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LEAN LOGISTICS FOR VACCINES- A SUCCESS CASE IN URUGUAY:FROM THE AIRPORT TO THE PATIENTSEPTEMBER 2021

Uruguay was the only country in the world to store, prepare anddistribute vaccines directly from the airport to the vaccination
centers and was able to vaccinate its population at a very fast rate.

1.
TABLE
TABLE
OF CONTENTS
OF CONTENTS
1. Executive summary

03

2. Status and Challenges04

3. The Solution

05

4. Results

14

5. Benchmark towards other airports and countries

17

6. Lessons learned and Recommendations

19

Contribution and support:- Raúl Bianchi- Marcel Barceló
For Pharma.Aero:- Bruno Guella- Trevor Caswell- Frank Van Gelder- Sara Van Lerberghe

“It was a wise move to choose the airport for the storage and handlingin ultra-cold conditions. It allowed for quick implementation andavoided chain failures.”Dr. Daniel Salinas, Minister of Public Health“The flexibility of the design helped us to adapt the plan as newchallenges arouse. In addition, the inter-institutional collaboration
was pivotal in reducing inefficiencies, margin of error and lead times.
This was key to the success of the vaccination plan”
Lic. Jose Luis Satdjian, Vice-Minister of Public Health1.

Executive summary

Uruguay has a successful tradition of mass vaccinationplans. However, the Covid-19 pandemic created an
unprecedented challenge. The vaccine delivery system
had to be modified in order to significantly exceed
historical vaccination rates under much more demanding
circumstances. It also had to use a new network of
vaccination centers so as not to affect the rest of thevaccination plans.

The strategy of the distribution system was designed to beable to leverage the best practices of a logistics operation,
based on the Theory of Constraints, in order to optimize timeand resources. To that end, a last-mile distribution model
was adopted, involving the preparation of unit orders anddirect delivery from the airport to the vaccination centers,
shortening the supply chain and improving the lead times
within the value chain of the vaccines. This was a key
factor in Uruguay’s successful strategy to reduce time andrisk throughout the logistics chain.

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2.

Status and Challenges

Covid-19 raised challenges globally, both for healthcare
systems and for vaccine development at unprecedented
rates to end the pandemic, which, as of early July 2021,
had already caused nearly four million deaths.

of usual vaccination plans, nor were there calibrated
devices to control and monitor such low temperatures.
On the other hand, the use of dry ice implied a complex
and costly operation.

The distribution of vaccines has been the greatest
logistical challenge in history: all countries
simultaneously had the same urgency to receive
them; while the availability of international flights was
substantially reduced due to the pandemic; and toensure safety, traceability and cold chain requirements
had to be maintained along the supply chain.

The experiences of other countries also provide insightand background, by the information gathered by
Pharma.Aero on vaccine logistics at the international
level, as well as the experience in the developmentof vaccination plans, which was accessed throughgovernment contacts.

Moreover, the vaccine supply chain remained very
uncertain, while pharmaceutical companies were still inthe midst of vaccine development.
In Uruguay, at the end of 2020, it was not known yet
what type of vaccines would arrive, nor how many,
nor when, or the requirements for their storage andtransportation. The only certainty was that they would
be arriving through its International Airport.

04

Being aware of this, the cargo terminal at theinternational Airport of Montevideo, Uruguay (TCU
- MVD Free Airport), launched in October 2020 the
project “Acercar Vacunas” (Bringing Vaccines Closer).
Based on its experience in pharmaceutical logistics,
the company decided to take a leading role in thedesign of fast, safe and efficient logistics, anticipating
the challenges and leaving nothing to chance. The
government, based on the country’s successful traditionof mass vaccination plans, had also been working on thedefinition of the vaccine distribution system. However,until now, the need to vaccinate more than 70% of
the population with two doses in less than six months
had never arisen; an objective that the plan originallydesigned by the government could not achieve.
The studies carried out by the government had alreadywarned of the difficulty of distributing, throughout thecountry, a vaccine that requires a demanding cold
chain, such as the one developed by Pfizer. In Uruguay
there were no ultra-cold freezers available as part

1

Finally, in early January 2021, these efforts converged
in a cooperative multi-task team integrated by the
public and private sectors, comprising representativesof TCU - MVD Free Airport, the Ministry of Public
Health (MSP), the National Emergency System (Sinae),
Calmette laboratory1 and the company va-Q-tec, allunder the overall coordination of the Presidency of the
Republic.

