I’ll understand if you wish this newsletter would move on from coverage of the vaccination effort and get on to more exciting topics such as whatever insanity Marjorie Taylor Greene uttered recently. (She’s the topic of three of the top four stories on Politico this morning.) But it is not understating it to say that the vaccination effort is the most important thing going on in the United States today. It is also the effort that President Biden and his administration have said is their most important task, and what they ought to be judged upon. On the menu today, why the vaccine distribution is bottlenecked, why pharmaceutical companies can’t simply make more vaccines quickly, and a revealing statistic about which medical workers are declining to get vaccinated right now.
Sorting Through the Vaccine-Distribution Bottleneck
Yesterday morning, I laid out how non-higher-risk Americans were unlikely to start getting vaccinated before May. Yesterday afternoon, health officials in the state of Washington offered a new projected timeline that echoed that grim conclusion. “Phases 2, 3 and 4 of Washington’s COVID-19 vaccine distribution plan were initially expected to begin in May 2021 and extend through December, but the state DOH is now predicting a start date of summer or fall 2021. Health officials have yet to outline who will be included in those phases.”
(Note that Washington’s system has categories such as “Phase 1B Tier 4,” which seems needlessly complicated. Even group “1A” has two tiers. It would be much simpler and easier to understand if each category just got its own number, but I suspect some hotshot communications consultant concluded that “1B Tier 4” sounds better and like a shorter wait than “Group Six.”)
The Biden administration’s proposal to put more vaccine in each vial — creating more doses in each one — will probably help a bit. The rollout of vaccines directly to pharmacies will probably help even more. Starting February 11, CVS will begin to offer COVID-19 vaccinations to eligible populations at a limited number of its pharmacy locations in California, Connecticut, Hawaii, Maryland, Massachusetts, New Jersey, New York, Rhode Island, South Carolina, Texas, and Virginia — and they’re in talks for a similar programs in Indiana and Ohio. (As I noted on Twitter, based upon my past experience with CVS, I expect I’ll get a coronavirus vaccine with a reasonable wait, friendly service, and a 40-foot-long receipt.)
We will have more distribution centers and fewer bottlenecks soon, but will the supply increase at the same pace? Americans are currently getting the Pfizer and Moderna vaccines. The test results from Johnson & Johnson are good enough — preventing death and hospitalization are all that we really need — and they’re expected to submit their vaccine for an emergency-use authorization from the FDA. Americans “could receive their shot of Johnson & Johnson’s vaccine as early as March.” But today’s New York Times cautions that J&J “might be able to deliver only as few as seven million doses before April.”
On January 29, NovaVax submitted the results of its testing study in the United Kingdom of more than 15,000 subjects and concluded it was 89.3 percent effective against the standard SARS-CoV-2 virus and has 60 percent efficacy in preventing mild, moderate, and severe COVID-19 disease in its testing in South Africa — suggesting it works against the South African variant. (If you’re underwhelmed by that 60 percent number, keep in mind the unvaccinated efficacy number is zero.) NovaVax still has to submit its vaccine to the FDA as well, and so this vaccine is expected to arrive in April.
And then there’s the Oxford-AstraZeneca vaccine — usually referred to as just the “Oxford vaccine,” sorry, AstraZeneca — which looked like a leading contender early on in the vaccine development process, and then hit snags during testing. The United Kingdom, among other countries, gave the Oxford vaccine emergency authorization on December 30. But this vaccine will probably be authorized for emergency use in the U.S. in April.
Add it all up, and we should be getting a significant expansion of supply by the time the baseball season gets started. Until then . . . we’re going to have to hobble along as best we can.
You’ll probably be hearing a lot of arguments that amount to “the companies should just make more of the vaccine faster!” Over at Science Translational Medicine, Derek Lowe walks through the process of developing and manufacturing a vaccine, and pours cold water on the arguments that “Pfizer and Moderna could share their design with dozens of other companies who are ready to produce them.” Lowe writes that each step of the process requires . . .
. . . special-purpose bespoke machines, and if you ask other drug companies if they have one sitting around, the answer will be, “of course not”. This is not anything close to a traditional drug manufacturing process. And this is the single biggest reason why you cannot simply call up those “dozens” of other companies and ask them to shift their existing production over to making the mRNA vaccines. There are not dozens of companies who make DNA templates on the needed scale. There are definitely not dozens of companies who can make enough RNA. But most importantly, I believe that you can count on one hand the number of facilities who can make the critical lipid nanoparticles. That doesn’t mean that you can’t build more of the machines, but I would assume that Pfizer, BioNTech, Moderna (and CureVac as well) have largely taken up the production capacity for that sort of expansion as well.
