The Big Question: Can a Covid Vaccine Reach Enough People?

(Bloomberg Opinion) -- This is one of a series of interviews by Bloomberg Opinion columnists on how to solve today’s most pressing policy challenges.

Max Nisen: The U.S. is going to have to vaccinate hundreds of millions of people in a short amount of time to bring Covid-19 under control. Various logistical and political challenges complicate that goal. The virus response hasn’t been the best advertisement for America’s public-health infrastructure. Does the country have to start from scratch, or are there existing systems the U.S. can rely on?

Dr. L.J. Tan, Chief Strategy Officer of the Immunization Action Coalition: When H1N1 hit in 2009, we already had a very strong pediatric infrastructure because of Vaccines for Children, the public-private sector partnership to administer vaccines. Our coverage rate in peds is over 95%. The problem is that the adult infrastructure was not in place.

We hadn’t really done as well at vaccinating adults, and that’s not to say we’re doing well now. But the private sector, which is where adult immunizations reside, is actually much more cognizant of the importance of adult vaccines as a result of the last 10 years of effort.

Many health systems have implemented infrastructure to give access to adult vaccines. Some of those are things we’ve talked about for Covid-19, like facilitating vaccinations at alternative locations, using pharmacists, drive-through clinics, no appointment necessary walk-in clinics, occupational health. These are things that were really not looked at 15 years ago but are now becoming commonplace because of the innovations of these systems.

Sometimes when we’re reacting to a crisis we can become a little short-sighted. There is an existing infrastructure that can get vaccines all across the lifespan to the U.S. population. It’s stronger in pediatrics, weaker for adults, but it is an infrastructure that we should not have to reinvent.

MN: How do you prioritize what’s likely to be a limited early supply of vaccine? And after that, how do you avoid the racial and economic disparities that have plagued the Covid response?

LT: We asked almost exactly the same question for H1N1 and during our flu pandemic planning in the mid-2000s. Flu has similar vulnerable populations as Covid-19. In our entire seasonal flu efforts, we have had racial disparities in getting people vaccinated.

With Covid-19, we’ve seen that we have problems with access to health care. But it’s not as if we weren’t previously aware of those kinds of problems.

For pandemic planning [during the H1N1 outbreak], we had a large working group of experts from both the National Vaccine Advisory Committee and the Advisory Committee on Immunization Practices meet very regularly to come up with a priority list for vaccination. It had five tiers. The first tier was health-care workers. We then had the elderly as the next camp, over children. When we went to do a couple of quick focus groups, it became very clear that the elderly, the grandparents, were not going to take the vaccine ahead of their grandchildren. And so, as a result of that feedback, the priority populations were flipped. Children went up because we have to recognize that there’s an ethical and social component to consider.

Second, access. It’s a great question and one that we’ve dealt with for many years. We are very aware that we have multiple factors that impact access to not just vaccines, but health care in general. Covid-19, because of the way it came in and the fact that we didn’t know how to react, exposed a lot of those existing problems of access and health equity.

We need to be very cognizant of how social determinants are going to impact access. You’ve heard of things called food deserts? We need to make sure we don’t have vaccine deserts. We need to ensure we are getting a Covid-19 vaccine to locations that are accessible to minority populations and disparate, underprivileged populations. We need to make sure that we’re considering that all in our distribution plan.

MN: What do you worry might get in the way of a successful Covid vaccination effort?

LT: I always worry, What if you build a vaccine and they don’t come? Even with H1N1, we had some policy missteps, and the reason for that was because of the timing of the pandemic and the arrival of the vaccine after the peak. And so a lot of people said, “Well, you know, why should I use the vaccine?” There were some negative repercussions on safety because one of the vaccines that was used in Europe actually induced narcolepsy. That kind of tainted that process a little bit.

With Covid-19, timing for the vaccine isn’t going to be the issue. But we do have a small but very vocal anti-vaccine coalition out there. And I worry that they’re going to be able to manipulate the narrative against a Covid-19 vaccine. They’ve aligned themselves with the political nature of some of the ways we’re dealing with Covid-19, which is troubling. The idea of mandatory mask-wearing, and how you have anti-mask people saying its personal autonomy, it’s my rights, you can’t make me wear masks, etc. — well, that coincides very nicely with what the anti-vaccine people say: “It’s my body. It’s my rights. You can’t make me take a vaccine.”

So I worry that when there is a vaccine, people are just going to get inundated with some of this negative information and they may not show up.

The other thing I worry about is reaching high-risk populations. For example, we know that if you’ve had chronic heart disease and you get influenza you have an eight-fold higher risk of heart attack, yet we don’t vaccinate people with cardiovascular disease with the flu vaccine the way we should. We need to figure out how to reach these populations we have not been good at getting to in the past.

MN: How do we overcome people’s hesitancy about getting the vaccine?

 LT: If we do a really good job with the transparency of our communication of what we do know and don’t know, I think it’s going to defuse a lot of the hesitancy.

As I keep telling people, the way out of the pandemic is a vaccine. You’ve got to get to herd immunity, and if you look at the prevalence rates across the world, we’re a long way from there. In order to get out of it, we need to get through it. Getting through means all the things we’re already doing, social distancing, washing your hands, sanitizing your hands, wearing a mask, all of that. I think there’s a lot of demand for that vaccine to get us out of it, because the getting through part is really, really hard.