“It is important to highlight the interinstitutional collaboration. Together
with the Ministry of Health, manyorganizations contributed in a coordinatedapproach, including: the Ministry of Social
Development, the Association of State
Medical Services, the National Emergency
System, as well as many actors in theprivate sector. This was pivotal in reducing
inefficiencies, margin of error and leadtimes.”
Lic. Jose Luis Satdjian, Vice-Minister of Health

For the Covid-19 vaccination campaign, Uruguay
decided to use vaccines from Sinovac, Pfizer andAstraZeneca. This document describes the operational
solution used for the Pfizer vaccines, as it required moresophisticated logistics and shorter delivery times.

State laboratory responsible for the planning and execution of all vaccination plans at the national level.

3.

The Solution

3.1 Strategy
The strategy for designing the National Vaccination Plan
solution was based on the Theory of Constraints TOC.
This is an organizational management tool developed by
the Israeli physicist Eliyahu Goldratt2.
The core idea of this methodology is that the maximum
performance that can be achieved by any system isdetermined by very few elements, in most cases only one:the constraint (Fig 1).
Based on this approach, a strategic and tactical roadmap
was established for the continuous improvement of
the processes involved in the implementation of thevaccination plan in Uruguay:- Identify the constraint in the system that defines the
maximum number of people that can be vaccinatedper week. In this case, the rate at which vaccines would
arrive in the country.
- Ensure that the constraint operates at maximum
capacity. This implies avoiding the loss of any vaccine
doses and sizing the rest of the components of the
distribution system (ultra-cold freezers, vaccination
centers, refrigerated boxes, means of transport, etc.)with a capacity that exceeds the rate of arrival of
vaccines.

Fig 1

In this way, the pressure for greater performance reliedon the Executive Branch, which negotiated with thelaboratories the quantities and frequency of deliveries.

2

In the event a significant increase in the rate of arrival of
vaccines was achieved and this was no longer the limiting
factor in the rate of vaccination, the review cycle would
begin again to identify the new constraint and subordinate
the operation of the rest of the distribution system.

3.2 Tactics
The implementation of the defined strategy involved thedevelopment of two key concepts: avoiding the loss ofdoses and ensuring protective capacity throughout thelogistics system. Based on Pfizer specifications, training
needs were identified to ensure vials would only behandled by fully qualified personnel.

3.2.1 Avoiding Losses
The first concept was reflected in the following design
criteria:- Minimize handling operations to reduce risks byeliminating non-value-adding activities.
- Strictly comply with Pfizer’s standard operatingprocedures for storage, handling and distribution
activities.
- Centralize vaccine storage in one location: thededicated pharmaceutical warehouse at the airport.
- Create a scheduling system so that every patientis previously registered in the government healthdatabase. This allowed for proper segmentation andprioritization (exposure risk, ages, comorbidities, etc.)- Based on the agenda previously defined, prepare
orders on a daily basis and ship them overnightfrom the airport directly to every vaccination centerin the country, with the exact amount of vaccines forthe people scheduled for the next day, plus 5% forcontingencies.
- Ensure that only qualified personnel are involved in theprocess of preparing and packing the vials (small glass
vials containing the vaccine doses)- Use only validated containers for distribution withtemperature recorders and tracking & tracing systems.
Optimize reverse logistics of containers, ensuring
availability for future shipments.
- Not maintaining safety stock at the vaccination centers
to avoid reverse logistics and transfers between
vaccination centers. This simplifies handling activities
and minimizes the risk of doses being lost.
- Monitor the program through daily inventory checks ofeach vaccination center.

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https://goldrattgroup.com/

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3.2.2 Protective Capacity

3.3 Operations

This concept refers to the fact that the infrastructure andthe capacity of the required processes, from the receptionof the vaccine to its application, must be sized based on
the possible peaks of demand and not on the average.

