The three of us have worked in global health for our whole careers, and we are eternal optimists who believe that by using science we can change things for the better. While 2020 has been a tumultuous year, we all have good reasons to be optimistic. One reason is that over the course of the year, COVID-19 vaccine development has progressed faster than for any other pathogen in history, with unprecedented investments in scientific discovery and manufacturing capabilities. This has led to 234 vaccine candidates, 10 vaccines being tested in a Phase III trial for safety and efficacy, and one complete Phase III trial that shows great promise for providing some protection.
Still, there is a lot that we do not know about the vaccines: how effective they will be over time, how safe will they be, whether vaccinated people can still transmit the infection, how long it will take to have enough to vaccinate the population, when exactly they will be ready, and how willing people will be to accept them. The situation is much more complex than most headlines acknowledge. While Pfizer and BioNTech, for example recently, instilled hope with their vaccine appearing to be 95% effective and Moderna’s vaccine, 94.5% effective, we need to continue to collect information for a longer period of time to ensure the protective effect lasts, to monitor their safety, and to understand their impact on transmission. Some side effects are very rare, even in large samples (the trials together enrolled nearly 75,000 people), and others may not show up immediately and take time to detect. Phase 4 post-marketing studies must continue to collect information to help us learn more about these unknowns. We also have a lot of work to do to ensure we have the right systems in place to deliver the vaccine effectively. Some vaccines need to be kept in 80-degrees-below-zero freezers and the mRNA vaccines discussed require a two-dose course separated by several weeks. We still have a lot more to learn about this vaccine and how to get it to people.
In addition, it is unclear exactly who will get the scarce initial supply. The Centers for Disease Control and Prevention in Atlanta and the National Institutes of Health requested the National Academies of Science, Engineering and Medicine (NASEM) form a committee to produce a consensus study to assist policymakers in the U.S. and globally in planning for equitable allocation of COVID-19 vaccines. One of us, William Foege, co-chaired this committee with Helene Gayle and synthesized input from experts in ethics, infectious diseases, epidemiology, economics, and many other fields. The group had to grapple with tough questions: is the most important aim preventing deaths? Preventing infection? And how do we balance equity, efficacy, and efficiency? The research and debates led to a Framework for Equitable Allocation that suggests several phases of vaccine delivery:
- 1A: high-risk workers in health facilities and first responders
- 1B: people with significant comorbid conditions and people living in congregate care settings
- 2: critical workers in other high-risk settings (public transit, grocery stores, etc.); teachers and school staff; people with moderate comorbid conditions; all older adults; people in homeless shelters or group homes; and incarcerated people or staff who work in jails
- 3: young adults; children; and the remaining critical workers.
- 4: anyone residing in the United States who didn’t have access to vaccines in prior phases.
Georgia’s state plan closely mirrors this suggestion, with some detail added to the categories.
When we took these recommendations, looked at how many people qualify for each phase, and how many vaccine doses will be available at the outset (data and visualization available at https://covid19vaccineallocation.org), it is clear that in the next few months we will not have enough vaccines for even those in the first phases. In Georgia, it is likely that initially there will only be enough vaccine for about 10% of the high-risk health workers, first responders, and those with preexisting conditions or living situations that make them vulnerable.
This means the vaccine, when it is approved and distributed, will be added to, but not replace the public health measures we know work. Even if the new vaccines turn out to be 95% effective in preventing illness and to be safe, we will still all be vulnerable. When a vaccine is 95% effective, there isn’t much room to make it more effective. However, no one will know if he or she is in the 5% not protected; or if once vaccinated, people can still transmit disease without showing symptoms; therefore, even the vaccinated must continue to wear a mask, avoid gathering, and keep their distance.
The problem of 50% vaccine hesitancy compounds the problem. When people refuse to get vaccinated, they don’t increase just their own risk, but they increase the risk to the most vulnerable parts of the population. There is a lot of work to be done to engage communities, help people become vaccine literate, and restore some of the trust that has been lost.
With case counts reaching never-before-seen levels around the country, pandemic fatigue setting in, and the holiday season coming, we need to act now. We cannot wait idly by for the vaccine to save us. Too many people are dying. Too many jobs are being lost. We cannot afford to wait 60 days until the new administration takes office and implements new policies. The Biden administration has already convened a COVID-19 Task Force that can develop a strategy and policies that state, territorial and local health officers and tribal councils can rally behind to stop the holiday massacre that threatens to sweep the country, while preparations are made for vaccine delivery.
Even though changing human behavior is not as neat and tidy as the biological science that takes place in a laboratory, they are effective when applied. Still the U.S. Marine Corps has shown in San Diego that public health measures, even without a vaccine, can allow normal activities while protecting marines. As one said, “It simply requires discipline.”
We know so much more about what we can do as leaders and as individuals to prevent continued tragedies than we did nine months ago. And we must put this evidence into action. Social scientists can help us understand why the interventions that work to prevent the spread are not being practiced more widely. Theoretically, better information on transmission and risk reduction behaviors means we should be able to enjoy better lives with more safety, more relief and more connections. We also know that we need to start now a major effort to identify trusted people who can make the case for prevention to each segment of society, especially those most hesitant to use life-saving vaccines.
Being concerned doesn’t mean we can’t remain optimistic. There are good reasons to be optimistic. We know that eventually there will be enough vaccines for everyone, and if we all act together to keep ourselves and our communities healthy -- by keeping our masks on, maintaining physical distance and following guidelines -- it will not be like this forever.
With the vaccines on the way and our resolve to each do our part, we can ensure a better future for all of us.
Julie Rosenberg is an assistant director at Ariadne Labs and deputy director of the Global Health Delivery Project at Harvard University. Mark Rosenberg, M.D., is president emeritus of The Task Force for Global Health and retired as assistant surgeon general after working 20 years at the CDC. He is also Julie Rosenberg’s father. William Foege, M.D., is a former director of the CDC, a university professor emeritus at Emory, and recipient of the Presidential Medal of Freedom.
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