Welcome to Ellis each team viral season 3, a podcast, exploring the science behind Global and public health.

I'm Naomi Stewart, I'm Carl burn, and I'm Amy Thomas, and every Fortnight will explore the latest developments in the covid-19 pandemic and take a deep dive into vaccines and vaccinations.

Worldwide.

There have been a hundred and sixty four million cases of covid-19 with over 3.4 million deaths to date.

The largest vaccination program in human history.

Continues to roll out globally with over 1.5 billion doses.

Having been administered.

China has given out nearly 436 million of these while.

The USA have given out 275 million in the midst of a devastating wave of the virus, which has swept through the country in the past few months, India has administered.

Nearly a hundred and eighty-six million doses.

The variant be 1617 to, which was first detected in India and suspected to be more transmissible than other variants continues to spread worldwide countries, continue to debate with the idea of a vaccine passport for travel as some restrictions slowly lift, while in Malawi Health officials publicly burned expired AstraZeneca, doses, in an attempt to increase public trust and confidence that they would only be Given safe vaccines here in the UK.

They have announced trials on a third dose of the vaccine.

This, the world's first trial of the sort will start in June and look at how a third dose May function as a booster.

In this episode, we are speaking to Danielle boetsch, professor of tropical medicine at the London, School of hygiene.

And tropical medicine is a co-principal.

Investigator of a trial of an Ebola vaccine in the Democratic Republic of the Congo and an expert in the control of emerging viruses.

Dan will be speaking to us about the global access and distribution of covid-19 vaccines what this means for other vaccination programs and trials.

And when exactly the pandemic may end, So welcome Dan.

I am a nice to be with you.

So the first question I want to ask you is how do countries access covid-19 vaccines in the first place.

So I think there's two elements of access to the first one of course is placing an order and that comes through a couple different modalities we've seen in this has created tension.

Will course.

There's the Kovacs system that is designed to deliver vaccine and provide access to vaccine for her low and middle income countries.

Trees around the world, which many countries around the world have contributed to.

Although we're have a lot of problems with implementation, but once that order is in through Kovacs for a low, and middle-income Country, or in some countries just to direct order through.

For example, the United States, for the most part just directly ordering from the manufacturer.

That's a contract, of course, as it would be with any other vaccine and then there's the logistics of delivery and not a small challenge as we know travel, for all of us, has been difficult throughout the covid.

McCann, of course it's difficult for a vaccine to travel as well.

You know, normally after an order is placed, a vaccine would get put into the appropriate cold chain into reportable freezers and, and or on dry ice depending upon the particular vaccine and then shipped with the appropriate import permits to the country that and where it is ordered that that's the system that's in place and has been the system in place for other vaccines as well.

But its implementation in the ear of covid has been quite challenged.

Obviously, the world's been focusing on the covid-19 vaccination program, which is the largest historical rollout of a vaccine.

How does the focus on this particular program affect other critical vaccination programs as well as with trials, like with ebola the the global supply chain for covid-19.

But for anything else has been severely disruptive.

You asked about ebola, for example, one of my roles over the last few years has been the co-pi for a trial of an Ebola vaccine takes place, primarily in Goma and then Aquatic Republic of the Congo and it has been very challenging for us to continue that trial and many other trials of malaria vaccines and things like that have been halted part of, it is logistics of getting the supplies into the field.

And then part of it is, of course that all this takes human resources and then Human Resources can be diverted to other important activities and to Patient Care to trying to make sure that we keep up with other health problems and other vaccines.

And then what we've seen in the Really terrible example of what's going on in India.

Right now, the human resources are what makes this happen.

And when you have large number of people who start to get sick themselves with a given disease, the whole thing breaks down that has had a major impact on trying to keep up our Healthcare delivery for other non covid illnesses as well as on research.

And you mentioned a bit earlier the distribution pattern we're seeing with the vaccines at the moment, is heavily skewed towards high-income countries that can make these direct purchasing writers so I With manufacturers.

What impact does that have on the way, this or any pandemic would play out, it's having a huge impact approach through Kovacs, which basically was a buy-in procurement system for many countries for rich countries to help poor countries if you will.

And then also, to assure access, it was a nice conceptual idea.

I think we still need to fight for it, but we're seeing that it really hasn't been implemented for a couple different reasons.

One of them to just be fair as it's human nature for One to protect their own in the first instance, if you will.

So as a just a rough example, if there's not enough food but in you are there with your family, it's human nature.

That the first thing that's going to happen as you've probably to try to procure food for you and your family, and before you start to share it with others, I think that's just human nature.