3.3.1 Demand Management

Given the uncertainty that existed in January 2021 asto what vaccines would be available in Uruguay, inwhat quantities and when they would arrive, efforts
were made to create a protective capacity throughout
the supply chain, airport, distribution center and vaccine
centers that would be able to adapt quickly to different
scenarios.
Storage capacity at -70°C had to be sized for the mostdemanding scenario. The delivery time for ultra-coldfreezers was approximately two months. One to two
weeks are required for installation and validation testing,so it was not possible to quickly install new equipment incase of an increase in the number of vaccines received.

06

In another sense, vaccination teams could be designed
in a flexible manner and adapted to the pace ofvaccination. Multidisciplinary teams were defined withwork contracts that ensured payment for availability,
which made it possible to increase or decrease thenumber of vaccinators without significantly affecting
their salaries. This way of organizing human resources,
together with a weekly planning horizon with daily
reviews, made it possible to maintain a continuous flowof inoculation.
This last concept, the continuous flow concept, wasvery important to ensure the use of each dose and reduce
the risk of losses. The guidelines initially established by
Pfizer indicated that the shelf life of the vaccines, once
thawed and shipped to the point of inoculation, was lessthan five days. Therefore, in order to avoid stopping theoperation in the vaccination centers and restarting days
later, thereby generating vaccine balances that would
not be used the following day, it was sometimes decided
not to use all the available capacity, but only the capacity
necessary to maintain a continuous flow of vaccination.
Therefore, it was not necessary to appeal to social
networks or other means to quickly recruit people to be
inoculated before the doses expired, as happened inother countries.
Based on these concepts, it was possible to install avaccination capacity that ensured a daily minimum of 1%of the population with the possibility of rapidly doublingit. This flexibility ensured that the limitation of the system
was always fixed in the amount of vaccines arriving in
Uruguay.

In order to ensure a constant flow of vaccination, avoid
waiting lines and take advantage of the facilities, asystem was developed to register all persons willing to be
vaccinated. The system then allocated quotas according
to the priorities set by the commission of vaccine experts,
the amount of vaccines available in the country and thecapacity of each vaccination center.

3.3.2 Supply Frequency
To ensure that each vaccination center had only enoughvaccines to cover the daily demand and to avoid therisk of stock-out, a daily replenishment frequency wasdefined and a maximum time of 12 hours from the time avial was thawed until delivery to the vaccination center.
Once the demand for each vaccination center was
confirmed, the orders were prepared overnight at the
airport facilities and shipped the following morning
directly to their destination.

3.3.3 Storage
Given a high degree of uncertainty and many open
questions during the planning stage, the design andsizing of the vaccine storage system had to be able toaccommodate different scenarios, such as handlingvarying sizes of the batches arriving in Uruguay and theavailability or lack of ultra-cold freezers.
At the beginning of January 2021, supply agreementswith Pfizer had not yet been finalized, so there was no
precise information on the quantities and dates of arrivalof the vaccines in Uruguay, and there was a lack ofsuitable equipment for storing vaccines between -80°C
and -60°C in the country.
From this starting point, parallel progress was madealong two paths:- Obtain ultra-cold freezers or other equipment capableof storing vaccines between 80°C and -60°C as soon
as possible.
- Design a storage system that would include the use of
dry ice.
In Uruguay there was little availability of ultra-coldfreezers and the maximum capacity of vaccines that
could be stored was unknown. In addition, there was ahigh demand for this type of ultra-cold freezer equipment
worldwide.

The government contacted institutions and suppliers that
could provide this equipment in the short term. As a result,a local representative initially delivered two ultra-coldfreezers on loan while the purchase and delivery of two
new ones was being negotiated. In addition, four additional
pieces of equipment were purchased and transported
from the U.S. by the Uruguayan Air Force to ensure their
immediate installation at the airport in Montevideo.
These ultra-cold freezers were installed and calibrated at
the airport prior to the arrival of the first batch of vaccines,
creating a total storage capacity of 800,000 doses.
This capacity not only exceeded the largest batch of
vaccines that could arrive in the country simultaneously,
but also provided backup capacity in case there was any
equipment failure.
The other option was to periodically replenish the dry ice
in the original boxes received from Pfizer, keeping them ina chamber at -20°C to minimize thermal loss. According to
Pfizer’s initial specifications, this would allow the vaccines
to be stored for a maximum of 30 days, so the vaccine
batches had to be small and received as often as possible.
In Uruguay there are two suppliers of dry ice and only
one of them can produce it in flakes, which is the preferred
requirement to replenish the boxes. It was also necessary

