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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.”

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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.

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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 that the 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.”

  • Does anyone around here remember the 1976 Swine Flu vaccine fiasco in the US?

    Or kept on top of the latest CDC VAERS adverse response case statistics? Sobering reading.

    Absolutely everything I have read in the published literature indicates that the very premature rollout of SARs CoV 2 vaccines will be an even bigger fiasco that the 1976 flu shot debacle. There is are very good reasons for the typical 4 to 6 years FDA 501(1)(b) approval timeline. And if you read the literature for previous HCOV vaccine candidates over the last 20 years and why they failed I see no reason why any of the current mass inoculation vaccines would actually have passed a proper FDA 501(1)(b) approval process in their current configuration.

    There is absolute no reason to believe that the current experimental SARs Cov 2 vaccines will be any more effective than any of the current Influenza vaccines. In fact all the substantive evidence is for a much lower effectiveness for the same kind of limited timescale. The numbers are not that great.

    I fear that the current rush to roll out mass vaccinations using experimental vaccines of very limited effectiveness for purely political reasons will eventually turn out to be the biggest single public health disaster of the modern era. Doing irreparable harm to the reputation of all the other vital vaccines which are so important to the good health of so many and which have saved so many lives in the last few generations.

    Just look at the damage one crank paper in The Lancet did to childhood vaccination rates. With such serious long consequences. So just image the reputational damage that will be done to public health vaccinations once the story comes out that current SARs CoV 2 vaccines will have little or no positive effect in the high risk population of older / sick people. Just like with the Influenza vaccine. Vaccines like those need a strong immune system to work against. But with a vaccine adverse reaction motility rate about 70x the Influenza vaccine and looks like treble that for the > 70.

    I am very pro vaccination. But only when the vaccines have passed the full 501(1)(b) approval process and all the relevant multi-year datasets are available and have been properly analyzed. Not rushed out purely for the purpose of political expediency.

    • I remember 1976 quite well.
      The swine flu fiasco was a big factor in why Gerry Ford was not re-elected.

  • Well all over the world , i have never heared anyone looking at possible errors of spike protein translation in the ribosomes….when in fact even in normal protein translations errors does occur resulting to 3 possibilities: that of catastrophic outcome for a phenotypic disease, the missence protein may desintigrate or it can be advantageous for the cell….how long shall be the observation period of long term effects can be somewhere between 5 to 20 years??? That is to consider the number of years for any disease to progress and manifest after a gene error occurs unless the cell harboring the genetic errors eventyally undergoes apoptosis and no daughter cells survive after each cell cycle….errors can start mutation, polymorphism, or may create new variants….can be harmful or not…..but by enlarge, i aggree with vaccination it is our public mandate to protect…of course any long term effects i believe still outweights the best outcomes of vaccination…nothing is perfect it is normal to have untoward effects ….

    • From a public health point of view, the main fact is that a small outbreak presents a smaller number of possible mutations, but a large outbreak provides more opportunities for the virus to evolve.
      Once nCoV got into the general population, it was only a matter of time before we had 100,000,000 cases, which would be inevitably followed by mutations.
      Oh, I’m sorry, the word “mutation” is verboten; I mean to say “variation” 😐

  • Any day, a variant that is not susceptible to any of these wonderful vaccines may appear. The worst case, a possible one, is the end of human life. We must DPA frozen food transport trucks, every vaccine making facility, every doctor, dentist, veterinarian and their staffs and offices on 12 hour shifts. We must have everyone vaccinated by May 31st.
    Grocery freezers should be DPA’d for vaccine storage. Our current tepid approach to an apocalyptic threat is mind boggling.

  • After all these words , tell me by vacine J&J, Moderna, etc etc , HOW MANY PEOPLE AND FOR HOW LONG DID EACH OF THESE GET TESTED !!!! THAT HAS NEVER BEEN TOLD – and what nations tested what and for WHO?????
    Give us a LIST EASY TO READ and NOT BLAH BLAH, just cold hard facts in a simple list –

    example- J&J – in USA tested and 8 people for 6 months = results??? etc etc? Can you do that instead of a lot of words? by names of company and place and how many tested and for how long ? CAN YOU DO THAT !!

  • I have no knowledge about whether the effectiveness numbers are biased according to the time and sample location of testing, or if they were how much. This could just be a tempest in a teapot. But consider the alternative. Suppose the mRNA vaccines are more effective, what then?