And we need to take that into account and expect that there are also just very significant political pressures on political leaders as to vaccinate their own population before we start to give vaccines, Others.

I'm not saying that, that is how the world should ideally work, but I think we just have to recognize that human nature of that looking forward.

Now, what do we do?

We have some of the Richer countries in the world that are starting to make progress in vaccinating, their populations.

We need to make sure that some of the excess vaccine that is in various countries.

You know, the UK, United States Canada, various countries that have orders, actually, that would allow them to vaccinate their population.

For five times over that.

Excess vaccine could go to some of the other countries and people that need it on the long term.

We need to think about Supply and delivery chains that are more efficient, the vaccine manufacturing is really restricted to, you know, a few key players in the world and key countries in the world.

So if we look, for example, at sub-Saharan Africa there are very few vaccine production facilities in the ones that exist or for the most part.

What we would call Phil and finish meaning that they put kind of the last touches on a vaccine, but they can't produce from the beginning.

In the long-term, we really need to think about Supply chains that have manufacturing distribution.

You want can think of kind of a hub-and-spoke sort of system where, you know, if a vaccine needs to be produced for populations in West Africa, for example, okay.

What are the manufacturers in that region of the world that could produce vaccine?

Where would that vaccine go in the region?

And not have it all?

Come just from a relatively small, handful of suppliers, and you mentioned the politics of and I wanted to dig into that a little bit.

So, Obviously this is shown just how political the nature of vaccine distribution globally.

Oh.

So I guess actually, what I want to ask is this changing our approach to vaccines as a global community.

And also what you think about the discussions around vaccine nationalism is part of it.

I think it will change our approach.

It needs to change our approach.

I mentioned earlier the vaccine nationalism.

It's not, it's not that I want to ignore that or promote that, but I do think that we have to anticipate that that's going to be the case and probably in Future epidemics, and pandemics recognized that, that human nature, if you will, of kind of taking care of One's, Own is probably always going to be there.

So we can expect from just a few sources of vaccine for it to be shared equitably, probably in the first instance.

And so we need to think about the long-term nowhere vaccine gets manufactured and so there's some equitable distribution of manufacturing to begin with rather than just thinking about the distribution side of at the political ramifications.

Of course, For a leader who says, well I'm not going to worry about completely protecting the people in my country.

But we're going to send vaccine elsewhere, probably unrealistic that that's going to happen very often and then the other very political and controversial element that has come up.

Very recently is the idea of waiver of the IP which would allow vaccine makers around the world to make vaccine even though there was a patent on the product as they were developed.

So there's been, you know, back and forth and you'll see Foreign countries and political leaders, a few who have advocated, a waiver of the intellectual property rights for the existing vaccines.

That could be done through various measures through the World Trade Organization that does create some challenges.

So on the first instance, of course, you know, we liked the idea and the humanitarian effort to deliver vaccine to all the people in the world who need it.

And recognizing that this whole thing isn't over until we really get everybody protected.

There's a significant motivation to do that.

But we also Need the vaccine manufacturers to produce the products when we have something that comes up like covid-19, like Ebola.

And so, we need to make sure that they are engaged.

So, if we take steps, that's vaccine, manufacturers would say, well, last time we produce this product that the world needed, you took away all the rights from it.

And so, why should we do that again?

This is the balanced discussion.

That's ongoing right now and it's not an easy discussion, and as part of that there's obviously quite a situation happening in India now.

So, What do you think the main challenge is that India specifically is facing in this pandemic.

So, India is a key country in vaccine production.

First of all, of the serum Institute in India is one of the major Global vaccine suppliers and would be one of the suppliers for much of the vaccine going for the Kovac system, to low and middle-income countries.

There were a few different things that happen.

First of all, India as a country.

But I think all of us globally fell into a little bit of a level of Decency and thinking that India had dodged the bullet.

Some of the countries that have not had rampant circulation of covid, you know, we tend to think.

Okay, well they dodged the bullet it's over there.

They don't need to worry too much about it.

So, three or four months ago, in India might have said, well hasn't really been as big a problem there and says in some other countries, but that doesn't mean it can't be a problem with letting their guard down.

I think you've seen that.

It has been a big problem and that and that should be a lesson to all countries in the world that even if covid Been a huge problem for your given country or region.

Doesn't mean that it's over and it doesn't mean that you're safe, we need to keep up the precautions and we need to push on with getting the vaccines in to as many people as possible.