to consider the generation of CO2 inside the cold chamber
and to define a safe operation mode for the staff. Although
this mode of storage was ultimately not implemented, thework carried out was useful to have an alternative in theevent of an extreme case.
When the arrival of the first ultra-cold freezer was confirmed,
TCU - MVD Free Airport adapted the installation site of theequipment and ensured the supply of electrical power byadopting redundant infrastructures as a back-up. The staff
had previously been trained under the “Bring Vaccines
Closer” project to operate safely with materials at -80°C
through theoretical instruction and operational simulations.

3.3.4 Distribution
The size and topography of the Uruguayan territory does
not present major challenges for vaccine distribution,
since it is possible to cross the country by land in about
eight hours with good road conditions. The following map
shows the number of vaccination posts by department(Fig 2).
However, delivery times and schedules, the particularities
of Pfizer’s vaccine, as well as the characteristics of the
distribution to the vaccination centers, required somechallenges to be solved.

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Fig 2

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Thus, at 4:00 a.m., the thermal boxes with vaccines
were delivered to the Air Force, which departed with its
planes and helicopters from the Montevideo airport tothe different locations in the countryside, from where theArmy continued with the distribution to the vaccination
centers.

PROCESS STAGES Fig 3

10
11
12
12:00 to 17:00
Records
updatingand orders
calculation

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14
15
16
17

DAY -1

In order to achieve daily deliveries to each vaccination
center and not to exceed 12 hours from the preparation
to the delivery, the Ministry of Health made an agreementwith DAC, a private company with vast experience invaccine distribution, for deliveries in Montevideo and themetropolitan area. The rest of the country was coveredby the Air Force and the Army (Fig 3).

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19

From 6:00 a.m. onwards, the vehicles of the privatetransportation company DAC collected the thermalboxes with vaccines to arrive before 8:00 a.m. at eachvaccination center in the capital city and nearby areas.

20

18:00 to 24:00
Order picking

21
22
23

He mentioned as one of the main challenges for thisintegration the participation of multiple public and private
players. “We had never worked with an integration inwhich our carriers ended up being the Air Force with its
airplanes and the Army. We had to develop a training planfor the use of the tools, the processes, our technology andthat of TCU - MVD Free Airport and thus be able to have
all the information centralized for the different reports”.

24
00
01
04:00
Shipment tomore remote
areas
7:30
Vaccine delivery

06:30
Shipments toMontevideo andthe metropolitan
area

02
03
04
05

07:30
Collection of
empty boxes

06
07
08
09
10
11
12
13

08:00 to 22:00
Vaccination

DAY 1

08

Alejandro Méndez, Country Manager of
DAC, highlighted the integration work that
TCU - MVD Free Airport was able to doin record time, providing visibility to theprocess from the moment of arrival of thevaccines, the availability of stock,
the preparation of the orders, to thedelivery of the vaccines.

09:00 to 16:30
Return of boxes
to Va-Q-Tec

14
15
16

“The system for the logistics of the thermalboxes was a bit complex at the beginning,but then it flowed perfectly. The thermalboxes have been permanently monitoredby the system and none of them weremisplaced.”
Edgardo Ipar, Director of va-Q-tec Latin America

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18
19
20
21
22
23
24

17:00
Delivery ofconditioned
boxes to TCU

At the same time, police custody was initially assigned
to accompany the ground transportation vehicles,
considering the high level of attention that the distributionof the vaccines had attracted, which represented a riskof sabotage that had never been considered in previous
vaccination plans.

“Our company transports all vaccines,
but we had never had these safety devices
before. It was something very new,we didn’t know if anything could happen
during the transportation.”
Alejandro Méndez, Country Manager of DAC

3.3.5 Cold chain and Traceability
The maintenance of adequate storage and distribution
conditions throughout the logistics chain was the key
to guarantee the safety and efficacy of the vaccines.
Given Uruguay’s long and successful experience in theimplementation of vaccination plans, the procedures andequipment necessary to ensure these conditions werealready familiar (Fig 4).

