When will Nepal’s Covid vaccine turn come?

With the pre-winter resurgence of Covid-19 around the world and in Nepal, pressure is mounting on governments to procure vaccines to protect their populations.

Last week, the Nepal government set up a committee of secretaries of the Finance, Home, Health and Foreign Affairs ministries to study vaccines under development as well as procedures to procure them. But Nepal is far behind other countries, which have already ‘booked’ their future supplies.

On Wednesday President Bidya Devi Bhandari signed an ordinance empowering the government to import Covid-19 vaccines from international pharmaceutical companies, and to use them even if they are authorised only for emergency use.

VAX POPULI, Sonia Awale

However, there is no effective strategy to ensure vaccines for all as distribution in Nepal comes with the challenge of taking it to poor and remote corners of the country. Experts fear that even when the vaccines become available, the campaign will be plagued by the same socio-economic inequities that afflict the medical sector.

“We need to immediately start identifying vulnerable groups like frontline health workers, the elderly or those with comorbidities to prioritise for immunisation,” says Bikash Gauchan, a physician at Bayalpata Hospital in the under-served western district of Achham.

“We also need to set up proper cold chain facilities across the country as soon as possible and have a well thought out distribution plan so that when the vaccine does arrive, we can hit the ground running,” he adds.

The silver lining is that Nepal already has a successful childhood immunisation network that has successfully mobilised Female Community Health Volunteers, and they can deliver vaccines to the homes of the elderly who cannot make it to clinics. Monitoring the follow-up second dose for some of the vaccines will be crucial, although Nepal’s health system has experience with maintaining a cold chain for other campaigns.

Nepali diaspora hit by Covid surge, Nepali Times

Despite recent breakthroughs in trials (see box) public health experts stress the importance of exploring vaccine supply options closer to home. As of now, 11 vaccines developed in several parts of the world are in the third phase of clinical trials with many of them expected to be as effective.

Neighbouring China and India are at the forefront. And Nepal should have begun its ‘vaccine diplomacy’ much before this to secure its supply of shots.

There is also the uncertainty of vaccine efficacy depending on the strain: the same vaccine could be highly effective against people in the West but not as much in South Asia where people suffer from chronic malnutrition and multiple infections.

“For a working vaccine to be made within a year is an amazing victory for science but we also need to know that these vaccines are designed for their population. So I’d want to know more about the vaccines in India and China,” says Sameer Mani Dixit of the Centre for Molecular Dynamics Nepal. “Particularly China, as it was where the pandemic started but has since controlled it effectively unlike rest of the world.”

Buddha Basnyat of the Patan Academy of Health Sciences agrees. He says: “China looks at the reality in our backyard. So a more suitable vaccine for us could come from the Chinese, particularly because they have a track record of having developed better vaccine for this part of the world.”

Indeed, the JEVAX made by the researchers in Chengdu is now the most widely used jab against Japanese Encephalitis because it’s more cost effective compared to its western vaccines.

Nepal Health Research Council is once again considering conducting Phase III clinical trial of Coronavac by China’s Sinovac Biotech after an initial divided opinion over its safety. The vaccine has shown quick immune response in mid-stage trials in South America and parts of Asia.

In India, The Serum Institute has anticipated demand by already manufacturing 40 million doses of AstraZeneca’s potential Covid-19 vaccine. It will also soon manufacture Novavax.

Similarly, researchers at the Indian Institute of Science have designed a protein-based heat-tolerant vaccine that can stay stable for a month at 37°C, and could endure temperatures as high as 100°C if freeze dried, a feature that could be a game changer for mass vaccination campaigns in lower and middle income countries in Asia and Africa.

The other factor to consider will be the duration of the immunity after each vaccine shot, as well reinfection groups and if antibodies developed in the first episode helps fight the mutated forms of the virus.

With Covid-19 crisis continuing to spread rapidly across Nepal and at 10 fatalities per million population (same as Pakistan and much higher than China’s 3), it is not too early to start dialogue with Gavi, the vaccine alliance, COVAX and agencies like the World Bank and World Health Organisation to help procure the most cost effective approach to vaccines most suitable to Nepal’s conditions.

