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How do you ensure that ‘COVID-19 jabs are in arms, not fridges’? Roger Highfield, Science Director, talks to Dr Emily Lawson, England’s vaccine deployment lead in the National Health Service.

Since ‘V Day’ on 8 December – when Margaret Keenan  became the first person in the world to receive an approved RNA vaccine – the UK has given the first dose of COVID-19 vaccine to around 23 million people, of which 19 million were in England.

On Thursday 11 March, the Science Museum in London joined the vast nationwide network of coronavirus vaccination centres. Those eligible to be vaccinated will be invited to book through the national booking service. If you’re eligible, please visit the NHS website or call 119.

 

The Science Museum reopens as an NHS vaccination centre
The Science Museum reopens as an NHS vaccination centre.

To understand the complex logistics of delivering the vaccine, I talked to Dr Emily Lawson, chief commercial officer for NHS England, who is responsible for the vaccination programme in England.

A few days ago, she discussed the roll-out with HM The Queen, including Her Majesty’s own vaccination, who praised the nationwide programme.

Her 13-year-old daughter Phoebe is taking part in a children’s trial of the Oxford/AstraZeneca vaccine at the University of Oxford, St George’s University Hospital, London, University Hospital Southampton and Bristol Royal Hospital for Children.

Her edited responses are shown in italics.

Dr Emily Lawson (centre), pictured with Prince Charles and the Science Museum's Keeper of Medicine Natasha McEnroe
Dr Emily Lawson (centre), pictured with Prince Charles and the Science Museum’s Keeper of Medicine Natasha McEnroe

When did you start planning how to vaccinate england?

The NHS started planning the rollout before we even knew that we would ever have a vaccine, let alone which one we were going to have or what it was going to look like. That happened last summer when the Prime Minister asked the National Health Service (NHS) to take that lead.

What we had to do was to plan a set of sites, a supply chain and a model of delivery, which would work regardless of the characteristics of the vaccine or could work for a range of vaccines.

We set out to design a system that would be resilient in a range of scenarios and that would leverage the existing might of the NHS.

I started leading the programme in November, that’s when it started to get real, we knew it was likely to be the Pfizer-BioNTech vaccine which had to be kept at minus 70 deg C.  

You could have set up a new delivery system – why pick the NHS?

We always pointed out that the NHS already runs 17 different vaccination programs a year including winter influenza.

In the 2019-20 flu season, for example, more than 14 million adults and children were vaccinated across the UK (by comparison, an Office of National Statistics estimate says that more than 45 million people aged over 16 are eligible for a COVID-19 jab).   

We already had the infrastructure of 1250 primary care networks, PCNs, which are groups of include GPs working together that had been established as the NHS moves more towards system working rather than individualised working; as well as pharmacies, local hospitals and so on, all of whom play roles in existing vaccination programmes.

The argument was pretty compelling that if you’ve got a group of clinical professionals who are already experienced at delivering vaccines, completely starting from scratch makes absolutely no sense.

We started with the influenza vaccine and how that’s delivered and then worked through how to do that faster, at scale, to a more extended population with much more limitations on the how you can transport the vaccine for example, with the complexities of delivering the Pfizer-BioNTech jab.   

The science museum, football stadia, mosques and other venues are now being involved – why?

As we designed the possible roll out in the autumn, it became clear partly because of the different nature of the vaccines and also the supply we might get, that we wanted to plan for every scenario.

The goal was to ensure that the NHS was not going to be the pinch point in the supply chain. We will always get vaccine as fast as possible from when it arrives in the country into people’s arms.

The motto of the team was ‘Jabs in arms, not in fridges.’

To achieve that we needed to have some flexibility in capacity, centres which could deal with larger scale vaccination to more micro-level vaccination visits to a care home or visits to housebound people.

To deliver everything from a single visit for one person to being able to do thousands of people in a day at the same site, we needed to have that flexibility to make sure we could deliver on our side of the bargain.

We designed three major routes to the population.