MATERIALS FLOW

Fig 4

The vaccines arrived at the airport in the boxes provided
by Pfizer, including a temperature datalogger in eachbox. The information in every single datalogger wastransmitted to Pfizer headquarters, where the Quality
Assurance team analyzed the information of theshipment and released each box. This ensured that thevaccines were kept at the proper temperature throughout
the international transport, from the factories in Europe
and the United States to their arrival at the airport inMontevideo.
In addition, the ultra-cold freezers have a permanent
temperature register and alarms to warn of any change
outside the established range, and there is a procedurefor opening and closing the equipment to ensure that thestored vaccines are kept at the proper temperature.
At the end of the day the government planning team sent
the information to the airport to prepare the orders. TCU- MVD Free Airport staff removed the original Pfizer trays
containing 195 vials from the ultra–cold freezers andimmediately transferred them to a conditioned chamber
between 2°C and 8°C. To avoid handling frozen vials,
the total amount of orders to be prepared for eachvaccinator was rounded to a multiple of 195 vials.

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Inside the cold chamber, and after the necessary time
for the vials to be safely handled, the individual orders
were prepared with the exact quantities defined for eachvaccination center, which sometimes meant having to
split the Pfizer trays and prepare smaller quantities. Thisrequired designing new trays tailored to Pfizer’s vials,
as well as appropriate clamping mechanisms to ensurethat these trays did not move inside the va-Q-tec boxes
during transport. Each box was then closed and coded
to facilitate traceability, allowing real-time distribution
monitoring.
Traditionally, polystyrene boxes refrigerated with coolinggels were used for vaccine transportation in Uruguay.
However, the lack of experience worldwide regarding
the stability of mRNA vaccines made it necessary to use
the best available technology. This was made possible
thanks to the support of va-Q-tec, whose Latin American
headquarters are located in Uruguay.
The company specializes in temperature-controlled producttransport solutions. For this case, the va-Q-med 21
box was selected, designed for “last-mile distribution”
of pharmaceutical products, which has phase-change
exchangers, ensuring temperature maintenance for atleast 48 hours.

10

In addition, these thermal boxes have a temperaturerecording device that can be read from the outside using
a QR code. In this way, before opening the thermalboxes at the vaccination center, the temperature records
could be analyzed to ensure that the vaccines arrived ingood conditions.
The va-Q-tec boxes were also used to store the vials
during the vaccination days. At the end of each day, theleftovers were stored in the refrigerators installed in eachvaccination center, which were controlled by calibrated
temperature sensors.

“The key elements to ensure traceability
were that the thermal box is integrated in
the vaQtec planning system, which allows
us to know where the thermal box is fromthe moment the operation starts until it
ends, and having used what we call vaQ-nection, which is the state-of-the-art
thermograph that is activated by light.
This is what has allowed the thermographto be activated from the moment the box
is opened to place the vaccine, and that iswhen the process begins.”
Edgardo Ipar, Director of va-Q-tec Latin America

The next day, with the delivery of the new vaccines, theva-Q-med boxes used the day before were removed forreuse. At the va-Q-tec operations center, the boxes were
inspected, sanitized and conditioned to the specified
temperature for transportation. On a daily basis, speciallyconditioned thermal boxes validated by va-Q-tec weresent to the airport to prepare new orders and start anotherfour-day cycle: conditioning, preparation of the order,
distribution and vaccination, and reverse logistics.

3.3.6 Information System
The logistics chain design criteria for vaccines imposed
short lead times from the time demand was identified ateach vaccination station until the vaccines were delivered.

Meeting these criteria required managing the informationin an agile and secure manner, avoiding errors anddelays. In this sense, the flow of information from thevaccination schedules, the vaccine inventories at eachstation, the track and trace system of the distribution
company and the warehouse management system of
TCU - MVD Free Airport were integrated.
The objective was to use a single source of information,
eliminating retyping of data and monitoring the progressof the process throughout all its stages (Fig 5).
The demand at each vaccination center was registeredin the scheduling system of the Ministry of Public Health.
Those interested in getting vaccinated could register
through three channels: telephone, WhatsApp andwebsite, and the system would schedule the day, timeand place of inoculation for each one of the two doses
to be applied.
This information was transferred to the supply management
system which, integrated with the inventory of eachvaccination center, calculated the orders to be shipped.

