “logistics services”. However, the experts have integrated the difficult relationship of the French to vaccination into their strategy, and insist on the “need for clear and accessible information”.

2nd step: logistics after strategy

Based on the recommendations of the Haute Autorité de Santé, the government will then work on set up logistics which supports the defined strategy.
What is at stake here? Bring the vaccine to the thousands of nursing homes that are scattered throughout France, because we obviously cannot ask residents to go to vaccination centers.

To supply them, two flows are then planned, which rely on traditional logistics circuits. Around 25% of nursing homes are supplied by around 100 hospital pharmacies on which they depend. It was therefore decided to entrust these hospital pharmacies with organizing the delivery of vaccines.
To do this, it is planned to equip these, when they do not have one, with freezers to store the only vaccine available: that of Pfizer / BioNtech, which must be stored at – 70 ° C.

In addition, 75% of nursing homes are supplied by a referral pharmacy. Knowing that it is materially impossible to provide these thousands of pharmacies with the famous freezers, the state logically chooses to go through depositaries. Six logistics platforms are planned to centralize stocks and reach all of France.

These platforms, which will also have freezers to store Pfizer / BioNtech vaccines, will then be responsible for supplying the referent pharmacies located in their area, which themselves will finally be able to supply nursing homes.
As for the timetable, the government, while an uncertainty exists on the date of validation by the European Medicines Agency of the Pfizer / BioNTech vaccine, which should take place between the end of December and the beginning of January, foresees a real start of the campaign in early January.

3ᵉ step: the slow deployment of logistics

However, under pressure from Germany, Europe authorized the roll-out of vaccination one week in advance, starting on December 21, and the President of the European Commission officially launched the European campaign on December 27. These announcements then take France a little by surprise, which is then not quite ready: as revealed Mediapart, freezers, if delivered before Christmas, are not yet all installed and qualified.

In addition, this holiday season is obviously not very conducive to launching vaccinations in nursing homes. Between Christmas and New Year’s Day, while the number of vaccinated increases rapidly in most of our European neighbors, the counter remains stuck at a few hundred in France. While they started at the same time as us, this lag behind our neighbors is misunderstanding and leads many commentators to point fingers at the logistics.

The cause of this ignition delay is on the one hand, as we have just pointed out, the acceleration of the European calendar, which takes France by surprise. But as we will see, it can also and above all be explained by the fact that our neighbors have chosen other vaccine strategies, which have led to different logistics!


Extract from a Ministry of Health programming document dated December 23.
Mediapart document

Thus Germany, which in a first phase, planned to reach both residents and staff of nursing homes, like France, but also the public at risk: the very old, nursing staff and people with pathologies at risk. For this, alongside logistics targeting its nursing homes, which we can assume that it follows more or less the same steps as the logistics set up in France, Germany has from the outset planned the deployment of “vaccinodromes “. By nature, this second logistical scheme allows the Germans to very quickly increase the number of people vaccinated.

With these vaccinodromes, we first remove certain links that are necessary to reach nursing homes. These are indeed the people who come to the vaccine, and we understand that the time between when a vaccine enters the supply chain and when it reaches the patient is shorter here.

Furthermore, in order to vaccinate in nursing homes, the difficulty is to determine before shipment from storage places, exactly how many doses of vaccine to send to each nursing home, which is far from simple. Residents’ consent must in fact be obtained upstream, which implies coordinating with nursing home doctors (knowing that not all nursing homes have one), possibly interacting with the families of these residents (case of residents having Alzheimer’s, for which it is necessary to speak to the guardianship, etc.), in a holiday period which is not very favorable (possible absence of some caregivers on vacation, difficulty in contacting the families of certain residents under guardianship, etc.).

The stake is however crucial, because it is especially important not to thaw too many doses, at the risk of losing them and while we have a limited number! Conversely, such a problem obviously does not arise in the context of a vaccinodrome. Indeed, if there are anti-vaccines, there are also very many people wishing to be vaccinated, and the demand in these places is for the moment much higher than the number of available doses, as illustrated by the tails. that we can see all over the world.

There is even less risk of losing doses, since the vaccines are either stored on site in freezers, or delivered several times a week from a stock which is not very far away, and that it is possible in these structures much more easily adjust the necessary quantity to demand. All in all, the logistics underlying a vaccinodrome are therefore much faster to start!

4th step: a lack of logistical pedagogy

While this delay in starting up can be explained in particular by the acceleration of the schedule and the strategic choice made to target first the only nursing homes, faced with increasing criticism, the government is trying between Christmas and the day of the year to defend its strategy. He explains that his objective of targeting residents of nursing homes as a priority is justified by the fact that residents represent 30% of deaths.

However, such an explanation cannot suffice to explain the delay in starting. To achieve this, you have to go into logistical details, and follow the long course that I have just presented above.
This long course remains hardly compatible with the media time, the criticisms of the various political parties which all rush into the breach, and especially with the cards which circulate on Twitter and compare the number of people vaccinated in the various countries with France which has only vaccinated “Mauricette” so far.
Communication is all the more difficult because in the media, no one knows much about logistics, and no one in government is able to come and give such explanations. Worse, the government’s Vaccine mister even admitted in an interview with LCI that he does not knew nothing about logistics !

