Mike Ryan, the World Health Organization’s health emergencies director, had a conversation recently with his mother, the kind that lots of public health people are having these days, much to their dismay. Ryan’s mother was concerned about one of the Covid-19 vaccines in use in Ireland, where she lives. The one made by AstraZeneca.
Clinical trials had shown the vaccine offered protection against the disease, but less than the vaccine made by Moderna or the one made by Pfizer and BioNTech. Ryan’s mother was worried the vaccine might not be good enough.
Ryan, never one to mince words, decided it was time for a come-to-Jesus chat with his 80-year-old mother. “Whatever vaccine they show up with, you take it,” he told her. “Because that is the best decision you can make on that day for your health.”
That’s a message Ryan and other public health officials are trying to deliver to everyone — but it’s not necessarily one that is being well-received. News coverage and social media posts about clinical trial results are creating a hierarchy of Covid vaccines in the minds of much of the public: “good vaccines” and “bad vaccines.” The former you might try to seek out; the latter might even prompt you to step out of line.
That, health officials say, is a problem.
The concern isn’t just that people will get picky about which vaccine they want, slowing down the task of inoculating enough of the population to blunt the impact of Covid-19. Public health experts also worry a simplified narrative overlooks essential facts — say, that AstraZeneca’s and Johnson & Johnson’s vaccines were being tested in clinical trials after variants of the SARS-CoV-2 virus started to circulate widely, likely reducing their efficacy more than was the case with Pfizer’s and Moderna’s vaccines, the first to be cleared.
The vaccines perceived to be less effective also happen to be ones that may be the best option in rural America or in low-income countries because they don’t require the ultra-cold freezers and complex delivery systems more commonly found in or near major cities.
“I worried that we’re going to have that kind of consumer-driven ‘Oh, is it Moderna? Great! Is it [Johnson & Johnson]? No, thank you, I’ll wait,’” said Alison Buttenheim, an associate professor of nursing and health policy at the University of Pennsylvania, whose research focuses on vaccine acceptance. “That’s just going to delay getting to the coverage that we want to get to.”
In truth, the phenomenon is already playing out, even among some who understand the caveats around when the studies were conducted and the operational benefits of these easier-to-deploy vaccines. STAT asked Emory University immunologist Rafi Ahmed if he would specify a preference should his mother ask for advice about Covid vaccines. Ahmed replied without hesitation: He’d tell her to get one of the messengerRNA, or mRNA, vaccines made by Pfizer or Moderna. “It’s human nature,” he insisted. “It’s common sense.”
Experts say the that problem is likely to worsen with the authorization of more vaccines, each with varying efficacy, dosing regimens (one dose or two), and dose intervals (21 days, 28 days, up to 12 weeks in some cases and places). They also say there are only limited messaging strategies to do something about it.
“I think, right now, the message really has to be that the vaccines that are authorized for use are authorized for use because they will provide significant protection against Covid-19 illness. And if you’re not vaccinated, you have no protection against Covid-19 illness,” said Glen Nowak, director of the Center for Health and Risk Communication at Grady College of Journalism and Mass Communication in Athens, Ga.
Kasisomayajula “Vish” Viswanath, a professor of health communication at the Harvard T.H. Chan School of Public Health, said he is deeply concerned that decisions about where to use some of the vaccines that appear less effective will be viewed through a lens of racial or socio-economic inequality, even if the reasons to offer those vaccines in certain settings make sense from a public health point of view and gets vaccine to those places faster.
“This is going to explode in the near future, I think,” Viswanath warned.
This is not a problem that people in public health anticipated. Virtually no one, after all, expected Pfizer and Moderna, the first vaccine makers to produce clinical trial results, to report such stunning efficacy data, at roughly 95%. Seasoned vaccine researchers —with decades of experience in the often-frustrating field of vaccine development — broke into gleeful giggles when talking about the mRNA vaccines.
For a brief heady period, it seemed like the gods had taken pity on humankind. The Food and Drug Administration quickly issued emergency use authorizations for the two vaccines. Experts including Anthony Fauci, the nation’s leading vaccine official, were predicting multiple vaccines were almost certain to be effective, because they targeted the same protein on the SARS-2 virus.
