Mike Ryan, director of health emergencies at the World Health Organization, recently had a conversation with his mother, the kind that many public health people are currently having, much to their despair. Ryan’s mother was concerned about one of the Covid-19 vaccines in use in Ireland, where she lives. AstraZeneca’s.
Clinical trials have shown that the vaccine offers protection against the disease, but less than that of Moderna or Pfizer and BioNTech. Ryan’s mother was concerned that the vaccine might not be good enough.
Ryan, who never measured words, decided it was time for a chat about coming to Jesus with his 80-year-old mother. “Whatever the vaccine they come up with, you get it,” he said. “Because this is the best decision you can make that day for your health.”
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This is a message that Ryan and other public health officials are trying to convey to everyone – but not necessarily a message that is being welcomed. News coverage and social media postings about clinical trial results are creating a hierarchy of Covid vaccines in the minds of a large part of the public: “good vaccines” and “bad vaccines”. The first one you can try to look for; the latter can even get you out of line.
This, health officials say, is a problem.
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The concern is not just that people are demanding about the vaccine they want, delaying the task of inoculating a sufficient number of the population to lessen the impact of Covid-19. Public health experts also fear that a simplified narrative will ignore essential facts – say, that AstraZeneca and Johnson & Johnson vaccines were being tested in clinical trials after variants of the SARS-CoV-2 virus began to circulate widely, probably reducing their more effective than the case of Pfizer and Moderna vaccines, the first to be released.
Vaccines perceived as least effective are also those that may be the best option in rural America or in low-income countries, because they do not require deep-frozen freezers and complex application systems, most commonly found in or near major cities.
“I was worried that we would have that kind of consumer-oriented thinking ‘Oh, is it Modern? Great! That’s it [Johnson & Johnson]? No thanks, I’ll wait, ‘”said Alison Buttenheim, associate professor of nursing and health policy at the University of Pennsylvania, whose research focuses on vaccine acceptance. “This will only delay getting the coverage we want.”
In fact, the phenomenon is already happening, even among some who understand the warnings around when the studies were conducted and the operational benefits of these vaccines easier to implement. STAT asked Emory University immunologist Rafi Ahmed if he would specify a preference if his mother asked for advice on Covid vaccines. Ahmed replied without hesitation: He would tell her to get one of the messengerRNA, or mRNA, vaccines manufactured by Pfizer or Moderna. “It’s human nature,” he insisted. “It’s common sense.”
Experts say the problem tends to get worse with the authorization of more vaccines, each with varying efficacy, dosing regimes (one or two) and dosing intervals (21 days, 28 days, up to 12 weeks in some cases and locations) . They also say that there are only limited messaging strategies to do something about.
“I think, now, the message really has to be that vaccines that are authorized for use are authorized for use because they will provide significant protection against Covid-19 disease. And if you don’t get vaccinated, you won’t have protection against Covid-19 disease, ”said Glen Nowak, director of the Grady College Health and Risk Communication Center for Journalism and Mass Communication in Athens, Georgia.
Kasisomayajula “Vish” Viswanath, professor of health communication at the Harvard School of Public Health TH Chan, said he was deeply concerned that decisions about where to use some of the vaccines that seem least effective would be viewed through a lens of racism or socio – economic inequality, even if the reasons for offering these vaccines in certain places make sense from the point of view of public health and take the vaccine to those places more quickly.
“This is going to explode in the near future, I think,” warned Viswanath.
This is not a problem that public health people anticipated. After all, practically no one expected Pfizer and Moderna, the first vaccine manufacturers to produce clinical trial results, to report such impressive efficacy data, at approximately 95%. Experienced vaccine researchers – with decades of experience in the often frustrating field of vaccine development – burst out laughing when talking about mRNA vaccines.
For a brief dizzying period, it seemed that the gods took pity on humanity. The Food and Drug Administration quickly issued emergency use permits for both vaccines. Experts, including Anthony Fauci, the country’s top vaccine officer, predicted that several vaccines would be almost safe because they targeted the same protein in the SARS-2 virus.
