The TLDR: This is the second installment of our two-part series that looks at the immense challenge of actually vaccinating a country of 1.38 billion people. The first part examined whether India can acquire the required number of doses, pay that steep bill, and identify who needs to be vaccinated first. You can read it here.

In this final part, we look at logistics—an innocuous word that hides just how difficult it will be to deliver that precious injection to millions. Vaccines have to be stored at the right temperature, require additional equipment—vials and syringes—and need trained personnel to administer the dose.

Can we store the vaccine?

Freezing temperatures: Of the three leading candidates, Moderna and Pfizer have to be stored in deep-freeze conditions. Temperatures have to be as low as minus 80 degrees Celsius from the moment they are bottled to the time they are ready to be injected into the patients’ arms. The Oxford vaccine is the only one that is fine at minus 20 degrees—which can be achieved by most available freezers.

The freezer problem: 

• We only have 80,000 cold storage units—and will need twice as many to vaccinate the targeted 250 million. 
• Each of the ice-lined refrigerators recommended by the WHO cost thousands of dollars. And the solar-driven variety—needed where there is no electrical supply—are even more expensive. 
• Planes and trucks will have to be fitted with the right freezers to transport the vaccines.
• Once removed from deep-freeze, these vaccines have a very short shelf life. Moderna can be kept in a normal fridge for two weeks. Pfizer will last only 48 hours. 
• At room temperature, most vaccines will deteriorate very quickly. 

Point to note: If the winning vaccine requires deep-freeze conditions, it will be very difficult to administer them in smaller clinics. Rather, we will have to arrange mass vaccinations in large venues. As Mint notes:

“Camps in schools and stadiums—similar to election time—have to be set up.

Also in the primary health centres (PHC), established to cover a population of 30,000 in rural areas. While India has over 30,000 PHCs, many of them don’t function too well. The next few months is a good time to fix them.”

The dry ice problem: Now, dry ice—which is minus 79 degrees Celsius—can help lower the temperature in a typical freezer. And it will be critical in planes and trucks. But there is a significant shortage thanks to the virus. 

• Dry ice is a solid form of carbon dioxide—and is a byproduct of the production of ethanol. 
• But ethanol production—which is a key ingredient in petrol—is tied to the demand for gasoline. 
• When people stopped driving during the pandemic, ethanol production came to a standstill. 
• This in turn created a huge shortage in carbon dioxide, and therefore dry ice.
• The other issue: dry ice has to be replenished with religious precision for some of these vaccines—which is a big ask. One US immunisation expert says: “To actually train providers to use dry ice—to get them dry ice—you’re really going down a path that’s not feasible.”

Point to note: Delivery giant DHL recently estimated that delivering the vaccine across the world will require 15,000 flights carrying 200,000 bulk consignments—which then will have to be distributed in 15 million deliveries in cooling boxes.

What about vials, syringes etc.?

Cold-resistant glass: If the vaccine has to be stored in deep-freeze, so do the vials that contain them—and these are in short supply. In the US, Corning is developing a new kind of glass that can withstand the lowest temperatures—and is built to resist contamination. Again, none of this is cheap. The US government has shelled out $204 million to fund this special project.

Syringes: Most Covid vaccines require two doses per person. And if the government plans to vaccinate 250 million in the first phase, we will need half a billion syringes. But on this point, there is good news: India is one of the largest syringe makers in the world with a production capacity of over 1 billion a year. By the middle of 2021, we can ramp that up to 1.4 billion.

Human expertise: In India, only doctors and nurses can administer an injectable vaccine—and that won’t be sufficient to get the job done. We will have to train other staff such as pharmacists. The government is already working on “online training modules” for skilled staff who can both administer vaccinations and report any side effects. 

The big plan: The government will release its plan for distribution in the coming weeks—based on the assumption that it will have a vaccine by early 2021. These include a digital monitoring platform that will track the vaccines at each stage of the supply chain, and a cold storage supply chain that taps into private companies.

When will I be vaccinated?

The entire immunization programme will unfold over years. As one virologist points out: “One of the country’s largest vaccination campaigns so far—delivery of the measles–rubella vaccine to 405 million children, starting in 2017—has taken 3 years.”  And as we noted last week, the first priority are those most at risk: frontline workers, the elderly and those with underlying conditions. WHO has already said that the average young, healthy person will have to wait until 2022.

The bottomline: The first vaccines aren’t likely to offer some kind of golden shield—and there will be greater confusion because there are so many different kinds. The New York Times emphasizes: 

“The first vaccines may provide only moderate protection, low enough to make it prudent to keep wearing a mask. By next spring or summer, there may be several of these so-so vaccines, without a clear sense of how to choose from among them. Because of this array of options, makers of a superior vaccine in early stages of development may struggle to finish clinical testing. And some vaccines may be abruptly withdrawn from the market because they turn out not to be safe.”

So which vaccine’s requirements should the government plan for?

Reading list

• ICMYI: Be sure to check out part one of our explainer.
• New York Times (via ET) looks at the deep freeze challenge. 
• Times of India has a more India-specific overview of the delivery chain. 
• The Print focuses on the issue of cold storage. 
• StatNews raises seven key questions about delivery. 
• Also in New York Times: The chaos that will be triggered by multiple companies pursuing different vaccine candidates. 
• Reupped from our previous installment: Mint’s deep dive on delivering the vaccine in India.
• Bloomberg News looks at the pressure to develop a vaccine asap—and its perils. 
• Frontline takes a detailed look at the Indian vaccines.
• Healthline explains all the unexpected ways the vaccine could be delayed.