INFORMATION FLOWThe orders were sent electronically to the distribution
company and to TCU - MVD Free Airport in theappropriate formats so that they could be automaticallyuploaded to their systems. In this way, labels were printed
that allowed the registration and tracking of each stageof the distribution, and the operators at TCU - MVD Free
Airport received in their mobile terminals the details of
the orders to be prepared.
The lists of people scheduled were also generated andsent automatically, via e-mail, to each vaccination center.

“TCU - MVD Free Airport was able to do
all the integrations and make all theprocesses work seamlessly. Our own
operation was fully integrated from whenthe vaccines arrived and when they werein stock to when we had them delivered.”
Cr. Alejandro Méndez, Country Manager of DAC

Fig 5

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le each of the main players in the Ministry of Public
Health, DAC and TCU - MVD Free Airport distribution
had their own management information systems, they
were originally not integrated or designed to share datawith each other. The available deadlines did not allow thedevelopment of an integration between systems, so theexchange of flat files and automation and calculations
based on Excel spreadsheets and macros had to be
implemented. Although the solution could be consideredrudimentary, it turned out to be very secure and effective.
In addition, to follow up the entire process, a Balanced
Scorecard was developed to analyze the allocation of
vaccination quotas, the record of vaccination eventsby post and geographic area, and the percentage ofcoverage by target population and by risk priority group(Fig 6 & 7).

12“The flexibility of the design enabled us toadapt our policies: for example, swiftly
implement pregnant women prioritization,
the creation of new vaccination centersthroughout the entire Uruguayan territory
as well as the implementation of mobile
vaccination centers that reached eachremote town and underprivilegedneighborhoods in an organized and agile
fashion”
Lic. Jose Luis Satdjian, Vice-Minister of HealthBALANCED SCORECARD

Fig 6

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Fig 7

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4.

Results

Uruguay is among the countries with the highest
percentage of its population vaccinated, despite having
started vaccination several months later than the first
countries to do so (Fig 8 & 9).

“The vaccination plan was successful,exhaustively elaborated, taking into
account supply restrictions and preserving
the cold and ultra-cold chain.”Dr. Daniel Salinas, Minister of Public Health

14

Fig 8

Fig 9

“Although we had the know-how ofmany years of experience in handling
vaccine logistics throughout the country,
we did not have the infrastructure. TCU- MVD Free Airport provided us with
the infrastructure and human resources
to undertake a campaign that, in threemonths, distributed much more than what
is distributed in a year in the National
Vaccination Plan. And that allowed us tostart as quickly as we did and to carry thisforward. That was very important.”
Marina Monteiro, Technical Director of CalmetteLaboratory

The following graph shows the weekly progress of
vaccination (Fig 10). The valleys observed at the
beginning and in weeks 18 and 19 correspond to low
availability (decrease in vaccine supply from abroad),and the peaks occurring in weeks 14 to 16 and 20
to 23 are due to increased vaccine availability. This
reflects the success of the strategy: when there wereenough vaccines, the maximum capacity could be used,vaccinating daily more than 1.3% of the total population
in a sustained manner, and when there were few vaccines,
the vaccination rate was lowered to ensure continuity of
the flow while the next batches of vaccines were arriving.
As of August 30th, (six months after starting vaccination)
Uruguay had vaccinated 72% of its total population(almost 85% of the population over 12 years old) withtwo doses, thus far exceeding the target of vaccinating
70% of its target population in less than 6 months.

15

Fig 10TABLE OF CONTENTS

By the end of August 2021, 2633 boxes of Q med 21
had been shipped, with no cases of cold chain breakage
reported. The figure below shows one of the documents
used by va-Q-tec: the temperature report (Fig 11).

“The whole process was very positive.
We were able to have traceability of theentire system, despite some emergencies.
Having foreseen that there could be
emergencies also helped us.”The distribution of Pfizer’s vaccines amounted to around6,000 km per day, including air and ground transportation.
By the end of June 2021, only one event had occurred:on March 25, a mechanical failure caused a helicopter
to crash and a few doses were lost. The pilots were
unharmed. The contingency plan ensured that new
vaccines were delivered to the destination points, withoutcausing delays in the vaccination on that day.

