Cholera traces back to the 5th century BC, but as water sanitation has improved, cases have plummeted . However, recently “cholera epidemics have been increasing in intensity, duration and frequency” . Researchers have tied this increase to climate change: ocean warming and its effect on El Nino have paralleled a rise in cholera cases in endemic countries like Bangladesh & Peru . Using this methodology, researchers have also built models predicting a future with higher cholera prevalence in areas not currently affected (Figure 1).
Figure 1: Warm colors represent new areas that are projected to see increased cholera prevalence
International Global Health Community Supply Chain & ICG
As cholera grows, the global health community is struggling to meet increasing vaccine demand of governments. The International Coordinating Group (ICG) is the primary organization coordinating vaccine access. This conglomeration of four global health partners – International Federation of the Red Cross (IFRC), Medecins Sans Frontieres (MSF), UNICEF, and the World Health Organization (WHO) –forecasts demand, works with manufacturers to guarantee availability, and delivers supply to countries in need .
The ICG functions like a distributor but is also responsible for forecasting demand and informing production for manufacturers (see Figure 2). The increased number, severity, and geographies of cholera outbreaks make demand forecasting extremely challenging, resulting in vaccine shortages when the ICG underestimates demand. As cholera can take less than 18 hours from infection to death, a shortage can literally be the difference between life and death.
Figure 2: ICG is an international player in the global health supply chain
ICG’s Attempt to Keep Up
To address the growing demand of cholera vaccines, ICG created a supply chain buffer in 2014 by creating an oral cholera vaccine stockpile of 2 million doses [6 & 7]. However, in 2015 OCV demand exceeded supply by nearly 2.5 million resulting in an inadequate response to the cholera epidemic in Juba, South Sudan .
Figure 3: In 2015, doses of OCV requested exceeded doses produced by ~2.5M
To prevent another shortage, ICG has since focused upstream in its supply chain by strengthening manufacturer relationships. In the short-term, ICG has enabled tech transfers of the OCV technology to a second vaccine manufacturer, Eubiologics, and is continuing to work closely with this partner to ensure adequate supply . In the long-term, ICG is lining up a bench of back-up vaccine manufacturers such as Va-Biotech and Incepta to more effectively respond to changes in demand . ICG will have to invest considerable resources in supporting these manufacturers through pre-qualification, but in the long-term, their products can provide additional supply security.
Additionally, in the short-term ICG is also focusing on securing funding from GAVI, the Vaccine Alliance simply to continue the stockpile . Current funding runs out in 2018, and the stockpile currently operates in a model where ICG pre-pays the manufacturer and assumes all inventory risk, including vaccine expirations [6 & 10]. In the long-term, ICG is considering transferring this risk to the manufacturers themselves and having them forecast demand and produce accordingly . However, this approach has multiple risks with incentives still misaligned for for-profit manufacturers in global health, especially if producing at risk for epidemic-stricken countries .
Looking forward for ICG
Although ICG is taking effective steps to address its upstream supply chain – funding and manufacturers – I recommend they re-assess their demand forecasting and consider downstream supply chain as well. The 2014 recommendation of a 2M dose stockpile has not been revisited despite publication of higher-quality demand models as discussed in Figure 1. In the short-term, IFG should take these into account to provide more accurate estimates to their manufacturers.
Additionally, IFC’s downstream supply chain has areas for improvement (see Figure 4). They strive for a 7 day lag time between approving vaccines requests and vaccines arriving in country; however, it currently takes 14.4 days . This delay drastically influences overall demand because each day vaccines are not administered, more individuals are infected and spread the epidemic further. This ultimately requires more preventative vaccination and further increases demand. I would recommend assessing downstream causes of delay, particularly shipping times / patterns, to identify areas to cut down time.
Figure 4: ICG mechanism requires multiple touchpoints from request to in-country arrival
The future demand for OCV is uncertain but highly likely to increase as climate change continues to increase cholera’s prevalence. The strength of organizations like ICG’s supply chain and its strategic stockpile buffer not only symbolize business efficiency but in global health, also directly correlate to lives saved. Moving forward, its success will be determined by how quickly it can understand and adapt to changes in demand, and questions like “How can ICG balance spikes in demand and surplus inventory?” and “How will ICG incentivize manufacturers to share risk?” will be increasingly important.
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7. Yen, Catherine et al., “The development of global vaccine stockpiles” Lancet Infect Dis. (March 2015) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712379/
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9. Jerome Kim. Interview (May 29, 2017)
10. World Health Organization, “Annual Meeting: International Coordinating Group on Vaccine Provision for Cholera Control” (July 2016) http://apps.who.int/iris/bitstream/10665/255558/1/WHO-WHE-IHM-2017.10-eng.pdf?ua=1
1. Wendel, JoAnna “Climate change predicted to worsen spread of Cholera” EOS (Jan. 2015) https://eos.org/articles/climate-change-predicted-worsen-spread-cholera
2. Council of Supply Chain Management Professionals. Conference 2014 Report. Global Health Supply Chain
3. Desai, Sachin et al., “A second affordable oral cholera vaccine” The Lancet Global Health (April 2016) http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)00037-1/fulltext
4. World Health Organization “International Coordinating Group on Vaccine Provision: Online Q&A” (Jun 2016) http://www.who.int/csr/disease/icg/qa/en/