The other thing with India, of course, is that we somehow have forgotten and all this, that production capacity for a vaccine or for anything else is ultimately depending on people.

And so when you have now many many workers who are getting sick with covid or taking care of some with go with it really makes a big Make it actually into the production capacity.

So we're seeing the double effect unfortunately in India.

So not only has it been a devastating outbreak there in the last months or so with covid.

It's had a devastating impact on their production of the vaccine that they need nationally and that ideally was going to be the main production source for vaccines for other countries.

So in the last few months, the serum Institute has not been able to produce vaccine.

So the Indian populations, not getting a vaccinated at the rate that it needs to and nor is the vaccine available for other countries.

So a very, very severe impact and a reminder that when we're taking into account production capacity, we can't make the same calculations during a pandemic that we would make in other situations.

So if we say, okay, I'll give in place can produce so many millions of doses of vaccine per month.

That's, of course, in an optimal situation, it's not in a situation where inevitably there's going to be some risk of the people who produce the vaccine getting the disease themselves.

And so that's an unfortunate reminder of how important Important that is to take that into account.

Yeah, that's that's really interesting.

Reminds me of what you said in the past that when you know somebody's house down the street is on fire, you don't sit there at the bucket and wait, you go down and help them put it out, but when Oliver houses are in fire with the pandemic, do you think that we've been railing together enough as a global Community to help stop things as quickly as possible as efficiently as possible or other things that we could or should have done better as a global community?

It's hard not to say that there are things we couldn't do better, you know, we're in the midst of a pandemic and there's some depending on where you live in the world and how things look, perhaps some glimmers of light, you know, at the end of the tunnel.

But nevertheless, there's a long ways to go.

I think, you know, this has been an unprecedented situation.

Certainly it's a different situation.

Even if we go back to the 1918 flu, it's a different world.

So it was so we can't even compare exactly with that.

There have been some positives the vaccine Auction is really one of the greatest Public Health achievements of all time, probably.

And so, to be able to make as many vaccines as globally, we have and get them into millions of people this fast into a pandemic is certainly something that we've never seen before.

So you know we shouldn't minimize the impact of that.

And what that achievement is.

But we've also seen the, the many failings and so, of course we need to have better systems.

It really wasn't so much a problem.

Detection, but we need to have information that's transferred, quite readily.

In terms of what's going on, we were slow in many ways to organize testing in an efficient way, some countries have caught up on that and others are still struggling.

And then we need to really somehow get a handle on the transparent and effective communication, because what we've seen is, it's not all just about the biotechnology we have products.

Now that work that protect people against covid-19, even not in getting yet into the issues of different variants.

And things like that but these vaccines are powerful tools.

But we still have a lot of people that are not interested in the vaccine to have, not really seen the problem and the way that most of us feel that it exists and an evidence based on a scientific base, you know, we have a lot of different places in the United States but overseas as well talking with a colleague in Liberia, recently, you know, mentioned to me, that even though Liberia has received very few doses of vaccines.

So far that they were having problems getting people to take it because I just perceived That there was a need for that.

So the communications and really transparent message about the need for vaccine and the need for the other measures that are still appropriate to very degrees of course, but the masks and the social distancing know, those have not gone away.

It's not that we can just yet in the world, ignore those things.

So we've done a good job in some things, but a lot of work to do well, first to get us out of this situation but then, whatever comes next is not a pandemic.

It's something that does not impact Our Lives.

In our planet.

So profoundly and I wanted to pick that up on a bit.

The concept of these other public health measures like continue to wash hands and physical distancing, and all that, in terms of the vaccine, do you think that a vaccine roll out the way it's currently being planned?

Is enough to stop the pandemic or how will these other measures continue to influence?

Hopefully eventually ending this pandemic.

So I think we're seeing from the data that are available right now, look relatively optimistic that the vaccine These are preventing people from getting severely ill from covid-19 and they seem to have reasonable covered so far against even some of the more concerning variance.

And so, that's very good news.

We had concerns early on that as these different mutations and variance of covid-19 or SARS Covey to virus came out that we would say, okay now we have to re vaccinate everybody again and keep making more vaccines and keep getting vaccinated and you know, just a never-ending terrible cycle.

And what we've seen is that the data They are coming out so far have shown that the vaccines look pretty effective, they're pretty good and so they are not a hundred percent but they protect people from severe disease which is of course, what we care about the most and they seem to protect against most of the variants that are circulating in the world.

So you know, that that is the number one thing, of course that with the world has been relying on until we are first of all, sure that that's the case and until we are sure that everyone in the world has access to a vast.

