Very troubling indeed!
"Developing a global adult-vaccination programme out of the infrastructure built for covid-19 would be as profound a legacy for public health as the creation of the United Nations out of the ruins of the second world war was for international relations."
Health care after covid-19
Sir John Bell on reusing covid-19 medical systems for other health goals
Having built the infrastructure to deliver vaccines globally, we should maintain it for a global programme for other ailments, says a health-policy expert
HEALTH CARE systems everywhere scrambled to respond to covid-19—it would be a waste if the new infrastructure isn’t kept running to handle other health needs, by way of a preventative, global adult-vaccination programme. This could provide immunological coverage to soften the blow of future pandemics and address other disorders, from HIV and tuberculosis to obesity and heart disease. Covid-19 has cost millions of lives and exposed weaknesses in public health care. We have a moral responsibility to learn from it, act and save others.
In the past, it was impossible to imagine a global adult-vaccination programme. Today it is realistic. This is because the pandemic has accelerated advances in vaccine development, manufacturing and delivery, as well as the build-out of technology systems, health centres and trained staff. We can leverage this to initiate a vaccination campaign to fight infectious diseases and develop population-level immunity against respiratory diseases like influenza and pneumonia. This could go beyond the traditional definition of a vaccine and include preventative and therapeutic injectables for HIV, cholesterol and blood-pressure management, contraception and other conditions.
Vaccinating the entire world for a single pathogen in a narrow window of time has never been done before, but that is what is happening for covid-19. It is far from easy. A more systematic approach is needed in all countries. Even in the poorest, it requires that health-care systems identify individuals, prioritise them, vaccinate them and ensure that second doses and boosters are given appropriately. Though specific processes are tailored to different health systems, common elements are needed, such as a back-end technology for personal identifiers and secure databases.
Countries are already building new infrastructure to support covid-19 vaccination and these should be applied to other adult vaccines and injectable medication. If built well, the systems could be a highly cost-effective way to achieve other public-health goals, especially for emergency treatments or vaccines in the event of another pandemic. If the systems are not reused after covid, much of that work and investment will have been squandered. Far better to keep it warm and functional.
For example, Senegal has issued electronic vaccine certificates based on a digital register accessible over the web—a step-change improvement in public-health record-keeping. Tanzania has opened more than 1,500 vaccination centres and installed a data-management system, which could be a boon for other health objectives if kept in use. Rwanda collected data on patients with underlying conditions before vaccines arrived so it could prioritise distribution. Unless this sort of infrastructure is immediately put to new use, it may lie fallow and public health may revert back to its pre-pandemic state.
As for the tools themselves, there is good news. Vaccine technology has progressed dramatically, in a revolution that began well before covid-19. Methods such as using RNA and adenovirus have made it much easier to develop new vaccines, and the evolution of adjuvants such as ASO1 (used in tuberculosis vaccines) and lipid nanoparticles mean that a new generation of tools will soon be available to tackle many of the most dangerous pathogens in the world. The large-scale trial of the tuberculosis vaccine has generated very good efficacy data and a malaria vaccine has just reported durable efficacy in children of almost 80%. Progress is evident with dengue and new HIV vaccine studies are planned.
So-called “multiplex” vaccines will be able to manage the array of variants seen with influenza and coronaviruses. And new development methods can bypass the traditional approach (where the virus is incubated in chicken eggs), which is slow and cumbersome. Single vaccines will probably be developed to cover a range of respiratory viruses. Yet in some places, rates of vaccination against influenza are as low as 1%, which needs to increase.
Of course, not all threats to public health come from infectious diseases. An epidemic of chronic ailments accounts for more deaths than the major infections. The problems of cardiometabolic disease—such as obesity, hypertension, lipid abnormalities, diabetes and cardiovascular disease—loom large. Long-acting injectable therapies are now becoming available for these.
For example, an annual injection of a medication based on small interfering RNA (siRNA) technology, called inclisiran, could reduce cholesterol. Similar siRNA compounds might be used to manage hypertension with an annual injection. There are other long-acting, preventative injectable drugs, such as cabotegravir for HIV, and injectable birth control such as Depo-Provera. These interventions are preventative; equivalent to vaccines. They could be delivered by the same infrastructure as for covid-19.
Yet making a global adult-vaccination programme a reality requires increasing manufacturing capacity, particularly in Africa. A hard lesson learnt from this pandemic has been that the baseline manufacturing capacity was inadequate for the scale needed and controlled by a small number of companies with competing interests. Very few countries had the facilities to supply vaccines. An adult-vaccination programme would create a commercial way to build and maintain additional manufacturing capacity for new products and an ongoing stream of demand. This makes the facilities more economically sustainable. And they could rapidly respond to new global threats.
Public-health monitoring, which has improved considerably because of covid-19, would need to become better still. An expansion of local, population-level epidemiological surveillance, real-world data collection and genomic sequencing capacity is needed to track vaccine effectiveness and disease flare-ups as well as to identify new variants and novel threats. The technology is rapidly progressing, with software such as the Global Pathogen Analytical System and an emerging standardised method for identifying and tracking pathogens.
The creation of large-scale “biobanks”, as exists in Britain, to collect, store and analyse biological data on large numbers of healthy adults and relate them to the development of disease will be useful. Similarly, novel ways to conduct bio surveillance of humans with first contact with animals to monitor the spread of zoonotic diseases is possible. The monitoring can go beyond covid-19 to include other diseases, including HIV, dengue, malaria and antimicrobial resistance.
The economic case for a global adult-vaccination programme is compelling. The International Monetary Fund notes that a global vaccine programme for covid-19 at a cost of $50bn would bring economic returns of some $9trn. The case for adult vaccinations have failed in the past for single vaccinations when the infrastructure to distribute them did not exist, and manufacturing required disparate platforms. However, a global programme with multiple vaccines delivered through the same infrastructure could yield a far better return on investment, especially when one considers the value of pandemic preparedness on top of better healthcare.
Developing a global adult-vaccination programme out of the infrastructure built for covid-19 would be as profound a legacy for public health as the creation of the United Nations out of the ruins of the second world war was for international relations. It can prevent early death in millions of people each year and give better quality of life to many millions more, fueling stronger economies and societies. The world can emerge stronger and healthier for a relatively modest investment, provided we don’t waste this moment.
Sir John Bell is the Regius Professor of Medicine at the University of Oxford. He was the president of the Britain's Academy of Medical Sciences in 2006-11 and chair of the Office for Strategic Coordination of Health Research in 2006-16. He advises the British government on covid-19 and the life sciences, and served on the board of directors of Roche from 2001-20.