Category: Uncategorized

Vaccine Supply Capacity

Posted on by Philip J Palin

Governors, mayors, health commissioners and others are complaining about a “vaccine shortage.”

Los Angeles County Public Health Director, Dr. Barbara Ferrer, recently told CBS-Los Angeles, “The only thing standing between us and doing more vaccination is actually getting more vaccine… We’re ready right now today, at the drop of a hat. If somebody said ‘here’s 400,000 more doses,’ we would get them into people’s arms next week.”

I’m sure that is true. It is, however, a statement that obscures rather than illuminates our current situation.

So far in 2021, roughly 10 to 12 million doses of the Pfizer and Moderna vaccines have been filled, finished, and distributed each week across the United States. By most counts, about 14 million doses per week is the upper limit of current production capacity. (I have seen one credible estimate of 18 million doses, but this is an outlier.) During the third week in February a flow of 13.5 million doses is being projected.

Efforts are ongoing to increase this capacity. Some current constraints could be loosened (update).  Some additional production lines might be opened.  There are credible reasons to anticipate that new capacity from Johnson & Johnson and perhaps, Novavax will deliver several millions of doses by this summer. All of this is well-reported by the media and often-referenced in official statements. It is also consistent with production capacity projections originally laid out at least as early as October 2020.

There is a huge gap between the vaccine doses available today and the demand (need) for vaccinations today. Is this a shortage?

If you mean there is a deficit, then yes there is a deficit of supply. There is a scarcity of vaccines. There is a lack of vaccines to fulfill demand.

In English there is a subtle suggestion that a shortage is caused by a reduction in prior abundance. An English-speaker will hear that something has been shortened, cut, curtailed that has now resulted in a shortage. With the coronavirus vaccine, this is not true. Rather there has been an amazing production of millions of doses from absolute scratch only a few months ago. We are well on our way to having plenty in just a few more months.

Is this etymology or hermeneutics?  What I am sure about is that in discussions with both senior policymakers and vulnerable people looking for vaccinations, there is a sense of shortage that, in my judgment, unnecessarily complicates thinking about demand and supply.

We have a fairly accurate sense of demand. We have a fairly accurate sense of supply. We can be certain of a continuing but narrowing deficit of doses for the next several months. This reality should frame our expectations, preparations, and actions.

Vaccines versus Variants?

Posted on by Philip J Palin

While most seem fixated on vaccines, I am fixated on the variants. I have even become concerned that too much attention to vaccines can obscure our very present (if admittedly unclear) vulnerability to the variants.

Three variants are of particular concern (more). Each is more infectious than previous strains.  Each of the variants has been confirmed in the United States. One or more of these variants are likely to be widespread — even prevalent — in the United States by the second half of March.

It is not yet possible to assess the comparative lethality of these variants. Some early studies have not, however, been encouraging. In any case, all other elements being equal, a more infectious variant will increase case counts, which will increase hospitalizations, which will increase fatalities.  When and where hospitalizations overwhelm clinical resources, quality of care can suffer and incidence of death will increase… even if the variant is not innately more virulent.

Since the variants began to circulate only in recent weeks, it may well be two or three weeks before we see US case counts climb.  It will then be another two weeks — mid-March — before we see hospitalizations increase.  By mid-March it will be too late to undo the consequences of transmission from today until then.

Despite tight slow-down and shut-down measures since mid-December, Denmark reports that 27 percent of those who tested positive for coronavirus during the first week in February carry the “new” B117 strain.  Denmark has developed the ability to track these shifts with much greater accuracy than most countries.

Earlier this week the German government chose to continue rigorous Non-Pharmaceutical Interventions to mitigate circulation of variants. The German Chancellor explained that despite a recent decline in hospitalizations and deaths, the variants must be mitigated now.

In Denmark the current covid fatality rate per million persons is 1.95. Germany is at 5.88.  While the US covid death rate has slowed compared to early January, on February 12 the fatality rate was slightly above 9.0 per million.  If during January and early February the United States had a fatality rate closer to Denmark’s at least 65,000 fewer Americans would have died. Covid was the cause of at least 90,000 US deaths in January, our worst month so far.

Overall population circulation, as measured by cell phone data, is down over fifty percent in both Germany and Denmark. Compared to pre-pandemic patterns, US population circulation is down about one-third.  Commercial restrictions intended to discourage circulation (and therefore disease transmission) are much tighter in Denmark and Germany than in most US jurisdictions (see Danish regulations). Meanwhile, with Iowa’s current covid death rate at about 9.0 (admittedly a huge improvement from December’s peak of over 20 per million), the state’s mobility pattern is about 27 percent pre-pandemic, and on February 5 the governor lifted most covid-related public health restrictions.