    Yes, for any given individual on any given day, taking the less effective vaccine is way better, individually and socially, than spurning it, but pull back from that decision and consider the larger social pattern. If it is indeed true, as Viswanath says, that low income and minority people are disproportionately getting weaker protection, all hell *should* break loose.

    And the discussion about J&J’s one-shot as being more appropriate for workers who can’t afford to take more than one day off work, well the class paternalism is transparent.

    You might ask, what vaccine are the people with real money, the one percent of the one percent, putting into their arms? The CEO’s of hospital chains? High level politicians? I’ll have what they’re having.

    • It seems you are the specific type of person the scientific community was worried about. No one is getting a vaccine more effective than the other in regard to severed illness or death. Out of all the vaccine reports, no one post vaccination has had more than a mild symptom and there have been no deaths. The stats are positive test rates and their differences. No vaccine available completely prevents against contracting Covid, but regardless of what shot they all have prevented severed illness and death which makes them all equivalent.

    • Bethany, thanks (I suppose) for the designation, but I think you misunderstand what I wrote. I fully agree that getting the vaccine, any vaccine, as soon as possible is the right decision for each of us for ourselves and the community. I am not advocating any form of refusal.

      I also don’t know the extent to which measured differences in effectiveness are artifacts of the testing environment. My response was conditional on there being some difference. To this I would add that health outcome metrics with covid have been seriously deficient, with almost no attempt to identify and quantify symptoms that don’t require hospitalization. We know almost nothing about the extent of long-lasting or permanent damage to lungs or kidneys, for instance. This too casts a shadow on vaccine tests: viral loads insufficient to cause “severe” disease (requiring hospitalization) may nonetheless be consequential.

      My point was that social patterns in which higher up people get one vaccine and lower down get another (or different proportions), where the first vaccine tests better than the second — however this test discrepancy is qualified — is wrong. Of course, this pattern characterizes a lot of our health system.

    • The Chinese government knew that they had a serious, human-human transmissible disease which resembled SARS on December 5, 1999.
      They covered up that fact until December 31 (New Year’s Eve).
      The falsely claimed that the disease was not contagious, and pressured the WHO to not declare an epidemic for almost a month.

      Nobody believes that their vaccine works.
      The CCP has told too many lies about this.
      They have no credibility.

  • I am 79 and because I had a rare side effect to PAVNAR 13 pneumonia vaccine – GI side effects that lasted months, I am hesitant to get COVID vaccine. My GP has recommended I wait to see if any GI side effects show up in the available vaccines. Have any such side effects shown up? I can find no answer to this question. Would you please comment on this for me? My husband is 80 and has gotten one shot and will get the second 3/8. I do not want to get COVID and expose him. Thank you!

  • I’ve wondered whether it’s possible to be vaccinated first with the J&J vaccine (if that’s all that is available) and later with one of the mRNA vaccines when they become more widely available.

    • That’s so common-sensical it will likely be ignored by the talking heads. The future of COVID vaccines might be a cocktail of sorts, blended from different products.

  • el problema radica en que no podemos hacer lo que dice USA,no siempre tiene la razon y lo ha demostrado muchas veces, aunado a nuestras autoridades de mexico en salud y politica que son titeres de ellos, entonces nunca se dice la realidad, hoy por mucho supero a ambos paises la enfermedad,precisamente por su negligencia .Tomemos la experiencia del oriente controlo mas rapido su pandemia,siendo asertivos concientes y cientificos y no porque dicen, aqui solo que FDA autorice si no no,creo que FDA no es dios, rusia japon china corea, nos han demostrado que con su regimen de salud estricto,cientifico bien documentado y con una gran expectativa en temas de salud,nos han demostrado mejor capacidad que el resto del mundo,estan mejor preparados porque realmente trabajan y demuestran con estudios clinicos lo que necesitamos,no bla bla bla como lo hace USA Y MEXICO. Tomemos de ejemplo hagamos lo correcto y espero que nuestras autoridades sanitarias,se preparen mejor para dar informacion adecuada ,para la gente tome conciencia de lo que debe hacer. Porque la gente no hace conciencia ?por la negligencia y desinformación que dan las autoridades en ambos paises..Asi de simple.

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