Then reality set in. The first data on the AstraZeneca vaccine, released in late November, suggested the protection induced by the British-made vaccine was more moderate, somewhere around 62%, depending on the interval between doses.
More recently, clinical trials of two other vaccines have produced results — the Novavax recombinant protein vaccine, based on testing in Britain and South Africa, and Johnson & Johnson’s potential game-changer, a one-dose vaccine.
The Novavax vaccine was nearly 90% effective, except in South Africa, where in the face of a widely circulating variant it was about 60% effective. The efficacy of the J&J vaccine was 66%, though that varied a bit by geography too.
If results of the trials of these vaccines had been the first to be released, the world would have been popping champagne corks. But because the data came after the wildly positive results seen from Pfizer and Moderna, enthusiasm has been muted.
Anna Durbin, a vaccine researcher from Johns Hopkins Bloomberg School of Public Health, noted that most of the trials have focused on the vaccines’ ability to prevent any symptomatic infection — and by that measure there are some differences among the vaccines.
But Durbin, who is running one of the sites for AstraZeneca’s U.S. trial, said many of the infections being detected in the clinical trials are so mild they are only being noticed because trial volunteers are monitored so closely. A report of a sore throat can lead to a Covid test; if it’s positive, that’s a case. By that measure, the differences between vaccines may not prove to be quite as meaningful.
Durbin emphasized that what the world needs is vaccines to prevent severe disease, hospitalizations, and deaths due to Covid. On that front, all of the vaccines tested so far seem to be quite effective.
“I believe that in all the clinical trials that have been done so far, with the seven or eight candidates that we know about, there has been no case of a death or a severe disease with hospitalization occurring in the vaccine group, regardless of which vaccine,” Soumya Swaminathan, the WHO’s chief scientist, said at a press conference last week. “So I think that is clear it is protecting against severe disease.”
That point, however, is getting lost in conversations about the vaccines among ordinary people. So, too, is the fact that the AstraZeneca, Novavax, and J&J vaccines are less expensive than the mRNA vaccines, making them more affordable in developing countries.
The J&J vaccine has another advantage in that is administered in a single dose, which would make vaccinating homeless people much less complicated, to say nothing of people who might otherwise struggle to get time off work to get a two-dose vaccine.
The J&J vaccine is likely going to be the third authorized for use in the U.S.; the FDA’s advisory committee meets to consider it on Feb. 26 and it is widely expected to be authorized by the agency for emergency use within days.
That, experts say, is when the challenge of messaging will likely get harder.
“To me, one of the trickiest things about this is that we are likely to end up with a vaccine — the J&J — that is showing somewhat less effectiveness than these amazing first two that came out of the gate and is also most appropriate for rural settings, low-resource settings, settings without really great freezers,” said Buttenheim.
“And while it would be great … to say, ‘Let’s use J&J in settings where it’s going to be most feasible and appropriate,’ once it’s thought of as the less well-performing vaccine, then it’s like ‘Great, send the [expletive] vaccine to the poor people,’” she said. “There is no easy solution to that. I think from a behavioral science standpoint, the fact that we are anchoring from these 95% effective vaccines is tough.”
The J&J vaccine rollout will be a harbinger of bigger problems to come, Viswanath worries.
“If certain groups in the system get certain kinds of vaccines with differential efficacy, all hell will break loose,” he warned.
Black and Latino Americans have suffered disproportionally higher rates of infection in the pandemic, and are getting vaccinated at lower rates so far than white Americans. “If there is a kind of a differential allocation, even if the reasons are good, that will definitely explode into allegations of racism and mistrust,” Viswanath said. “We already have a lot of mistrust in the system.”
To forestall this, public health officials will need to be fully upfront about which vaccine is being used where and why, Viswanath said. Nowak agreed: “I think transparency is going to be essential. Honesty is going to be essential.”
“The message that what we’re doing is guided by the desire to get as many people vaccinated and protected from Covid-19 illness as fast as possible is the underlying driving motivation,” Nowak said.
Ryan, the WHO official, believes being able and willing to show that vaccine is being allocated through a process that is based on operational needs will help.
“People don’t like it when it’s black-box decision-making,” he said. “Because then they can add the conspiracy theory to it. ‘Ah, you see, the reason why they’re doing that is they don’t like people in rural areas.’ And I can imagine in the U.S. how that might play.”