Despite official warnings (more) and recurring media attention, I perceive a wide-spread tendency to overestimate how vaccines will flip-the-switch — near-term or long-term — and to underestimate the value of care-giving self-restraint to protect the community.  Near-universal face coverings, avoiding interior crowds, better ventilation, physical distancing, more testing, and much more effective tracing and public health interventions will — along with whole-population vaccination — significantly reduce covid related disease and death. With this reduced risk, social interactions, cultural life, commercial activity, and economic bustle can again approach pre-pandemic patterns… with positive adaptations.

There is, I perceive, an urgent threat facing us today. We do not — yet — have sufficient vaccine supplies to significantly reduce the escalating variant threat. How many will die in March and April depends on the care each of us practice today and in the next few weeks. Then as future variants of covid ebb and flow, consistently cultivating the same simple habits that protect ourselves and others will generate significant health and economic benefits for years to come.  “If not now, when?”

Vaccination Update

Posted on by Philip J Palin

On January 6, according to data available that morning, the national Vaccine Utilization Rate (VUR) was 30.7 percent. As of January 30, the national VUR was 59.2 percent. The US rate of vaccine consumption has basically doubled in three weeks time. As February begins the number of vaccine doses distributed in the United States will cross the 50 million threshold.

Recent outbound flows of the two currently available covid-19 vaccines have been averaging 1.2 million-plus doses per day. Given availability of upstream inputs and throughput at the finishing plants, current upper-end North American production capacity for these two vaccines is estimated to be about 2 million doses per day. (The highest credible estimate of current capacity that I have seen is 2.5 million doses per day.) To consistently achieve maximum capacity for a never-before-produced vaccine is unlikely this early in production, but flows are projected to more consistently achieve full capacity by the end of March.

Improved Vaccine Utilization Rates are due to several factors including, moving beyond holiday-related friction, accumulated vaccination experience, reformed procedures and processes, more person-hours spent jabbing, expanding the size of priority populations, enhanced flexibility serving priority populations, and increasing the number of access points. Larger-scale drive-through vaccination venues have received significant media attention. Here is a report on the quick standup of a “Vaccination Superstation” in San Diego County.  Data are not yet available to assess which method or combination of methods have been most helpful to doubling the consumption rate.

As higher velocity vaccinations are achieved, it will be even more important that planning and execution reflect effective demand management. (The linked WSJ report is consistent with Supply Chain Resilience TA principles.). Late Friday, January 29, the editors of the Journal of the American Medical Association published an editorial on demand management  very similar to the approach the TA program has outlined since October.  For this virus, better risk prioritizing also advances greater equity. 

The Kaiser Family Foundation reports that the American public is demonstrating increasing confidence in — and demand for — vaccinations.   As demand signals — population pull — increases, it will be even more challenging to effectively target available push. Most outbound flows are not yet structured to support variable demand. Over the weekend a colleague also commented, “The most obvious concern to me is burning out human resources as we poorly manage supply and demand of product. We will continue to need so much from [medical staff and volunteers] in the coming months. That is why making their time as productive as possible now, not slowing them down with paperwork delays [and other distractions], is important.” 

Despite current supply limitations, up to twenty-million doses (about 40 percent of flows) are reported to be “deployed” but not yet administered. The improved VUR is encouraging, but there are also increasing concerns to vaccinate as many risk-prioritized populations as possible before more contagious variants of the virus become dominant. The authors of a variant study released last week conclude, “this virus is traveling in a direction that could ultimately lead to escape from our current therapeutic and prophylactic interventions directed to the viral spike. If the rampant spread of the virus continues and more critical mutations accumulate, then we may be condemned to chasing after the evolving SARS-CoV-2 continually, as we have long done for influenza virus. Such considerations require that we stop virus transmission as quickly as is feasible, by redoubling our mitigation measures and by expediting vaccine rollout.” The more quickly risk-prioritized vaccinations are administered, the more this threat is mitigated.

Potential expansion of production capacity for current vaccines is being explored. But realistic options are unlikely to produce more flow before late Spring if at all. The distribution-friendly Johnson & Johnson single dose vaccine seems likely to receive an Emergency Use Authorization in coming weeks.  J&J anticipates having the ability to produce 100 million doses by the end of June.  Some virologists expect one or more variants to be dominant by the end of March.