Then reality settled in. The first data from the AstraZeneca vaccine, released in late November, suggested that protection induced by the British vaccine was more moderate, around 62%, depending on the interval between doses.
More recently, clinical trials of two other vaccines have produced results – the recombinant protein vaccine Novavax, based on tests in Britain and South Africa, and the potential game changer for Johnson & Johnson, a single dose vaccine.
The Novavax vaccine was almost 90% effective, except in South Africa, where, in the face of a widely circulating variant, it was about 60% effective. The effectiveness of the J&J vaccine was 66%, although it also varied slightly by geography.
If the results of testing these vaccines had been the first to be released, the world would be bursting with champagne corks. But as the data came after the extremely positive results of Pfizer and Moderna, the enthusiasm was muted.
Anna Durbin, a vaccine researcher at the Johns Hopkins Bloomberg School of Public Health, noted that most tests focused on the vaccines’ ability to prevent any symptomatic infections – and by that measure there are some differences between vaccines.
But Durbin, who runs one of the AstraZeneca study sites in the United States, said that many of the infections detected in the clinical trials are so mild that they are only being noticed because the study volunteers are closely monitored. A report of a sore throat can lead to a Covid test; if it is positive, it is a case. By that measure, the differences between vaccines may not be as significant.
Durbin emphasized that what the world needs is vaccines to prevent serious illnesses, hospitalizations and deaths caused by Covid. In that respect, all vaccines tested so far appear to be quite effective.
“I believe that in all clinical trials conducted so far, with the seven or eight candidates we know, there has been no case of death or serious illness with admission to the vaccine group, regardless of which vaccine,” said Soumya Swaminathan, chief scientist at WHO at a news conference last week. “So I think it’s clear that it protects against serious illness.”
This point, however, is getting lost in conversations about vaccines among ordinary people. The same is true of the fact that AstraZeneca, Novavax and J&J vaccines are cheaper than mRNA vaccines, making them more accessible in developing countries.
The J&J vaccine has another advantage because it is administered in a single dose, which would make vaccinating homeless people much less complicated, not to mention people who would otherwise have difficulty getting a work permit to receive a vaccine two doses.
The J&J vaccine is likely to be the third vaccine authorized for use in the United States; the FDA advisory committee meets to consider it on February 26 and is widely expected to be authorized by the agency for emergency use within a few days.
It is there, experts say, that the messaging challenge is likely to become more difficult.
“For me, one of the most complicated things about this is that we will probably end up with a vaccine – J&J – which is showing a little less effectiveness than the first two incredible ones that have emerged and are also more appropriate for rural applications, configurations of few features, configurations without really big freezers, ”said Buttenheim.
“And while it’s great … to say, ‘We will use J&J in environments where it will be most feasible and appropriate’, once it is considered the lowest performing vaccine, then it’s like ‘Great, send [expletive] vaccine for the poor, ‘”she said. “There is no easy solution for this. I think that from the point of view of behavioral science, the fact that we are anchoring from these 95% effective vaccines is difficult. “
The launch of the J&J vaccine will be a harbinger of bigger problems to come, Viswanath worries.
“If certain groups in the system receive certain types of vaccines with differentiated efficacy, hell will explode,” he warned.
Black and Latino Americans have suffered disproportionately higher rates of infection in the pandemic and are being vaccinated at lower rates so far than white Americans. “If there is a type of differential allocation, even if the reasons are good, it will certainly explode on allegations of racism and distrust,” said Viswanath. “We already have a lot of suspicion in the system.”
To avoid this, public health officials will need to be completely direct about which vaccine is being used, where and why, said Viswanath. Nowak agreed: “I think transparency will be essential. Honesty will be essential. “
“The message that what we are doing is driven by a desire to vaccinate and protect as many people from Covid-19 disease as quickly as possible is the underlying motivation,” said Nowak.
Ryan, the WHO official, believes that being able and willing to show that the vaccine is being distributed through a process based on operational needs will help.
“People don’t like it when it comes to decision making in the black box,” he said. “Because then they can add the conspiracy theory to it. ‘Ah, you see, the reason they are doing this is that they don’t like people in rural areas.’ And I can imagine in the US how it can work. “