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The Covid-19 vaccine’s 2 big challenges

The US has authorized a coronavirus vaccine. That doesn’t guarantee a quick end to the pandemic.

A vial of the Covid-19 vaccine produced by Pfizer and BioNTech.
A vial of the Pfizer/BioNTech Covid-19 vaccine at a UK health center on December 8, 2020.
Justin Tallis/Getty Images

America has, finally, authorized a Covid-19 vaccine for the general public. Priority groups — health care workers and people in nursing homes — are now starting to get a vaccine. And if things go right, most of the country could be vaccinated by the end of next summer.

But that’s the caveat: if things go right. The development and authorization of a vaccine don’t mean that the US is guaranteed to get people inoculated quickly, or even that the country is on a certain path to conquer the coronavirus.

Experts caution, instead, that the country still faces two major challenges in its vaccination efforts.

First, the US has to manufacture and distribute a vaccine to more than 300 million people. As Johns Hopkins Center for Health Security senior scholar Crystal Watson told me, “This is going to be the largest mass vaccination campaign that the US has ever attempted.” It’s an effort so big, some experts have compared it to a New Deal. The logistical challenge isn’t just to produce all the vaccine doses required, it’s also shipping and storing them around the US at cold temperatures, and then administering them to people. If each person needs two doses (as is true for the vaccine authorized so far, although one-shot vaccines are in development), the difficulties are doubled.

But even if the US is able to pull off a feat of logistics, a second challenge looms: People will need to be persuaded to get a vaccine. That this will happen is not guaranteed. Polls suggest as many as half of Americans are resistant to getting a Covid-19 vaccine. Those hesitant people will need their concerns addressed, including worries about whether the quick development process sacrificed safety, what common side effects are expected, and what rare side effects may pop up. Doctors and public health officials will also have to communicate why it’s important for people to get a vaccine even if they don’t feel Covid-19 is a threat to them.

Experts caution that how the US deals with both these challenges could determine if Covid-19 remains a widespread problem by late 2021 or even 2022. It’s what will decide whether we get back to normal, and how many lives are saved — or unnecessarily lost — along the way.

On the first challenge, the US has done considerable work. Under Operation Warp Speed, the federal government has helped expedite research into the vaccines and committed to purchasing hundreds of millions of vaccine doses. Federal, state, and local governments now have plans, or are working on plans, for how to widely distribute a vaccine in the next several months.

But on the second challenge, experts say, the US is falling behind. When I asked if the country is prepared on the public opinion side for widespread Covid-19 vaccination, Texas State University medical anthropologist Emily Brunson told me, “No, we’re not.” So far, no real federal education and awareness campaign is underway. “It would have been ideal to begin months ago,” Brunson said.

The good news is that the US is now talking about these problems at all. Several months ago, experts warned a vaccine could take years to develop — and instead, some people are getting vaccinated in the same year that the Covid-19 pandemic took off. We can see a finish line much earlier than even some optimists were expecting.

The objective now is making sure we get through that finish line as quickly and safely as possible.

The first big challenge: Manufacturing and distributing a vaccine

Getting a vaccine out to more than 300 million Americans within months will be like nothing the US has done before. It will require enough raw materials to manufacture the doses and enough factories to produce them. Those doses will then need to be purchased and shipped to all 50 states. The states will then need to distribute the vaccines to different localities, which will have to distribute them at the local level based on need — all while keeping the vaccines safely stored at the right temperature. Health care and communication systems will need to be set up to prioritize people for the first shots and ensure everyone gets a second dose, which the current vaccines require, weeks later.

All of this will have to happen thousands to millions of times throughout the country in a matter of months.

Kendall Hoyt, a vaccine and biosecurity expert at Dartmouth, put this simply: “We need a lot of forward planning.” The White House, along with federal agencies like the Food and Drug Administration and the Centers for Disease Control and Prevention (CDC), will need to coordinate and provide guidance for those efforts.