Edgardo Ipar, Director of va-Q-tec Latin America

TemperaturereportReference
Order:
Box ID:

Shipment Summary

16

Shipment OK

F00027524
101BC0004660000809

Start: 2021-05-29 21:12 (UTC-0) [Loaded]
Temperature results
Number of datapoints:
494
Lowest temperature:
3.94°C
Highest temperature:
6.81°C
Average temperature:
4.89°C
Mean kinetic temperature: 4.94°C

Temperature Zone Table

Zone
Above maximum
Within Limits
Below minimum

Above (>)
8.00°C
2.00°C

End: 2021-05-31 14:22 (UTC-0) [Received]
Duration:
TimeStamp Lowest:
TimeStamp Highest:
Standard deviation:
Activation energy used:

Below (<) Samples in Zone
0.0 %8.00°C
100.0 %
2.00°C
0.0 %va-Q-nection Configuration
Sensor ID:
Min limit:
Time allowed < Min
Start and End
Box Loaded:
Box Received:

7E57F293
2.00°C30 [min]2021-05-29 21:12 (UTC-0)
2021-05-31 14:22 (UTC-0)
2021-05-31 11:22 (UYT,-0300)

Open and Close Events
#
1
2
3

Open
2021-05-29 21:12 (UTC-0)
2021-05-29 21:49 (UTC-0)
2021-05-31 14:05 (UTC-0)

1 day(s), 17 Hour(s), 9 Minutes
2021-05-29 22:24 (UTC-0)
2021-05-31 10:24 (UTC-0)± 0.87°C
83.144 [kJ/mol]Time in Zone
0.00 [h]41.17 [h]0.00 [h]Degree Minutes
0 [°Cmin]0 [°Cmin]Box ID:
Measurement interval:
Max limit:
Time allowed > Max

101BC0004660000809
5 [min]8.00°C30 [min]by:by:va-Q-nection Light sensor
EX002 Sarandí del Yí
Montevideo (Laboratorio Calmette)

Close
2021-05-29 21:12 (UTC-0)
2021-05-29 21:51 (UTC-0)
2021-05-31 14:05 (UTC-0)

Duration [min]1
2
1

Fig 11

5.

Benchmark towards other airports and countries

To learn about the type of operations that have been
carried out in other countries and the infrastructure andprocedures dedicated to the management of vaccines,
Pharma.Aero conducted a survey among its partners.
Ten responses were received from airports, groundhandlers and freight forwarders from Asia, Latin
America, North America and Europe (Fig 12 & 13). The
results obtained show the uniqueness and sophisticationof the solution developed in Uruguay.

NUMBER OF ANSWERS RECEIVED Fig 12

TYPE OF COMPANY Fig 13
Airport50%

2

Airport/groundhandler 10%
Freight
Forwarder

1

4

10%

3
Groundhandler 30%

First, we asked about the role of the airport in the vaccine
logistics chain. Most of the participants received vaccinesfrom abroad and shipped them in transit to other airports
or to distribution centers in their countries, just as theyreceived them, with no further added value (Fig 14).

Uruguay is the only case where the airport operated asa last-mile distribution center, preparing unit orders to be
shipped directly to the distribution centers.

17

We received vaccines from abroad, stored them, picked andprepared unit orders (splitting and opening the original packaging)and then shipped them directly to the vaccination centers
We received vaccines from abroad, stored them and shipped them infractional batches according to demand
We received vaccines from abroad and they were shipped in fullbatch (as received) to warehouses and distribution centers outside
the airport
We received vaccines by land for shipment to other countries

We received vaccines by air in transit to other countries

We do not operate with vaccines

Fig 14

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Regarding the type of infrastructure and equipment
available to operate with vaccines, most of them had
cold chambers, but only 2 out of 10 respondents had
ultra-cold freezers for storing vaccines at -60°C.