Vaccine and that is protected.

Then of course the other measures are still there.

So it's still important.

Even in the UK we're not quite there yet to all right, where the UK has done a good job recently and getting vaccines into people but we still have a quite a large population that has not been vaccinated.

And so you know we still need to recognize that even though the restrictions have been lessened recently that you may be amongst people who are not protected.

And and again recognizing that a real danger of that might not be that they get covid.

They may be Young healthy, 20 year old who is not particularly vulnerable for severe disease.

Although it still could happen even in that group but they get perhaps a symptomatically infected and then go home and have contact with their grandparents who are susceptible to severe disease.

So those other things as I've said are still extremely important right now.

We still need to think about social distancing.

We still need to think about masks and remember these things.

The sad part about all of this.

Whoa beliee has just been that we had and have opportunities to limit transmission without Even having to wait for the perfect vaccine, there are many things that we could have adopted if we could get them into place, early enough and have enough behavioral change to allow us to keep shops open and allow us to keep the economy moving rather than a false dichotomy that ended up existing between full lockdown.

And or these kind of Public Health measures, they're both important, but if we can use, vaccine, continue to be careful with our, with our social distancing and masks, and hygiene no.

Then we can start to see what we're seeing.

Here in the UK seeing in the United States and some of the other places where I'm vaccination has picked up that you can start to open up and get back to some semblance of what we thought of as normal life.

Is it possible to speculate on the sort of timeline for the rest of the pandemic?

I guess, not individually as countries but globally, how we started shift ourselves out of this and how long that might take?

Well, that's exactly the right question in the way you put it.

So, so we do need to recognize first of all that it's globally.

It's not this.

An epidemic or pandemic is not finished when everyone in the UK is protected or everyone in the United States or any given country is protected because we know that that's a global world.

And so we are all connected, whether we want to be connected or not.

And so we're connected through the travel that we do for Commerce and trade and tourism.

It's not just a question of, you know, one country being protected.

I think that we will see taking out my crystal ball here.

Now, on me, in to try to give you some time line, if we can Push on with vaccinations in resource-rich areas of the world, like the UK, the United States, and other areas of Western Europe.

And some areas of Asia, I think we'll see things start to stabilize.

And the next let's say, six months and we're already seeing that, you know, we're both here in the UK today and seeing that's in the last few days, shops and restaurants and things have open.

And we're starting to see some, you know, pendulum swing towards a little bit more of a normal life of What we knew before.

I think that then the places that will have access to vaccines that you will see that happening as we go forward in the next.

I hope you know three to six months in other countries.

It may not be the same way and so what we're seeing it's going to take India.

It's still going on there and a very sad difficult time and situation in Indian.

It's going to take a long time to kind of get that back towards normal life.

And then we still have many, many countries.

I don't want to sound too pessimistic, but we have huge area.

Of sub-Saharan Africa that are susceptible in own.

What's happening?

In India, could happen there and it doesn't mean that people aren't doing their best to take the precautions, but there's still a lot of vulnerable areas of the world and until all those areas, get protected, then we're not really going to see truly for lack of a better term, normal life.

So I think an individual Regents my crystal ball tells me in the next three to six months will start get something back towards more normal life, doesn't mean that it will be exactly the same normal life that we had before.

Or in terms of all offices opening and crowding in and things like that.

But something that's a little bit more of a tolerable and regular routine on a global scale.

I think to really just put covid in the rearview mirror and say it's not something we're thinking about or worried about.

I think we're still a year or two off So thinking a bit more about the future as well.

So, no and public, and Global Health.

Everybody was pretty familiar with the concept of epidemics and pandemics.

But for most of the world and most people outside communities that experience, it's been quite a shock, you know what seems like a once-in-a-lifetime experience but there's also a lot of discussion in the global Public Health communities that this this isn't the first and it won't be the last.

So thinking about how we've responded and what we've been learning?

Do you think that we will be prepared for different?

Future epidemics and pandemics.

Well, we have learned enough when we have the infrastructure and knowledge of how to respond as a global Community, I hope we will and sometimes people ask me, you know, what's my biggest fear out of all this and on one level my biggest fear is that we don't learn the lesson.

It's just a continual challenge that we have rire to this, pandemic to get the right financing and focus on on public health in general, and it is no surprise.

Rise.

If you will to any who one who works in the field of outbreaks and virology that we would have all said, of course.

There's it's just a question of when not, if a pandemic is going to come and that's true for covid.

It's true for whatever comes next and so hopefully it won't come next.