Fundamentals of Vaccine Demand Orientation

Posted on by Philip J Palin

From a supply chain perspective, the goal of vaccination is to minimize demand for critical health care. We need to avoid hospitals being overwhelmed. Emergency room/ICU resources and staff are the crucial bottlenecks (hourglass structures) that are at highest risk of collapse. Our supply chain resilience objective is to maintain a reasonable equilibrium of demand and supply for critical health care. If this equilibrium can be maintained, deaths and disease can be minimized and economic continuity (recovery) can be maximized.

Contributing to vaccine confidence

Posted on by Philip J Palin

As we saw last week, anytime a new flow is channeled where there was essentially no previous flow, there is likely to be — almost certainly will be — surprises (more and more and more and more). Some happy, some unhappy. But there is cause for confidence that vaccine flows will grow considerably over the next several weeks (more).

At this point, with something between sixty and 120 days until population-wide Phase III inoculations can be seriously started, and with sources, scale, and scheduling of vaccine flows necessarily ambiguous, one of the most constructive steps available is to reduce vaccine hesitancy. Most epidemiologists continue to call for at least 60 to 70 percent of the population to be vaccinated. Some resources:

1.  A December 14 opinion piece in the Journal of the American Medical Association (JAMA) is entitled, “Behaviorally Informed Strategies for a National COVID-19 Vaccine Promotion Program.”  The authors outline five specific recommendations: 1) Make the Vaccine Free and Easily Accessible, 2) Make Access to Valued Settings Conditional on Getting Vaccinated, 3) Use Public Endorsements From Trusted Leaders to Increase Uptake, 4) Provide Priority Access to People Who Sign Up to Get Vaccinated Before Vaccines Are Widely Available, and 5) Transform Individual Vaccination Decisions Into a Public Act.  More details on each recommendation are available at the JAMA link.

2.  A December 10 feature story in the New York Times Magazine is entitled, “We Know How to Curb the Pandemic. How Do We Make People Listen?”  The article concludes with, “Right now, everyone is flooded with Covid information from all kinds of sources; it’s unlikely that a single public health initiative will change the trajectory of the virus. But employing research-based communication strategies could help scientists and government officials make their messages more influential, thereby saving lives. Yet… the focus instead has been “on health science, epidemiology and medical science. Not on behavioral science.”  Several behavioral science principles and practices are outlined.

3. A December 18 thought-piece from McKinsey & Company is entitled “COVID-19 Vaccines Meet 100 Million Uncertain Americans“. With convenient alliteration, the consultants encourage a three-fold strategy of commitment, convenience, and costlessness. (Beginning to see some recurring themes?) Related to commitment, one angle involves, “Our peers may be the most potent influencers of all, and peer encouragement will be vital if COVID-19 vaccines are to become the norm. Normalization can occur based on social-media posts, sharing with friends, and even wearing “I was vaccinated” stickers. The reciprocal approach—the social stigma of going against the group—is also powerful, sometimes even more so. If the consequences of harming other people by not being vaccinated can be demonstrated, a stigma could attach to those who eschew the vaccine and are perceived as harming others.”  It is another aspect of the behavioral science approach noted in the NYT and JAMA pieces.

I also suggest reading Thinking Fast and Slow by Daniel Kahneman, the psychologist who won a Nobel prize for economics. There are deep issues of bias, heuristics, and narrative that will need creative attention to achieve effective demand management… just as much as any of the pandemic-specific and vaccine-specific issues outlined in the other three sources. Kahneman is great on all these factors. The classic text on motivating demand for innovative products — such as entirely new vaccines, made with a brand-new technology, very rapidly implemented — is Diffusion of Innovations by Everett Rogers.

In any supply-constrained environment there is an understandable temptation to focus on maximizing supply. This can, however, be myopic and strategically self-subverting. The more high volume, high velocity supplies are needed, the more valuable is validated, differentiated targeting of demand. This may seem a subtle distinction. But as a matter of strategic discipline it is as different as night and day. By knowing what is needed when and where by who… you are much more likely to optimize your limited supplies.

One final suggestion (possible nag): Many of the good ideas set out in the first three sources above are a bit tarnished by treating the population as something to be manipulated, rather than fellow human beings with whom you want to collaborate and co-create (not just enforce compliance). Asking questions, listening carefully to answers, and authentic conversation is a very good place to start.