We’re not dealing with vaccine technology that’s never been done before, despite what anti-vaccine people would like to tell us. Even the mRNA technology, even the adenovirus technology, while they’ve never been used to produce a licensed vaccine, they have been used to create vaccines. There’s a wealth of research and development between those vaccines and those platforms. So we need to make sure that we can tell that to the public in a very good and transparent way.

We also need to reassure the public that the United States has one of the best, if not the best, vaccine-safety surveillance systems in the world. We have a system that’s been in place for 20-plus years. There’s VAERS, the Vaccine Adverse Events Reporting system and VSD, the Vaccine Safety Datalink, all of these surveillance and testing mechanisms out there to look at vaccine safety. So we have this incredible surveillance system to take over once the vaccine gets approved. I think we need to make sure the public is aware of that.

The final point is that we need to be very clear about what we don’t know. Something we’re going to continue to look at is long-term vaccine effectiveness, because obviously we’re not going to have 10, 15, 20 years of clinical-trial data. We need to be very clear about all of this and to be upfront so that the public is reassured that this vaccine is safe and effective and will continue to be safe and effective.

MN: The people who will be doing the vaccinating are an underrated part of the process. How do we support them?

LT: The providers first need to feel assured that the vaccine is safe and effective. It can be a flyer, a tip sheet, it can be the data itself, whatever comes out of the clinical trials and ultimately is used by the Food and Drug Administration for approval. As advocates we need to make sure that our providers have that in the back of their heads so that they can be really positive about vaccination, because their recommendations will be critical for getting vaccines into the arms of the public.

We also need to make sure that the providers are aware of the administrative work that has been done so that they will get paid. Granted, the vaccine itself is free, but there is cost incurred for giving the vaccine. We need to assure the providers that’s been taken care of and they will get paid.

The third thing is we need to be sure target populations know who the providers are. There will be populations that will be targeted for prioritization at different levels. We should not leave it to the provider to have to sort too much of that out. The provider should feel very comfortable not having to convince people. If we educate the public well, the provider should be able to just give the vaccine. There shouldn’t be a lot of conversation back and forth between the patient and provider. If we’re going to vaccinate about 300 million people, we had better be able to do it rapidly.

MN: How did you end up focusing on public health and vaccines specifically?

LT: My journey is probably different from many. I’m a basic scientist by training, a microbiologist. That’s what my Ph.D. is in. I love basic research, and I understand immunology. But I ended up leaving basic research at Northwestern University Medical School to join the American Medical Association because I have a strong interest in policy as well. And at the AMA, I was given the opportunity to actually do translational science, to take basic research and convert it to clinical knowledge that could be used to guide policy.

MN: It's sort of a strange moment to be a public-health professional. This is what your profession was made for, yet the public-health response to Covid in the U.S. has been rocky, to say the least. What can we do next time around to make sure the response is smoother?

LT: I have colleagues who have been in the field of public health and epidemiology and preparedness even longer than I have. And they’re grieving because you are right. They say, you know, we trained and practiced and prepared ourselves for 30 to 40 years in our careers for exactly this moment, right? And instead of shining and being allowed to shine, they’re not. They’ve neither shone, nor been allowed to shine. I think this is hopefully going to be the subject of a huge retrospective examination so that we are prepared for future pandemics.

I think national leadership is required for pandemic preparedness. In 2009, with H1N1 we had a national agency in the Centers for Disease Control that was able, for whatever reasons, to lead. I remember [deputy CDC director] Dr. Anne Schuchat — I think she’s just an awesome spokesperson — in front of the TV and cameras every day giving briefings. I remember when the anthrax attacks happened back in 2001 and Dr. Julie Gerberding was at the CDC at that point and calmly, patiently went up in front of the media to lead the public-health response to anthrax. I think that’s what we did not have this time around.

MN: One somewhat unique aspect of Covid is the sheer breadth of possible outcomes. It’s really bad for a lot of people and causes no symptoms in others. How might that affect vaccination efforts?

LT: One of the things that I would say very clearly is that there’s a lot more to discover about Covid-19. Why gamble, right? I just think it doesn’t make sense to say, “Well, I’m not in one of those currently identified high-risk groups, I’m not going to get vaccinated.” For example, in H1N1 we found out that obesity was a high risk for mortality and morbidity, and that was actually added into the risk conditions later on.

We’re still an altruistic society, and this is an incredibly contagious virus. This is the other difference, right? The way this thing has continued to spread, it’s been remarkable. Vaccination will help us reduce that transmission rate. And that means protecting your friends, protecting your family, protecting your community. That’s something that we can do with this vaccine.

I think that’s something we need to keep working on, to help people understand that that it’s not just about themselves, just like social distancing is not just about yourself. It’s about protecting the community around you as well. I think we need to reignite that American altruism that we’re famous for. Hopefully that will overcome any political tribalism that we’e seeing.

MN: So what’s the bottom line? What are the most important things we need to do to get to the other side of the pandemic and do better next time?

LT: Elevation of evidence and science in decision making.

National leadership by public-health authorities is required.

We need to get through it to get out of it. In order to get through it, we need to do all the things we’ve been doing for the last six months. It’s social distancing, masking, immaculate hand hygiene, don’t touch your face. Take whatever we’ve learned and built and sustain it.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Max Nisen is a Bloomberg Opinion columnist covering biotech, pharma and health care. He previously wrote about management and corporate strategy for Quartz and Business Insider.

©2020 Bloomberg L.P.