The task will also require a lot of resources — money — from the federal government. Local and state governments are cash-strapped from dealing with the ongoing economic downturn brought on by the pandemic. It’s not clear that the federal government is doing enough yet: Some officials say states need $8.4 billion to do this work; so far, they’ve gotten $340 million.

Transportation and storage could be particularly tricky for the current vaccines, which will require very cold temperatures to maintain their efficacy. That might require hospitals, pharmacies, and other storage facilities to buy new refrigerators and freezers, or prepare to administer the doses they have as quickly as possible, before they go bad. Particularly for more rural and smaller institutions, this could prove not just logistically difficult but very expensive — and they may only be able to do this with some sort of government support.

Another looming challenge is getting people to get their second dose of a vaccine. It’s well established in the medical literature that people are bad at follow-up appointments — with half of patients or more missing second doses for a similar hepatitis B vaccine regimen. While that might differ with a potentially lifesaving vaccine in the middle of a pandemic, local and health care agencies will need to be ready to aggressively follow up with people to get them to go back for a second dose.

Just as crucially, government and health care agencies will have to ensure those second doses actually are available to people. Without proper planning, supply could run out as people need to go back for their second doses.

These challenges could be especially magnified in historically underserved areas. One of the problems that has come up with coronavirus testing across the country is it can be much harder to get a test in low-income, minority areas. These also, however, are frequently the places hit hardest by Covid-19. Addressing these kinds of disparities — making vaccines available in neighborhoods where it might be harder for public health officials to reach people, or for people to get to the places the vaccines are distributed — will be a major challenge.

Different levels of government should also prepare for likely supply chain problems. These, too, popped up with testing, as testing collapsed in much of the country due to a shortage of vials, swabs, reagents, and other materials. The same thing could play out with vaccines, whether it’s the materials for doses, syringes, dry ice, storage equipment, or another thing entirely. The better prepared different places are, the quicker such problems can be fixed — and the less of a burden they could be on the whole supply chain.

“That is the kind of thing we should expect more and more,” Hoyt said. “There’s going to be a crush in demand. We’ve never had so much demand for needles, syringes, glass vials, and some key raw materials.”

The good news is there has been a lot of work done in this area. The federal government had plans in place to distribute the vaccine within 24 hours of authorization. Many states have already developed plans, and some are even running drills.

The question is whether this is all enough. Before the coronavirus, the US had plans in place for how to handle a pandemic, and officials and experts ran simulations to further prepare. But many of those plans and simulations were based on faulty assumptions — for instance, that the US would easily scale up testing nationally in response to a big outbreak. Infectious disease epidemiologist Saskia Popescu previously told me that in pandemic preparedness simulations she took part in before Covid-19, testing didn’t even come up as a possible problem. “We always assumed we would have widespread testing capabilities,” she said in the spring.

That assumption was disastrously wrong. The CDC initially botched its Covid-19 tests, causing delays in how quickly the process got started. Then, a lack of federal leadership led to preventable supply chain issues, a dearth of coordination across the country that left states fighting for limited supplies, and a failure to follow up on completed tests with adequate contact tracing programs. Months later, America’s testing and tracing capacities are still nowhere near where experts would like them to be.

Those kinds of problems could play out again with a vaccine.

The second big challenge: Persuading the public to take a vaccine

It’s not enough to make and distribute vaccines. “You can have a vaccine that … is fairly effective,” Brunson said. “But if no one takes them, that doesn’t matter.”

The biggest question of all is cost: If a vaccine is too expensive, people simply can’t and won’t get it. The federal government has laid out plans to try to ensure a vaccine is free for everyone, but it’s possible some people, particularly the uninsured or underinsured, could fall through the cracks.

Even if a vaccine is free for everyone, though, there are still other problems.