And let’s not forget: the rest of the drug industry is already mobilizing. Sanofi, one of the big vaccine players already (and one with their own interest in mRNA) has already announced that they’re going to help out Pfizer and BioNTech. But look at the timelines: here’s one of the largest, most well-prepared companies that could join in on a vaccine production effort, and they won’t have an impact until August. It’s not clear what stages Sanofi will be involved in, but bottling and packaging are definitely involved (and there are no details about whether LNP production is). And Novartis has announced a contract to use one of its Swiss location for fill-and-finish as well, with production by mid-year. Bayer is pitching in with CureVac’s candidate.
This is all good news, but it’s a long way from that tweet that started this whole post off. There are not “dozens of companies who stand ready” to produce vaccines and “end this pandemic”. It’s the same few big players you’ve already heard of, and they’re not sitting around and watching, either. To claim otherwise is a fantasy, and we’re better off with the facts.
The bad news is that bad weather canceled planned vaccinations in a lot of northeastern states this week. According to the Bloomberg chart, 1.6 million Americans received a shot on Saturday and 1.3 million received a shot on Sunday. That dropped to 1 million Monday and 868,000 on Tuesday, although Tuesday’s figures could be updated.
If Hospital Cafeteria Workers Don’t Want to Get Vaccinated . . .
The amount of worry and discussion about vaccine hesitancy still seems wildly out of proportion compared to the problem of getting the vaccine to people who want it and can’t get it. Every person who declines to be vaccinated is one less person standing in line ahead of those who want it, and who don’t need to be enticed with Waffle House gift certificates.
You’ve probably heard some version of “a surprising number of health-care workers are turning down the vaccine.” But these statistics from a recent article in The New Yorker clarify which health-care workers:
Despite confronting the damage of covid-19 firsthand — and doing work that puts them and their families at high risk — health-care workers express similar levels of vaccine hesitancy as people in the general population. Recent surveys suggest that, over all, around a third of health-care workers are reluctant to get vaccinated against covid-19. (Around one in five Americans say they probably or definitely won’t get vaccinated; nationwide, hesitancy is more common among Republicans, rural residents, and people of color.) The rates are higher in certain regions, professions, and racial groups. Black health-care workers, for instance, are more likely to have tested positive for the virus, but less likely to want a vaccine. (Thirty-five per cent turned down a first dose.) Compared with doctors and nurses, other health professionals — E.M.T.s, home health aides, therapists — are generally less likely to say that they’ll get immunized, and a recent survey of C.N.A.s found that nearly three-quarters were hesitant to get the vaccine.
At Yale-New Haven hospital, ninety per cent of medical residents chose to get the vaccine immediately, but only forty-two per cent of workers in environmental services and thirty-three per cent of food-service workers did. The problem may be most pressing in nursing homes. In December, the governor of Ohio, Mike DeWine, said that sixty per cent of the state’s nursing-home staff had declined the vaccine; in North Carolina, the number is estimated to be more than fifty per cent. According to the C.E.O. of PruittHealth — an organization that runs about a hundred long-term-care facilities across the South—seventy per cent of employees in those facilities declined the first dose.
That article by Dhruv Khullar suggests that with time, this wariness may fade, characterizing the hesitancy as “less outright rejection than cautious skepticism. It’s driven by suspicions about the evidence supporting the new vaccines and about the motives of those endorsing them. The astonishing speed of vaccine development has made science a victim of its own success: after being told that it takes years, if not decades, to develop vaccines, many health-care workers are reluctant to accept one that sprinted from conception to injection in less than eleven months. They simply want to wait — to see longer-term safety data, or at least to find out how their colleagues fare after inoculation.”
Almost 34 million Americans have been vaccinated so far; severe reactions are few and far between, although a decent number of people are reporting chills, fevers, head and body aches after the second shot. As more people see their peers, friends, and relatives getting vaccinated with minimal side effects, they will probably become more willing to get vaccinated themselves. And I cannot emphasize this point enough: At a time when so many elderly and immunocompromised people need the vaccine and can’t get it yet, a healthy janitor or cook who turns it down is actually doing us a favor.
Are food-service workers in hospitals at higher risk of exposure to SARS-CoV-2 than the average person? Sure. But they’re at less risk than those interacting directly with infected patients. It would be preferable if every last hospital employee chose to take the vaccine when given the opportunity. But these workers are generally under age 65 and are probably at lower risk of having a serious or life-threatening reaction to COVID. It would be nice to reduce vaccine skepticism among hospital workers, but at the moment, that’s a secondary problem. Washington State might even classify it as a “1B Tier 4” problem.
ADDENDUM: Yikes. Ramesh notes that in March 2020, Congress appropriated $13.2 billion for an “Elementary and Secondary School Emergency Relief” (ESSER) fund. November 30th, state departments of education had only spent $3 billion out of the $12.8 billion.
America’s schools have a lot of problems at the moment, but a lack of financial support from the federal government is not one of them.