Nowhere to hurry?

A woman gets her CoviShield vaccination in Kolomiya, Ukraine. The first batch of the India-produced AstraZeneca/CoviShield vaccine of 500,000 doses arrived in Ukraine on February 23rd. Photo: Erika Richard / Shutterstock

What has caused Ukraine to fall behind others was mainly the late start of the vaccination campaign, triggered by delays in the vaccine procurement process. The first doses of vaccine arrived in Ukraine only on February 23rd. Since then, all promised vaccine supplies have been either postponed or delayed, and as of mid-April only 832,000 doses were actually supplied. The national coronavirus vaccination plan in Ukraine in April was four times behind the schedule. As of mid-May only 1 952 000 doses were supplied, which is still a very small number.

Poor start

Already during the summer of 2020, Ukraine’s health minister, Maksym Stepanov, announced that he personally was leading negotiations with vaccine manufacturers. However, it was only on December 30th that the State Enterprise Medical Procurement of Ukraine finally signed Ukraine’s first agreement for the supply of 1,913,316 CoronaVac doses, provided by the Chinese company Sinovac. The procurement procedure was accompanied by a corruption scandal: the vaccine was bought not directly from the manufacturer, but through an intermediary firm, previously known for winning government tenders during the pre-reform era of Viktor Yanukovych’s presidency.

Arsen Zhumadilov, the general manager at the State Enterprise Medical Procurement of Ukraine, said that it was Stepanov who insisted on concluding the agreement through this intermediary. Moreover, he accused Stepanov of slowing down the negotiation process with another manufacturer. These corruption allegations were supported by investigations by some parliamentarians, NGOs and journalists.

Throughout January and nearly all of February, Ukrainians continued to wait for the arrival of vaccines, as CoronaVac was still in the third phase of clinical trials. The vaccination campaign only took off in April, although an emergency permit from the WHO was still pending. Neither did Ukraine adhere to the rapid vaccine rollout mechanism within the global vaccine-sharing COVAX framework – the ministry of health initially announced that the first batch of vaccines (117,000 doses of the Pfizer/BioNTech vaccine) would arrive by mid-February. The delivery was postponed to April.

In January, the Crown Agents international agency joined the purchase which significantly accelerated Ukraine’s vaccine procurement process. Already on February 5th, they agreed to the supply of 12 million doses of AstraZeneca and Novavax vaccines for Ukraine. The first batch of the India-produced AstraZeneca CoviShield vaccine – 500,000 doses – arrived in Ukraine on February 23rd. The vaccination process finally began the next day. By the end of March, Ukraine was to receive another 1.5 billion doses of the same vaccine. But on March 26th it became apparent that there would be no supplies – India had announced its intention to make domestic vaccination a priority due to the growing number of cases in the country. As a result, 500,000 doses of CoviShield was all that Ukraine had until mid-April. Vaccination with CoronaVac, purchased at the end of last year, began on April 13^th. However, as of April 16th, the country only received a small batch – 215,000.

On April 16th, under the auspices of the COVAX initiative, Ukraine received a supply of 117,000 Pfizer/BioNTech doses, which enabled some 58,000 Ukrainians to receive the jab – the vaccine must be administered twice, so half of the doses were immediately reserved for re-administration. While February’s batch of CoviShield was coming to an end – 433,000 doses out of 500,000 were used – Ukraine found itself in a situation where it would not have any vaccines left. Only on April 30th 500,000 doses of CoronaVac arrived, while the next 500,000 doses Ukraine received on May 9th. Another delivery of COVAX took place on May 18th, which included 122,850 doses of the Pfizer-BioNTech vaccine. In total, all the deliveries are still too small for a country with a population of 44 million people.

Not according to plan

In April Ukraine’s Cabinet of Ministers allocated 6.5 billion hryvnias (around 195 million euros) for the purchase of 10 million doses of Pfizer vaccine. Stepanov promised that it would begin to arrive in the coming weeks. But so far, Ukraine has received Pfizer only from COVAX.