Polls show a considerable number of Americans — as many as half, based on a previous study by Gallup — may be reluctant or refuse to get the vaccine. That already seems to be changing as preliminary studies suggest the vaccines are very effective: A Pew Research Center survey found 60 percent of Americans said they would get a vaccine in November, up from 51 percent in September. But that’s still a lot of Americans who are at least skeptical.

Experts caution that this skepticism should not be treated as conspiracy theorizing or typical anti-vaxxer sentiments. There are more understandable reasons for some of the current vaccine skepticism — from the fact it’s a vaccine for a new virus to the incredibly quick process behind the vaccines to the massive amount of political polarization that’s overtaken all things Covid-19.

So simply trying to shame people into getting a vaccine isn’t going to work. The public will need to be persuaded — convinced that, as the clinical trials have demonstrated so far, the vaccines are safe and effective.

That will require transparency, acknowledging not just the benefits of the vaccine but also the possible side effects. With the Covid-19 vaccines, some people can expect to get ill in the hours after a dose — nothing life-threatening or dangerous, but symptoms like fatigue, headaches, chills, and muscle pain have been reported. It’s important, experts said, for officials and health care workers to communicate the symptoms are normal, temporary, a sign that the vaccine is actually working, and worth the benefits of avoiding a much more dangerous illness.

There are also more specific concerns for certain demographics that will need answers. Young people may feel like they don’t need the vaccine because they’re at lower risk for Covid-19, but it should be clearly explained to them that young, seemingly healthy people have gotten sick too — one of the worst things about the coronavirus is its effects can be so unexpected. People of color, especially Black Americans, distrust a health care system that frequently discriminates against them and used them for experiments in the past without their consent; those concerns should be taken seriously, while noting a vaccine has been vetted in clinical trials and will save lives.

Then there’s the political divide to overcome. Based on public opinion surveys, Democrats appear more likely to get a vaccine than their Republican counterparts. It will be on Republican leaders, like President Donald Trump and former President George W. Bush (who has already said he’ll get vaccinated publicly) to persuade people that a vaccine is truly safe and effective.

The public also has to be prepared for the unknown. There’s a chance, however small, that the vaccine could produce a rare side effect — people need to be told why that might be an acceptable risk if it’s truly rare, given the massive damage Covid-19 is inflicting on society as a whole. People will also experience health issues completely unrelated to the vaccine after they get vaccinated — that’s natural as hundreds of millions of people get vaccinated — and some may incorrectly link such issues to the vaccine; officials will need to be ready for that, too.

“In the normal course, people will get sick and die from a variety of things, many of which will now be attributed to the vaccine,” Hoyt said. “There needs to be a lot of forward communication about the baseline incidence of various ailments so people don’t rush to judgment. We can expect that people still will, but we need to develop a game plan to respond to that.”

At the same time, it’s important to not make people too confident. There are still questions we don’t know the answers to. Do Covid-19 vaccines actually stop transmission, meaning people can stop masking and distancing relatively quickly, or does it only stop people from getting sick, which will require precautions for longer? Are vaccines’ effects long-lasting, or will people need boosters to refresh their immunity? People need to be told these are major unknowns that should influence post-vaccine lifestyle changes, at least in the short term.

The government could do many things to push people to get a vaccine. It could ensure a vaccine is free. It could do a large, national public education campaign. It could even pay people to take a vaccine, or try to mandate vaccination (though that would raise legal and ethical questions that could further polarize the issue).

But besides federal plans to make Covid-19 vaccines free, there hasn’t been much movement in these areas. “There’s been no promotional campaign at all,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy, told me.

Right now, America can finally see an end to its Covid-19 outbreak. The first task is social distancing and masking to make sure more people make it to the point where they can get vaccinated. But then we need to make sure people actually can and want to get a Covid-19 vaccine.

It’s not clear that the country is up to those challenges.

“If we do [vaccination] right, it can be positive and have long-term implications for public health generally,” Brunson said. “But the opposite is also true: If this is done badly, you run the risk of undermining public trust in your entire public health system.”