Immunization in state of siege: the importance of thermostable vaccines for Ukraine and other war-torn countries and territories

KEYWORDS:

• COVID-19
• vaccines
• Ukraine
• war
• crisis

Dear editor,

We have perused with interest the expert review of Kumar et al. (2022) [1]. The authors provide a detailed account of the factors that lead to vaccine degradation and the strategies to increase vaccines’ thermostability. They stress that cold chain disruption occurs disproportionately in countries with limited resources and particularly in times of physical disasters. They illustrate the latter with several examples from the last decades and build upon this their conclusion that thermostable vaccines constitute a global requirement. While these arguments are certainly legitimate, we believe that elaborating on the impact of war and armed conflict on vaccine cold chain logistics is an equally valid and timely point of consideration.

The Ukraine–Russia war, which has unfolded since the 24th of February 2022, serves as the most recent example of vaccine cold chain disruption. As of 1 February 2022, Ukraine has facilitated a large-scale inoculation program against poliomyelitis in the Rivne region aiming to vaccinate at least 140,000 children. The onset of the hostilities put the vaccination efforts on hold leaving more than 100,000 children unvaccinated. Officials of the World Health Organization (WHO) and UNICEF consider the storage conditions of the vaccines that have already reached the region or were in the process of being delivered unsafe [2]. More serious concerns have been expressed with regard to the setback in COVID-19 vaccine delivery and administration, given that less than 35% of the country’s population is fully vaccinated against this disease [3]. Displacement of populations within the country can derail further the existing vaccine logistics and lead to outbreaks of vaccine-preventable diseases such as measles, as observed in the measles outbreak soon after the hostilities between Russia and Ukraine back in 2014 [4]. The same (displacement of population or unsafe vaccination delivers?) puts more pressure on vaccine supply chains in border regions of neighboring countries, where people from Ukraine are likely to seek refuge. Whether the healthcare infrastructure in small cities close to the borders of Romania, Poland, Moldova, Slovakia, and Hungary can support the storage and delivery of vaccines to refugees remains questionable [5].

Simultaneously, the sanctions imposed on the Russian Federation and Belarus have already halted the authorization and/or dissemination of the Russian Gam–COV–Vac (Sputnik V) vaccine in up to 70 countries [6]. Moreover, major academic institutions and pharmaceutical companies have put their collaboration with Russian researchers on hold, putting additional obstacles to collaborative efforts for thermostable vaccines against COVID-19 and other diseases [7]. Overall, the Russia–Ukraine war challenges vaccine delivery and administration both in the involved countries and worldwide.

Vaccination logistics have also been challenged in previous armed conflicts. Following the advance of the Taliban in summer 2021, several vaccination programs were delayed and put on hold. It took weeks to months for international health bodies to reach an agreement with the Taliban regime regarding the continuation of vaccination campaigns against poliomyelitis and other diseases [8]. The preservation of vaccines that have been shipped to Afghanistan before the agreement remains in question. Similarly, evidence for the conflict between Armenia and Azerbaijan in late 2020 suggests that a spike of cases in combination with shelling against healthcare infrastructure in the conflicted area of Nagorno–Karabakh rendered the delivery and administration of vaccines unsafe and ineffective. After the ceasefire, the involved countries sought help from neighboring countries and the COVAX initiative, in order to counter the vaccination vials that were degraded during the war [9]. Although this was finally achieved, the shipment o f vaccines to these countries hindered vaccination efforts in greatly unvaccinated low- and middle-income countries (LMICs) in Asia and Africa.

Similar observations indicating high levels of vaccine wastage in war-torn countries and territories including but not limited to Syria, Yemen, and the Tigray region in Ethiopia [10] have led to the development of a Vaccine Wastage Rates Calculator by the WHO. Investigating the components of the calculator suggests that the expected wastage range depends greatly on the type of vaccine and vaccine logistics-related factors such as the amount of levels of the supply chain, the density of production, storage and immunization facilities, and the frequency of vaccination sessions [11].

Delving deeper in history suggests that apart from conventional warfare, biological weapons and bioterrorism preparedness constitute a lofty opponent to vaccine delivery and immunization efforts. A historical review of Cohen et al. (2004) highlighted the negative impact of biodefense efforts on public health in the United States. For instance, accelerated mass vaccination against smallpox in 2002–2003 increased vaccine wastage. This happened because of incidental mismanagement in large-scale supply chains and because of vaccine hesitancy generated due to the provision of vaccination in individuals at high risk of active small-pox infection. At a broader scale, the allocation of funding to biodefense programs has also been associated with downgrading research and efforts related to all aspects of vaccines delivery and administration [12].

Overall, an outlook in the contemporary history of wars and their impact on vaccination calls for deeper and more accelerated research on thermostable vaccines. Evidently, war leads to increased vaccine wastage at the epicenter of the conflict. Additionally, the global sequelae of war, from financial sanctions to bioterrorism preparedness, deplete vaccine-related resources and derail efforts to increase the durability of vaccines. After the war, low vaccination rates in the conflicted areas can pave the way to outbreaks of vaccine- preventable diseases. The same applies to LMICs whose vaccination strengthening programs are hindered due to the urgent humanitarian vaccine rollout in the conflicted regions. Lessons from contemporary history in combination with the simultaneous occurrence of the Ukraine–Russia war with the COVID-19 pandemic and the outbreak of a debilitating vaccine-preventable diseases such as poliomyelitis serve as a warning. Therefore, experts and health bodies advocating in favor of thermostable vaccines should emphasize the impact of war on vaccination to persuade competent authorities to take relevant action.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

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Funding

This paper was not funded.