The Food and Drug Administration’s recent approval of Johnson & Johnson’s Covid-19 vaccine for emergency use in the United States is wonderful and welcome news. Its addition dramatically increases the likelihood that all adults will have a chance to be vaccinated before this summer — but only if people are willing to accept any of the three available vaccines.
That will happen only if people trust that the different vaccines are being distributed fairly.
To recap: The FDA has granted emergency use authorization to three Covid-19 vaccines. The first was for a vaccine developed by a partnership between Pfizer and BioNTech, soon followed by one developed by Moderna. The Johnson & Johnson vaccine makes three. The Pfizer/BioNTech and Moderna mRNA vaccines, both of which require two doses spaced a few weeks apart, initially needed to be stored at ultra-cold temperatures, though this has recently been eased. The Johnson & Johnson vaccine, which isn’t mRNA-based, requires just a single dose and has long-term stability at refrigerator temperatures.
The features of the newly authorized vaccine will increase the efficiency of immunization programs. From an equity perspective, these same features could also help address many vaccine roadblocks, such as resource constraints in the health care system and geographic barriers to health care access, that have been identified in indices such as the Covid-19 Vaccine Coverage Index.
At the same time, however, the Johnson & Johnson vaccine raises different equity concerns.
Before the ink was dry on the FDA authorization, news reports about differences between the Johnson & Johnson vaccine and the vaccines developed by Pfizer/BioNTech and Moderna began to circulate, fueling concerns that the Johnson & Johnson vaccine might be inferior. Although the J&J vaccine offered complete protection against hospitalization and death in the U.S. trial, rivaling that of the Moderna and Pfizer/BioNTech vaccines, it showed somewhat lower protection against less-severe disease.
While these differences are difficult to interpret because of differences in timing and in definition of outcomes between the trials conducted to test each of the vaccines, they have been enough to cause concern among some people.
People of color, as well as low-income and rural Americans, live in communities where roadblocks to vaccination are most prevalent. Using only one type of vaccine when three are available may create suspicion in these communities, especially when that vaccine is wrongly perceived as second-class.
Targeting the single-dose vaccine to hard-to-reach populations could easily be interpreted as evidence that, once again, the disadvantaged and disproportionately burdened are getting substandard care. This understandable interpretation, given the history and ongoing experience of structural injustice in American health care and public health, threatens to increase distrust in vaccines and the vaccination program.
At a time when many people, including those from disadvantaged groups, are questioning whether they want to be vaccinated against Covid-19, differential access to what are perceived as superior vaccines risks deepening distrust and exacerbating existing inequities in Covid-19 vaccine rollout.
These are risks the country cannot afford to take. To forestall any perception that the Johnson & Johnson vaccine is inferior or is being targeted to disadvantaged people, immunization programs should start with the presumption that the J&J and either the Pfizer/BioNTech or Moderna vaccines will be made available to all communities. Deploying the Johnson & Johnson vaccine in well-resourced areas will help contain the pernicious public health and equity implications of the narrative that it is a second-class vaccine.
In some communities or populations with fewer resources, there may be circumstances where the advantages of a single-dose, refrigerator-stable vaccine could be essential for efficiently meeting vaccine needs. Yet any determination to offer only one type of vaccine in a community should be made in consultation with community leaders and advocates — and with their endorsement. While it is always good practice for immunization programs to work in concert with local communities, in the case of Covid-19 vaccination it is imperative.
On March 16, 2020, the very first subject was enrolled in a Covid-19 vaccine trial. In the following 12 months, we lost over 500,000 Americans, an unimaginable tragedy. Remarkably, in that same time period, the combined efforts of scientists, governments, companies, and trial participants from around the world has now given us access to three vaccines that together would allow the U.S. to immunize its entire population and prevent additional suffering and death. But we will only reach this goal if we resolve to use all of these vaccines in what is, and what is perceived to be, the fairest way possible.
Ruth R. Faden is the founder and inaugural director of the Johns Hopkins Berman Institute of Bioethics. Ruth A. Karron is director of the Johns Hopkins Center for Immunization Research and founder of the Johns Hopkins Vaccine Initiative.