With the latest (mostly) good news about the effectiveness of a COVID-19 vaccine from AstraZeneca, there’s a chance that Americans will soon have cheap or cost-free access to no fewer than three different immunity-inducing shots for the novel coronavirus.
But there’s a point at which all this abundance could become a problem—or at least get confusing. Each vaccine has its own production, shipping, and storage requirements, as well as dosing guidelines. Sorting out which hospitals, clinics, and pharmacies get which vaccine and when—and then administering not just one but two injections to hundreds of millions of Americans—is a huge undertaking. Suffice it to say you almost certainly will not be in a position to have your pick from a vaccine menu.
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New York pharma Pfizer and rival Moderna in Massachusetts are closing in on emergency-use authorization from the U.S. Food & Drug Administration (FDA), an initial step toward approval for widespread use that could come within weeks for both companies.
On Monday, U.K. drug-maker AstraZeneca announced early results from large-scale phase 3 trials of its own vaccine. The company could apply for emergency-use authorization soon.
Green lights from the FDA will set in motion what experts have described as one of the biggest public health campaigns in U.S. history.
The government is buying hundreds of millions of doses that it will feed into existing private sector distribution networks for shipment to health-care providers, which will then administer them to the public at low cost or free, according to the U.S. Centers for Disease Control and Prevention. (The government is paying for the doses themselves, but some health-care providers may charge a small administration fee.)
In the meantime, the government, industry, and health-care providers should be pushing one clear message to the public, experts said: whichever vaccine you get, you need two shots to have a chance at immunity.
The stakes couldn’t be higher. With the onset of winter—with its lethal combination of denser, more transmission-friendly air, crowded indoor spaces, and holiday travel—record numbers of Americans are catching the respiratory novel coronavirus, portending a huge spike in both hospitalizations and deaths in coming weeks. In addition to the one we already have.
The common goal of the health-care and pharmaceutical industries and the U.S. government will be to match vaccines with communities in a way that gets as many people as possible fully vaccinated as quickly as possible.
To that end, Americans are lucky to have a mix of vaccine types at their likely disposal, experts said. The vaccines from Pfizer and Moderna are genetically engineered “messenger-RNA” vaccines that require careful handling and cold storage. But at more than 90 percent effectiveness, according to early data, they’re highly potent.
By contrast, AstraZeneca’s vaccine is a more conventional product based on a chimpanzee cold virus. At an average effectiveness of 70 percent, depending on the size of the dose, it’s somewhat less effective than the Pfizer and Moderna vaccines, and the company is under fresh scrutiny over its trial methodology and transparency.
One thing that vaccine candidate has going for it: it doesn’t require the same careful handling.
Those are some of the factors that the CDC—and, later, buyers at hospitals, pharmacy chains, and other health-care providers—will weigh as it decides which vaccine, and how much of it, to send to a particular community.
The feds are buying hundreds of millions of doses, but could face stiff competition for some vaccines from foreign health-care providers. “It’s a free market,” Jeffrey Klausner, a professor of medicine and public health at UCLA who previously worked at the CDC, told The Daily Beast.
Regardless, supply will be limited at first. Experts said up to 70 percent of Americans might need to get vaccinated in order to achieve population-level immunity. That’s 229 million people. All three leading vaccines from Pfizer, Moderna, and AstraZeneca require two doses. Leaving aside spoilage, that works out to a staggering 458 million doses.
Neither Moderna nor AstraZeneca responded to a request for comment. A Pfizer spokesperson told The Daily Beast, “We are very confident in our ability to distribute large quantities of our potential COVID-19 vaccine to customers with different infrastructures in all parts of the United States and all markets across the globe.”
All the major vaccine-makers have been trying to get a head start on production, each with big boosts from Operation Warp Speed, the federal government’s $13-billion vaccine-accelerator.
The feds dropped $2 billion to pay for the first 100 million doses of Pfizer’s vaccine and $1.5 billion for Moderna’s first 100 million doses. The government has pledged $1.2 billion to help AstraZeneca produce 300 million doses through next year.
Those orders alone could produce enough doses to vaccinate most Americans. But manufacturing will take time. By the end of the year, Pfizer expects to make just 20 million doses for health-care providers in the United States. Moderna also hopes to make 20 million doses for U.S. customers.