One is by primary care, which has done most of the heavy lifting so far, which is entirely appropriate for the most vulnerable groups.

One is the large-scale vaccination centres and sports stadia, the Science Museum and so on, and one is via the hospital hubs who do NHS staff vaccinations every winter, notably for flu.

The hospitals were very important in terms of designing the supply chain because we could be sure they could handle a minus 70 deg C supply chain.

At the moment primary care has delivered about 75% of the vaccinations, with the remainder being split between hospital hubs and vaccination centres.

Vaccination centres include both bigger and smaller sites and also includes community pharmacies where they may be vaccinating 100 people a day.

The scale is important but so is the flexibility and agility to deal with different vaccines and different needs of different populations.

Some people are very happy to go to a large centre like Epsom – like my parents-in-law who are very sprightly people in their 70s, for example.

But there are lots of people who’ve been shielding all year, who have really not seen anybody, feeling incredibly fragile and a trip to a bigger vaccination centre would be overwhelming and entirely the wrong thing to do.

So, a visit to their GP or the GP coming to vaccinate them, or indeed a visit to a community pharmacy they have visited before feels much more accessible.

We want to go to where people want to go, because the overall goal is to get people vaccinated, not to make it convenient for us.

What people and companies made nationwide delivery possible?

Several pieces of infrastructure helped the roll-out of vaccine. The first is that we’ve got amazing people running the logistical system – we brought in expertise that the NHS wouldn’t usually have in the form of Steve Gibb (who was the Supply Chain Director at Dixons Carphone) who’s helped me design that supply chain.

We also worked with existing medical supply chain experts and global leaders in deliveries to supply the consumables to where they are needed to underpin the vaccine supply chain.

There are 89 different types of products and around 340 different individual products involved.

Fridges and ultra-low temperature freezers obviously, but also the more mundane equipment like first aid and anaphylaxis kits, chairs that can be properly disinfected, gloves, masks, aprons, detergent wipes which are all needed to make vaccinations happen.

In total this has added up to almost 200 million items of consumables and equipment delivered so far.

What technology helped roll-out logistics?

We had to make sure we had the systems to track where everything was at all the times.

We have been using a central data storehouse – Data Foundryso we know where the vaccine is, and where the supplies are. It shows how much dose has been allocated to a site, when it’s scheduled to leave the wholesaler, when it arrives and is checked in.

GPs have chosen to use existing systems to record vaccinations and through GP records, doctors and their teams are able to tell if someone is eligible, any health conditions and their ethnicity and so on.

They’ve used their own booking systems that they already had in place, some of which are very sophisticated some of which are literally calling people up by phone – whatever works best for their community.

We decided to use existing methods because it gave us resilience and enabled us to work at speed.

All of the patient data drops into the existing National Immunization and Management Service, NIMS, which has the advantage that it can drop the information straight into patient records held by GPs within 24 hours.

So, for pharmacovigilance purposes, should anything go wrong such as a side effect, we have got a record of exactly when they were vaccinated the first time and what vaccine they had.

We did also design the national booking service so that we could use places like Epsom or the Etihad Stadium in Manchester appropriately, and that was built at speed by NHS Digital.

How did you deal with handling vaccines at -70 deg celsius?

The Pfizer-BioNTech vaccine was the first vaccine to be approved on 1 December and the first approved vaccine to be given anywhere in the western world, to Margaret Keenan.

All we knew in November is that it had to be transported at minus 70. Once it was thawed, it had 120 hours to go. It could have a brief excursion at room temperature in those 120 hours to be injected but once it had been out for more than six hours, it had to be thrown away.

We were desperately concerned about waste given the global shortage of the vaccine. That’s why we started with the 50 hospital hubs that first week of December. Those were all sites which had minus 70 degree freezers so they could receive the vaccine at minus 70 so they would not have to start vaccinating immediately on arrival.

At the beginning of December regulators, the MHRA, approved the vaccine but they also allowed it to be transported between 2-8 degrees Celsius. We hadn’t known we were going to get that approval.