Alternatively, many pharmaceutical companies will want to play the field in order to boost their profile. In fact, embassies and foreign donors are already hard at work pushing for trails and deals.

“There is bound to be vaccine politics and it will mostly likely be ugly,” predicts Sher Bahadur Pun of the Health Ministry. “But we should not lose track of two things: efficacy of the vaccine against our population and its economic viability. If we do that we should be on the right path, more or less.”

In all this excitement, Nepal’s health authorities must also keep an eye on the plight of infected people and many more to come as they wait for a vaccine. The results of current treatment regimens ranging from plasma therapy to administering Remdesivir have been patchy. And as scientists study the long-term impact of Covid-19 on patients even after they recover, making an optimal use of resources becomes even more significant.

So far, the government has been faulted for squandering months of lockdown, not carrying out sufficient tests and contact tracing, not increasing hospital capacity and equipment, and letting the people fend for themselves.  

The result is that Nepal is suffering a sustained surge, with more than 1,400 new cases a day, over 60% of them in Kathmandu Valley alone and a quarter of those tested coming out positive. There is also a surge in symptomatic patients, even among those without pre-existing conditions, and those sick enough to require ICU and ventilator.

Even when the government does act, the priorities seem to be misplaced. For instance, health experts say the emphasis in the past months should have been on high flow oxygen therapy or High Dependency Units rather than Intensive Care Units in hospitals.

“It would have been cheaper, it does not require highly trained staff or sophisticated equipment, and it would have freed up the ICUs for the really critical patients,” adds Pun, who himself is at the Health Ministry, and this possibly means his advice is not being taken.

Insiders say it will likely take upwards of six months for the first vaccines to arrive in Nepal, and there will be a rush by the rich, the powerful and those with political connections to get their shots. The marginalised, poor, those in remote areas will be the last to get their injections, unless the government has fair and effective rules in place and implements them.

Till then, there is little else to do than keep masking up this winter, avoid large gatherings, keep distance and wash hands regularly.

Says Buddha Basnyat: “The mask is the best vaccine we have at the moment. These safety measures have largely reduced hospitalisation due to other infections in 2020, masks in particular will also protect us from winter pollution in the coming months.”

The Vaccine Race

The global resurgence of Covid-19 in the northern winter has coincided with breaking news every day of successful new vaccine trials.

First the Russians announced a vaccine in September that is 92% potent against SARS-CoV-2.  Last week Pfizer unveiled a 90% effective vaccine, which on Wednesday was upgraded to 95% efficacy without side effects. Moderna was next with an efficacy of 95%, and not needing extreme refrigeration. More companies in China, India and Europe are conducting their own trials.

Public health experts have hailed the developments, but warn that vaccines will not be universally available till late 2021 and even so will not provide full protection. They suggest continuing with masking up, keeping distance and avoiding crowded indoor places.

Pfizer and its German partner BioNTech’s mRNA-based vaccine came out declaring over 90% effectiveness but only at -70°C ultra cold chain which will be a challenge even for countries with the best health facilities in the world.

Massachusetts-based Moderna’s RNA shot has 94.5% efficacy, seems to also prevent severe infections and remains stable in medical and home refrigerators for up to 30 days, in freezers (-20°C) for up to six months, and at room temperature for up to 12 hours.

Even so, poorer countries are unlikely to get coronavirus vaccine any time soon. Even the biggest pharmaceutical multinationals can only manufacture a limited quantity of the vaccine over the next year.

Pfizer has capped its production at 1.4 billion for 2021, 80% of which has already been booked through advance purchase agreement by the US, UK, EU, Canada and Japan. Moderna expects to manufacture 20 million doses this year and up to one billion in 2021.

On the other hand, Russian’s Sputnik V has been overshadowed by new developments, and due to lack of sufficient data to back up its claim of 92% efficacy. Although geopolitical rivalry with the West has given it negative publicity, some health agencies have not ruled it out.