And if it does it's many years off.

But the potential for different viruses, influenza viruses.

SARS virus has meant many others to start.

Pandemics is still going to be there and so We really need to make that investment and take that very seriously and it's not an easy thing to do.

There are many elements of this and discussions about how to shower up, surveillance systems and early warning and response systems to be ready for the next pandemic.

The harder part even though there's great technology at our disposition now but the harder part is it really depends on drilling down and health system strengthening on a very local level.

And so, we really need to I'd need to make the commitment, both the political commitment in the financial commitment to really work on that.

And make sure that we're taking this seriously and strengthening our health systems on a very local level.

It takes time, and it takes resources, and it's not a small and ever.

So, we shouldn't underestimate that, however, there's ample data and research that, that investment is well worth the investment.

And because really not only in terms of lives saved, of course, but just financially Always much better and ultimately, much cheaper to invest in those sorts of Health System.

Strengthening programs on the front end, rather than the billions of pounds.

That one spends.

Once you have something that comes up, how do we use what we've learned through this as a platform as leverage to say, you know, can we really make that investment and protect our communities for the long term so that I think is what we need to be looking forward to in lobbying for.

And so as the pandemic is on, and This vaccine program continues to roll out worldwide.

What are the most important things for you to stay focused on in your line of work?

First of all, I guess we get so inundated with the news every day, that's remembering that there's human suffering at the core of this.

And then if you're not a healthcare worker, who's seeing the patient, you may lose sight of that.

You know, you may think this is really frustrating because I'm not able to travel or I have to wear a mask or, you know, I can't do the things that I did before.

The people who work on the front lines and the patient care, they understand that it's not just an inconvenience that this is a life-threatening situation that we're in.

And so we need to kind of remember that because that's the sort of sad and difficult message, but the truth and the evidence that keeps us underscoring.

And keeping us honest in terms of what we do.

So I think making sure we're all outbreaks in the field that I'm in and making sure that we remember that.

It's about those people and that the humanitarian response and trying to save lives not to be too.

Too dramatic.

As you know what, we're really need to do here and we recognize that it's not only saving the life of the person who has covid, but all the other much more difficult elements.

And so we understand that the person who's lost their job who can't pay their rent to can't buy food that, you know, their life is threatened as well.

But remembering that for some of us for a person like me, you know, so far covid has been more of an inconvenience if you will, for me on a personal level.

But for many people, it's much more than that.

And so, that I think is the first thing of I'm focused on that.

And then after that, on a professional level and just keep on as much as we can doing our work.

And it's the nature of our work has changed drastically in the last year and a half you know much of what we used to do in person we do remotely and we're all tired of a million different Zoom calls and conference calls but we need to keep on and head has not been perfect and there's still much work to do but we're you know, we're seeing we're starting to turn the corner and so there we have to like keep a belief that we We can turn the corner and keep optimism, that we can can get there and that we can build back better.

Those are all great things to stay focused on.

I'm wondering as well.

If you had a key takeaway message for audience relating to the pandemic in the vaccines and the roll out, what would that be?

I think the vaccines are there not a Panacea.

They're not the thing that will make it all perfect, right away for us but they are extremely important.

I know that there's people who have hesitancy about vaccines, those are conversations that need to be had and we need to respect that but I think never less.

Chin is one key element of our road to a more sustainable future.

Not only for covid, but for many other diseases as well.

And so, I would encourage people to think hard about that and to respect the power of you, if you will of vaccines and what it can offer to us, and then, as I mentioned, it's not the only element but until we get to a situation in the world where everyone has access and we have, you know, large number of people who are protected from vaccines in the right context we Need to make sure that the other things and the masks and the hygiene and the distancing are still respected as well.

And the more we can do that right now and the more we can get vaccines into people's arms, the shorter that we'll have time we'll have to worry about that.

And so I think keep on keeping on with those measures and look forward to.

Once we do that for a while, look forward to the time when we say, okay now you don't need to worry about bringing mask with you when you go out, okay?

Well, thank you Dan.

And thank you as always to our listeners.

If this type of research and science interests you LS, H TM is running a short course on pharmaco, epidemiology and pharmacovigilance and applications for the twenty Twenty-One.

Twenty-two intake are now open visit L sh t m dot AC dot U, k-- to learn more Stay tuned for next week's episode with dr.

IOD alocasia, co-chair of the Africa vaccine delivery Alliance for covid-19 alongside lsh TMS director Peter piot, discussing the vaccine situation, across Africa until then stay safe and informed.