In the same timeframe, AstraZeneca expects to produce 4 million doses for the American market.
That’s enough for just 22 million Americans initially. State health authorities will determine who gets those first doses, but the federal government is recommending statehouses prioritize frontline health workers and vulnerable populations such as nursing-home residents.
It could be April before most Americans have access to a vaccine, according to Anthony Fauci, the longtime director of the U.S. National Institute of Allergy and Infectious Diseases.
For each immunization campaign, the CDC’s experts get together with experts from the National Academy of Science and health officials from U.S. states and territories—plus industry representatives and U.S. Defense Department planners. Together, they craft a plan for distributing vaccines.
Up to this point, the planning for COVID has focused on ensuring there’s enough cold storage for the initial batches of Pfizer and Moderna’s vaccines, a U.S. Department of Health and Human Services spokesperson told The Daily Beast. Planning should expand as FDA approval looms nearer.
Usually, the CDC’s vaccine plans are optional for the health-care providers, such as hospitals, that actually administer vaccines. But the government’s outsized role in the coronavirus pandemic—it’s paying for most of the required doses, after all—gives it more power to bend the private sector to its will.
So far, industry seems to be playing ball. CVS, one of America’s biggest vaccine-providers, is upgrading its pharmacies to accommodate a variety of COVID vaccines, Larry Merlo, CEO of CVS Health, told Forbes. “When that vaccine is available and we get the call—‘Are you ready?’—we are going to be in a position to say, ‘Where do you want us to go?’”
CVS didn’t respond to a request for comment.
Each vaccine lends itself to a particular market. Experts told The Daily Beast the volatile but potent mRNA vaccines could be the favorites in hard-hit cities with lots of big hospitals and extensive logistical infrastructure. The less powerful cold-virus-based vaccine from AstraZeneca might be a better fit for low-income rural areas lacking cold storage.
But there’s a wrinkle. Because it’s relatively inexpensive at just $4 per shot, the AstraZeneca vaccine could be in high demand in poorer countries. (Pfizer’s shot costs $20. Moderna’s, around $15.) Potential big orders for AstraZeneca’s vaccine from providers in India, Africa, and South America could squeeze supply, making it hard for U.S. providers to get their hands on large quantities of the same vaccine at first.
For that reason, plus Pfizer and Moderna’s head starts, the mRNA vaccines could be the most widely available in the United States early on. Still, there are important differences between the two that could further result in sorting them geographically.
Pfizer’s vaccine needs to be kept at -100 degrees Fahrenheit—a daunting challenge for smaller providers. Moderna’s vaccine keeps at just four degrees below zero. “I assume we will use the Moderna vaccine to get to hard-to-reach places in the U.S., particularly rural and poorer areas,” Lawrence Gostin, a Georgetown University global health expert, told The Daily Beast.
“Each vaccine approach comes with trade-offs,” added Cynthia Liu, a vaccine expert at CAS, an Ohio science information firm. AstraZeneca’s vaccine is marginally less effective than the Pfizer and Moderna vaccines, meaning more people might need to get dosed in order to get to that 70 percent threshold for population-wide immunity.
Potential foreign demand for the AstraZeneca vaccine, plus the refrigeration requirements of the Pfizer and Moderna vaccines, are probably the biggest factors shaping vaccine-distribution in the United States in coming months.
All three vaccines pose a daunting administrative challenge owing to their two-dose requirement. Generally speaking, you get an initial shot, then a booster two or three weeks later. Immunity is unlikely without the booster.
“How systems will remind someone to get a second shot in the specified amount of time, and how it will make sure it is the same one, is going to be important,” Jennifer Reich, a sociologist at the University of Colorado Denver specializing in vaccination, told The Daily Beast.
U.S. Army Lt. Gen. Paul Ostrowski is leading government efforts to link up existing medical databases in order to help track COVID vaccinations.
Even so, there’s a big risk of people blowing off the booster and still thinking they’re safe from COVID. “It will be critical to avoid confusion,” CAS information scientist Angela Zhou told The Daily Beast.
Experts said the government and industry need to get to work now making sure hundreds of millions of Americans understand that they’re going to need two shots of whichever vaccine their local clinic or pharmacy has on hand.
Which vaccine that is will likely have a lot to do with where they live.