9
7
2

18

7

Cold rooms between 2°c to 8°C
authorized by the competent authority
for the storage of pharmaceuticalproducts
Freezer chambers between-25°C to -15°C authorized by thecompetent authority for the storage ofpharmaceutical products

Ultra-freezers between -80°C to -60°C

Calibrated sensors for temperaturerecording and traceability

7

Alarm systems in case of out-of-range
temperatures

4

High availability power systems (backup
generators)

In order to know if they had to train their staff to operatewith vaccines, they were asked the following questions:
Was a specific training conducted to comply with SOPs andother specific guidelines defined by vaccine manufacturers?
(They could choose more than one answer)
The answers were as follows:

6

No special trainings were conductedsince our staff is already trained in thehandling of pharmaceutical products
and the operation of Covid-19 Vaccines
was standard

4

Existing internal procedures for thehandling of pharmaceutical products ingeneral were reinforced and employees
were trained in the handling ofpharmaceutical products

3

Special trainings were conducted basedon materials and specific information
received from external sources
regarding the handling of Covid-19
Vaccines3

We developed new activities (different
from the usual ones) that required
the development of new internal
procedures to adapt our operations to
special guidelines established by the
manufacturers of Covid-19 Vaccines

6.

Lessons learned and Recommendations

The experience in Uruguay showed that the logistics
model named as “the Gateway Access Point” is feasible
and efficient. Using an airport as a starting point for
direct distribution to consumption centers eliminates
unnecessary steps, reduces risks, costs and time, andprovides greater flexibility to the entire supply chain.

“The system designed made it possible toreceive, fractionate, prepare and distributethe exact quantities to the entire country
so that vaccination in the most distant cities
began just 10 hours after the vaccines werereceived at the airport from Europe.”
Bruno Guella, Manager Director at MVD Free Airport“Using the airport as a center for storage,
preparation and distribution of ultracold vaccines, including the handling ofindividual vials at extreme temperatures,is pretty unique.”Bruno Guella, Manager Director at MVD Free Airport

A key success factor in this case was that TCU - MVD
Free Airport did not simply limit itself to the role oflogistics operator, providing infrastructure and services,
but became directly involved in the design andimplementation of the distribution system. Its management
team and the contribution of external experts in the field
led to articulation between the public and private sectors,
integration of information systems, and development of
the supply planning system and the balanced scorecard
to monitor its performance.
The Director of Sinae (National Emergency System), Sergio
Rico, considered that the joint efforts “were excellent” andadded: “We all learned about the possibilities that eachone of us had”. Rico explained that Sinae worked withrepresentatives from the Ministry of National Defense andthe transport company DAC to coordinate the distribution
and managed to take the Pfizer vaccines “which were themost complex” to all areas of the country.
The protective capacity installed at the airport, as the only
distribution center, made it possible to save at least one
day in the supply chain, centralize stock management
and provide greater flexibility to schedule changes in thevaccination plan throughout the months.

The search for international support and cooperation to
analyze and learn from the experiences of other countries
helped to avoid mistakes and take advantage of goodpractices. Other actions complemented the initiative of
the “Bringing Vaccines Closer” project launched by TCU- MVD Free Airport in October 2020: the Uruguayan
team contacted scientific advisors and people who
implemented the logistics of Israel’s vaccination plan,
and with the scientists who implemented Pfizer’s Phase
III trial in Argentina.
The integration of the information systems of the different
players involved was essential for planning, executing
and controlling the distribution of vaccines, although
this was not noticed early enough to develop a morerobust system. When the work team began to operatein early January 2021, it focused more on the designof the flow of materials, to the detriment of the designof the information flow. Developing the information
system when the vaccination plan had already started
generated difficulties for some people to schedule their
appointments and the lack of a methodology to define
quotas in each vaccination center, which would allow amore agile and error-free supply scheduling.

19“The most difficult thing was to have thedata to define the delivery of vaccines toeach post. What took most time was toget the information from the vaccination
schedule to flow and give us quality data.
We should have worked on this issueearlier. We started to see the problems
when vaccination started.”Marina Monteiro, Technical Director of CalmetteLaboratory

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The speed with which the vaccination plan was designed
and implemented, and the results achieved were only
possible thanks to the cooperative work between the
public and private sectors, which integrated a teammade up of people with decision-making skills.

“Public-private cooperation allowed us toanticipate needs, develop different scenariosand contingency plans and respondaccording to what the country needed.”
Bruno Guella, Manager Director at MVD Free Airport

20“The Uruguayan population and theiradhesion to the vaccination program was
the basis for us currently having 76% of the
population vaccinated. This was a reflectionof their trust in the government and theMinistry of Health and the decision based on
facts and scientific evidence”
Lic. Jose Luis Satdjian, Vice-Minister of Healthwww.pharma.aero
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