According to Volodymyr Kurpita, an epidemiologist and senior lecturer at the School of Public Health at the National University of Kyiv-Mohyla Academy, “Large manufacturers still do not want to deal with the Ukrainian state because of the scandals that came to light in the past. Therefore, it is only logical that in January the government sought the involvement of an international company, Crown Agents. Why has this not been done before, over the past year? Purely for political reasons, I believe, because the leadership in the health ministry had previously criticised the international procurement conducted for Ukraine, among others, by Crown Agents.” He added that a division emerged “within the ministry [between] Stepanov who, was responsible for bilateral agreements, and his first deputy and chief sanitary doctor, Viktor Lyashko, was responsible for receiving the vaccine under the COVAX mechanism. There has been some sort of a competition as to who would be the first to deliver the vaccine.” In some circles, Lyashko is considered the next minister of health and appears to be a political competitor of Stepanov.

Ukraine’s Vaccination Roadmap identifies which priority groups are to be vaccinated first: doctors in COVID-19 hospitals and emergency care; other medical personnel; social workers and the elderly in specialised institutions; all persons over 60 years of age; the military and law enforcement; teachers; and finally, the rest of the population. In reality, however, this sequence often goes off track. At first, everything went according to plan. Throughout February and early March, specially trained mobile teams were vaccinating medical frontline staff. One team could perform a maximum of one hundred vaccinations per day. Yet in practice teams failed to make the target because some medical institutions did not have a hundred doctors from the priority group willing to receive the jab.

Many frontline staff refused the vaccine – either because they had already contracted the virus or because of vaccine hesitancy. Ukraine, in consequence, is in a situation where the country anxiously awaited vaccine supplies and mobile teams are still vaccinating the first priority group at a rather sluggish pace – from only 5,000 to 8,000 people a day.

Further, it was not uncommon that open vials (e.g., AstraZeneca packaged in 10-dose vials) were wasted instead of being used on someone outside the priority group. Queues of people wishing to be vaccinated with the unused vials formed very quickly, and the amendments to the ministry’s decree allowed vaccination with vial residues for public figures, although without any clear definition or criteria for such entitlement, which consequently resulted in abuse and manipulation.

Slight improvement

On March 22nd, the situation improved as the country opened 565 vaccination centres. Since then, everyone – primarily those over 80 years old –  can receive the jab by registering through their family doctor (Ukraine introduced a successful reform of primary care in 2017).  For those willing to be vaccinated, this scheme proved to be effective, although it can hardly be considered transparent. Since only family doctors have access to the registration lists, it depends entirely on their decision who receives the vaccine and when. It is common for doctors to refuse those who do not belong to any priority group – even in the absence of regulation. 

Unsurprisingly, chaos ensued. While some young people have already been vaccinated with the vial residues thanks to their family doctors, older people, including those from the priority groups, are still waiting. Consequently, on April 19th, changes in the Vaccination Roadmap allowed vaccine residues to be only administered among the priority groups, as well as those aged 80 or older.

At the same time, mobile teams across the country continue to administer the Pfizer vaccines among staff and patients of nursing homes and other specialised institutions, and CoronaVac to essential infrastructure workers and low-mobility groups. Simultaneously, some vaccines can be transferred to government institutions. On April 15th, for instance, 52,000 doses of CoronaVac were allocated to the central clinic of the ministry of internal affairs for vaccination of law enforcement officers. It is yet another departure from the Vaccination Roadmap – staff and patients of nursing homes and other specialised institutions have still not been vaccinated as a group, which contradicts an earlier statement by the ministry of health that all CoronaVac doses will be administered there first.