5th step: a review of the vaccination strategy

While following the case of the masks, then the tests, the state logistics behind the management of the epidemic have been the subject of much criticism, and confidence in the logistics capacities of the state remains very low, the battle for communication seems clearly lost.
The government then has no other choice but to question its entire vaccination strategy and to seek by all means to rapidly increase the number of people vaccinated.

For this, the Minister of Health Olivier Véran extends vaccination to caregivers over 50 from December 31, then on January 5 announces that it will soon be open to all people over 75 years old.
While he had expressed his reservations about vaccinodromes, in view of the strong desire for vaccine from part of the population, he also announced the opening of vaccination centers.

Operationally, pivot hospitals that have freezers are asked to quickly set up vaccination centers to be able to start vaccinating caregivers over the age of 50. Gradually, these centers and others that have been set up in conjunction with local communities are being deployed throughout France.
This allows from the first week of January to increase the number of people vaccinated. On Friday January 8, it is so according to the site Vaccine Tracker 34,305 people who were vaccinated in one day.

Building the strategy with logistics

What should we learn from this sequence and what lessons should the government learn from it? That in this crisis, the elements and logistical constraints are decisive and must be taken into account upstream (formulation of strategies) and downstream (communication).

So what the government is guilty of is having thought out its vaccine strategy first, and then organized the logistics of that strategy. This was a mistake because, as I have just explained, it led to opting for the strategy which was the most logistically complex to put in place. This strategy necessarily led to a slow start, yet many French people who believe in vaccines are just waiting for one thing: for it to happen quickly. In image terms, such a choice was politically bad.

The error was all the more noticed as the government, while the slowness of the departure was perfectly foreseeable, failed to communicate on the subject.
The fault is that despite the key role of logistics in this crisis, the government did not see fit to put forward a person in charge of logistics capable of teaching it to the general public (we can however, note that the government appointed following this crisis a new responsible for immunization logistics).

Logistics performance, a health impact

But basically what remains for me the main problem of this sequential logic (1) development of the vaccination strategy then 2) implementation of logistics, is that it has led the government not to consider in its strategy the criterion of “logistics performance”, even though this criterion seems to me to be key in terms of health.
In a context where vaccine doses are received in droplets and over time, due to limited production capacities, the medical issue is not only to determine who should receive the vaccines as a priority, but also to be able to administer the vaccines as quickly as possible, without losing doses, as soon as they are received!
The faster we transform the doses received into vaccinated people, the faster we will obviously be able to reduce the epidemic, reduce hospitalizations, deaths, etc., restart the economy and finally enjoy bars, restaurants, theaters again. and cinemas!
For this, it is logistically on the one hand to lose the minimum vaccine doses, and on the other hand to have a just-in-time vaccine strategy that allows the flow time between the moment when the doses are given and the time when they are injected is as short as possible. The strategy developed by the Haute Autorité de Santé should thus clearly have taken into account these aspects which have been totally forgotten …
If they had been integrated, a logical conclusion would then have been that it was necessary from the start, in addition to the flow to nursing homes, to set up vaccinodromes in order to be able to use the available doses as quickly as possible.
Because given the time needed to start the campaign in nursing homes, there were enough doses in stock to at the same time begin to vaccinate other segments of the population. Thus, nothing legitimized that the doses sleep in the freezers on platforms!

In addition, relying from the outset on two logistics circuits would have allowed greater logistical agility. However, such agility seems crucial here, given the uncertainties that exist both on supplies (which vaccines will ultimately be authorized and when? How many doses will manufacturers be able to deliver?), And on good vaccination practices. (do you need two doses spaced 3 weeks apart? Six weeks? One dose? Should the vial be used to give six doses instead of the five planned?).

What assessment?

To conclude, if we step out of the present tense and look forward to the coming months, one challenge will be to collectively and calmly assess the French vaccine strategy. For this, it is clear that it is absolutely necessary to go beyond the only simple indicator currently in use consisting of counting the number of people vaccinated.

Specifically, one challenge will be to look at two indicators that are familiar to all logistics managers and other supply chain managers: lead times and quality. How long on average does France take, once vaccines have been delivered by pharmaceutical factories to its logistics platforms, to vaccinate the population? What is the proportion of doses received that we lose, because we have not respected the cold chain, broken a bottle, etc. ?

In this spirit, it would be interesting for journalists who follow the subject to hold the government to account, and for the corresponding indicators to be disclosed. In the same vein, the state should also communicate on the number of people it has vaccinated within each of the priority population groups that had been identified in its vaccination strategy.
Because the urgency is of course to vaccinate certain people first as a priority, an emergency which also seems to have been forgotten by the media madness consisting simply of counting the number of people vaccinated! Whatever happens, it is clear that we will continue to talk about logistics in the coming months …The Conversation

Aurelien Rouquet, Professor of logistics and supply chain, Neoma Business School

This article is republished from The Conversation under a Creative Commons license. Read theoriginal article.