We had already designed, but subject to MHRA approval, a route to get the vaccine to primary care via clinically qualified wholesalers.

When we started the vaccination program on 8 December, we began with the 50 hospital hubs that we had already set up.

Regulators approving the vaccine being transported between 2-8 degrees meant we could then also turbocharge getting good distribution practice to primary care authorised to make sure their process was robust.

That led to a second supply chain where Public Health England delivered to the wholesalers. When they had a delivery of the Pfizer-BioNTech vaccine they then went through a structured defrosting process and then those defrosted boxes were shipped to primary care.

That’s what enabled us to supply the first 200 primary care sites on 15 December, just a week after the first vaccination. That marked an extraordinary supply chain and primary care collaboration.

It is a testament to primary care. It is daunting to be told:  You’re going to get this box of vaccine. You have got to do 975 doses between 90 hours and 100 hours, depending on how quickly we get across the country to you, after its defrosted. And after that, you’ve got to throw it all away.

Hats off to those first 200 sites – they seized that challenge, and they ran with it.

The next thing we had to do was to work with MHRA and the distributors to agree to ‘pack down’ the supplies of Pfizer-BioNTech vaccine so that, instead of distributing 975 doses, we could pack them down in boxes of 75 doses for distribution. That enabled the visits to care homes to really start.

At every stage, it has taken joint working between the regulatory agencies, the providers and the end users to try and adapt to the needs of the vaccine. If you speak to anybody in primary care, what they say is they were genuinely terrified that first week and then after that they were like ‘OK, we get it now. It’s not so bad’.

Are the military involved with the roll-out?

Yes. I had already worked with the Army’s 101 Logistic Brigade in the spring at the beginning on the pandemic and when I took over the vaccination programme in November I said we needed military logistics support. I thought the Army would send us a logistics team, but they sent me almost the same team with Brigadier Phil as my right-hand man.   

Brigadier Phil Prosser was taking part in an exercise with more than 2,000 soldiers on Salisbury Plain when he got the call last November instructing him to begin work on delivering vaccines. Days later, he and 50 military logistics experts were at work on the programme at the NHS headquarters in Skipton House, South London.

The army logistics team were working on the supply chain but particularly on planning. They had maps of vaccination delivery locations to analyse the distribution, how easily people can get access.

Every week, as we added more sites to make sure we were covering the country, we did overlays looking at hospital hubs, GP-led vaccination centres and NHS vaccination centres sure we had sites evenly spread. As a result, nearly 99% of the population is within 10 miles of a vaccine service.

They also introduced military rigor into each team. So, for example there is a military lead on the supply team, a military lead in the primary care team and military lead even in the workforce team, bringing in their planning expertise and their manoeuvres type expertise to keep everybody on plan and on target and keep a really good operating rhythm.

How did the decision to space vaccinations affect you?

We don’t make policy, in this case to focus existing supplies on first doses.

When that policy decision was announced by the Joint Committee on Vaccination and Immunisation on 30 December, we told each vaccination site that while they could continue doing second doses for that week, they needed to then start to cancel appointments for the following week onwards and to move to invite more people for first doses.

That measure had a big impact in that we could immediately release the stock we had been holding for second doses, which meant we could immediately start to vaccinate more people. But it was real challenge, getting the system to pivot to a different mode of operation.

Overall, it definitely sped up vaccination but if you’re in a rhythm operationally to change it, even if the new rhythm is much easier, that transition is challenging.

There was a lot of re planning of deliveries. We had to scale up the network speed. We had to change the planning of our outbound deliveries and so on. Then we also had to meet the challenge of deploying the AstraZeneca vaccine the following week.

As well as changing the Pfizer deliveries to increase first doses we had to make sure we could still vaccinate those who are most in need first.

Are you preparing to vaccinate against new strains?

A new partnership between the UK Government and vaccine manufacturer CureVac, based on RNA vaccine technology, has been established to rapidly develop new vaccines in response to new COVID-19 variants if needed.

The science needs to come first but the evidence to date suggests that the existing vaccines do protect against new strains as well.