According to Pavlo Kovtonyuk, an expert at the Ukrainian Healthcare Centre and former deputy minister of health, “there are four main problems with vaccination rollout in Ukraine. First, the government in Ukraine was unprepared and the vaccination campaign had a late start. In addition, in the first month of the rollout, Ukraine has the same rates of COVID-19 vaccination as at the beginning of the year. Second, it is the weak capacity of Ukraine’s government and public healthcare system. The vaccination rollout in Israel and the United States relies on the army, while Britain and Germany engaged volunteers. Ukraine needs to stop pretending that everything is under control and ensure a countrywide mobilisation to maximise the effectiveness of vaccination – currently, nothing is more important than that. Third, while many people are not ready to be vaccinated, a great share of others, on the other hand, want to receive the jab as soon as possible and cannot do so because of Ukraine’s complicated prioritisation mechanism. At the same time, those in doubt are just waiting for others to get the vaccine. Finally, Ukraine’s vaccine supply fell short. When most countries led active talks with vaccine manufacturers, the Ukrainian government was waiting for humanitarian aid while wrestling with its own procurement agency. As a result, deliveries are slow, and vaccines are registered even slower. A simplified mechanism for verifying vaccines, recognised by countries with strong quality control policies (i.e. the EU member states and the US), was never launched in Ukraine.”

Vaccine mistrust

To make matters worse, 51.5 per cent of Ukrainians, according to a poll conducted by the Razumkov Center in March, do not want to be vaccinated at all. The main reason is a distrust of the CoviShield vaccine, which was the only available option until April 13th. Among those who would refuse vaccination, 45 per cent consider CoviShield to be insufficiently effective or safe, but are willing to be vaccinated with “another” vaccine. It is worth exploring where the distrust came from.

In Ukraine, the anti-vaccine movement became widespread during a 2008 case when a 16-year-old boy died shortly after an unscheduled MMR immunisation with a vaccine manufactured by the Serum Institute of India, the current producer of CoviShield. The link between the tragic incident and the vaccine has never been proven; and since 2017, millions of children and adults in Ukraine have received tetanus and diphtheria vaccines produced by the same manufacturer. Nonetheless, a proportion of the population is still reluctant to get vaccinated. What is more, a number of Ukraine’s national TV channels have been leading a vaccine misinformation campaign, considering it an acceptable form of political struggle against the current government.

Even in parliament, the chairman of the European Solidarity party and ex-President of Ukraine Petro Poroshenko said: “When I asked why anyone would refuse to be vaccinated – I apologise for the non-parliamentary statement made by a doctor in despair – it is because they bought shit.” To increase confidence in vaccinations, Ukraine’s president and health minister, along with other senior officials, have been publicly vaccinated with CoviShield. In addition, the government has launched a special website dedicated to the support of vaccination, which offers information on each vaccine and its safety. It remains to be seen how effective these measures will be when the vaccine becomes widely available.

There is also the issue of trust in the information that is published by the government. For example, the vaccination website states that the effectiveness of the Chinese-made CoronaVac vaccine is 85.3 per cent, while the third phase of clinical trials in different countries have shown varying results: 65.3 per cent in Indonesia, 85.3 per cent in Turkey and about 50 per cent in Brazil. Why did the ministry of health decide to claim 85.3 effectiveness? It has to do with the fact that the agreement for vaccine supplies, concluded in late December, states that the contract is subject to cancellation if, in the third phase of clinical trials, the vaccine shows effectiveness below 70 per cent. Therefore, if the ministry took, say, the average figure from the different studies, vaccine supplies would come to an end.

Low rates of immunisation against COVID-19 in Ukraine can be explained by certain errors in the organisation of the process and the chaos on the ground, but ultimately the main problem is a lack of vaccine supplies. With the current number of doses available, Ukraine simply has nowhere to go – it is impossible to administer a greater number of vaccines. 

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While this text was being prepared for publication, minister Maxim Stepanov was dismissed. The reason for his dismissal was the failure of the vaccination campaign. Consequently, on May 20th, his deputy Viktor Lyashko was appointed minister. He promised to reach the number of five million Ukrainians vaccinated during the summer. Such words, of course, have caused strong scepticism given the current pace of vaccination.

Translated by Anastasiia Starchenko

Victoria Guerra is a Ukrainian journalist who covers health-related issues for Ukrainian press.

COVID-19, Ukraine, Volodymyr Zelenskyy