However, there is strategy work going on for what we will do next winter. We are working in alignment with the flu program so we can make the most of the infrastructure that we spoke about earlier and we will respond to whatever prioritization and clinical guidance we are given by the JCVI and Department of Health and Social Care.

How is vaccine hesitancy affecting the roll out?

The Science Museum recently held an event on vaccine hesitancy with US physician Dr Anthony Fauci, advisor to President Biden, and Vaccine Deployment Minister Nadhim Zahawi MP.

In America, for example, country star Dolly Parton was given a COVID-19 vaccine dose, after urging others to follow her example by reimagining one of her best known songs: ‘Vaccine, vaccine, vaccine, vaccine, I’m begging of you, please don’t hesitate.’

It has been a priority from the beginning. Our goal is to get everybody to come forward for the vaccine and it’s incredibly important for people to feel able to protect themselves, as well as their families and entire communities. And we heard that from Her Majesty the Queen herself.

We know people from certain ethnic minority backgrounds and of higher deprivation are less likely to come forward, so our job is first of all to make sure access is not the issue, and we’re working very hard on that.

That is why we published guidance to allow clinics to pop up in locations that might be more attractive to communities that are otherwise not keen to engage with health services. We’ve had pop-ups in mosques and churches. That faith-based support can be incredibly important.

We’ve also got a strategy to work with communities to increase the likelihood that people will come forward. We don’t tend to talk about vaccine hesitancy – we have had feedback that it can come across as quite patronising, as if we don’t really buy that there’s a reason why you might not be excited about receiving the vaccine.

We have an active program to combat misinformation, usually led by clinicians, but also by faith and community leaders. We have been looking at role models within different communities and asking them to talk about their experiences of vaccination, we are really keen that this is community led.

We’re trying not to impose single national solutions on communities, but to work with communities to say what would it take for you to feel confident? And then, and this is a more challenging one to think about, we need to recognise that some people may take longer to come forward.

This is an evergreen offer of vaccination. We’re not going to close down and say just because you didn’t come last month, you can’t have the vaccination because we’ve moved on a cohort now.

Please come whenever you feel able to come forward.

It’s incredibly important to us that we keep getting that feedback on vaccination so that we can keep innovating.

What happens next in the vaccination programme?

The NHS vaccination programme continues to make strong progress.

Thanks to the thousands of people involved, in just three months the health service in England has given the vital first vaccine dose to over 19 million people, opened more than 1,600 vaccination services, and visited over 10,000 care homes.

The job isn’t done yet, though, and we continue to go full steam ahead working through the priorities, those who are most at risk, as independently advised by the JCVI.

What has it been like to lead a vaccination effort?

This has absolutely been the privilege of my career. It’s just the most extraordinary experience, and it speaks to my own personal values of collaboration.

This is a team of teams, from the scientists who had the idea about the vaccine technology in the first place through all those in the manufacturing and the supply chains into those massive communities of people who’ve got together to make a vaccine centre operational. The clinical leaders, the administrators, the volunteers, the military support that we’ve had, I mean hundreds of thousands of people have come forward to help with this program. That’s the whole country pulling together in a way that that even The Queen, who’s lived much longer than I have, said she’s not seen before.

What an amazing privilege, and the fact that the NHS is at the heart of that as a mobilising force and a structure that everybody can group around to do something that’s making all of our lives better.

The NHS at its best, with a clear purpose, clear direction, is able to move countries, if not move mountains.

It’s energising. It’s heartening. It’s extraordinary.

How can i find out more?

The latest picture of how far the pandemic has spread can be seen on the Johns Hopkins Coronavirus Resource Center or Robert Koch-Institute.

You can check the number of UK COVID-19 lab-confirmed cases and deaths along with figures from the Office of National Statistics.

There is more information in my earlier blog posts (including in German by focusTerra, ETH Zürich, with additional information on Switzerland), from the UK Research and Innovation, UKRI, the EUUS Centers for Disease ControlWHO, on this COVID-19 portal and Our World in Data.

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