COVID-19 Vaccines Face Hesitancy, Fair Distribution Issues

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As a multitude of manufacturers around the world race to develop COVID-19 vaccines, experts on two recent webinars wrestled with logistical and policy dilemmas, including how to distribute vaccine fairly to all nations, how to prioritize dosing within a country, how to ensure that a successful vaccine will be affordable, and how to overcome vaccine hesitancy and already-exploding misinformation campaigns.

Still, vaccine development is moving with unprecedented speed. The federal government, through its Operation Warp Speed, will begin funding studies of three vaccines — being developed by Moderna, Oxford University and AstraZeneca, and Johnson & Johnson — this summer.

"It's very likely that we'll have a vaccine by the middle of next year, said Paul A. Offit, MD, director of the Vaccine Education Center at the Children's Hospital of Philadelphia, in a joint National Academy of Sciences (NAS) and American Public Health Association (APHA) webinar on June 10.

If that happens, it would cut a 10- to 20-year process down to 18 months, he said.

COVID-19 Hesitancy Already Here

The speed is a double-edged sword: It could end the pandemic sooner if there is equitable global distribution, but it could also trigger vaccine hesitancy if people believe that safety is being overlooked.

Many people, according to multiple polls, are already expressing doubts about whether they would accept a COVID-19 vaccine.

In mid-May 48% of respondents to an Ipsos/Reuters poll said they were cautious about a COVID-19 vaccine because they were nervous about a quickly approved product, Ipsos Senior Vice President Chris Jackson told the US Department of Health & Human Services National Vaccine Advisory Committee (NVAC) on June 9. A third of respondents said they did not trust the people making vaccines.

Jennifer Benz, PhD, deputy director of The Associated Press-NORC Center for Public Affairs Research at University of Chicago, told those at the NAS/APHA webinar that a mid-May survey her group conducted revealed that only 49% of Americans said they planned to be vaccinated. A third were not sure, and a fifth said they would not get a shot.

Just a quarter of African Americans — who have been disproportionately hit by COVID-19 — said they would get a vaccine, compared with 56% of whites who responded to the survey. Seventy percent overall said they would not get a vaccine out of concern about side effects, while 42% said they were worried about getting COVID-19 from the vaccine. A third said they don't think vaccines work very well.

Peter Jay Hotez, MD, PhD, dean for the National School of Tropical Medicine at Baylor College of Medicine, told the NVAC that the anti-vaccine movement has grown during the pandemic by joining forces with groups protesting social distancing and contact tracing.

Anti-vaccination proponents have traditionally claimed that vaccine development and approval is too rushed and disregards safety, said Hotez. For COVID-19 vaccines, "the way this is being rolled out and the language and the communications is very damaging," he said.

Hotez believes that the term "Operation Warp Speed" is a mistake. "It plays right into the hands of the anti-vaccine lobby," he said.

"We don't want anyone to have the impression that 'warp speed' means we're compromising in any way on safety," said Kathleen M. Neuzil, MD, MPH, director of the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine in Baltimore, on the NAS/APHA webinar.

"We certainly put a lot of effort into vaccine safety," she said.

Health experts at the webinar said trusted sources — including healthcare providers — could help build interest and acceptance of a COVID-19 vaccine.

Ipsos/Reuters poll respondents said they would have greater confidence in a vaccine if safety was proven in large trials, if the US Food and Drug Administration (FDA) approved it, if US health authorities said it would prevent a repeat of the epidemic, or if their doctor said it was safe.

"People tend to trust their healthcare provider, they tend to trust the frontline health workers and that's an important tool," said Seth Berkley, MD, CEO of Gavi, The Vaccine Alliance, at the NAS/APHA webinar. He said people also trust peers.

Gavi has been working with social media companies to point people to websites with good information, said Berkley. "That's an important priority," because of conspiracy theories being promulgated on the internet, he said.

Neuzil agreed with Berkley that trust in peers and those in healthcare were key. Fighting hesitancy means "making sure people get messages from those trusted sources," and that they understand the vaccine, she said.

"I also think it's helping people understand that sometimes it's not just an individual decision" to be vaccinated, Neuzil added, giving the example of helping to protect a relative in a nursing home.

It's crucial not to squander the confidence many Americans do have in vaccines, said Offit. As vaccine development moves forward, health officials and experts can "mitigate any potential risks by letting people know exactly what we know and what we don't know," he said, adding that experts should "be humble" about the all of the unknowns with SARS-CoV-2.

Even the pharmaceutical and biotechnology industries say public confidence is a top concern. "The promise of COVID-19 vaccines can only be fully realized when people are willing to get the vaccine," Amy Walker, MSc, senior manager for infectious diseases policy at the Biotechnology Innovation Organization, told the NVAC.

Healthcare Workers Likely First

Experts who participated in both webinars said healthcare workers are likely to be among the first Americans to receive a COVID-19 vaccine, especially if the vaccine is available initially only through an emergency use authorization, or if supply is limited at first.

The decision in the US will be made by the Advisory Committee on Immunization Practices (ACIP), which is part of the Centers for Disease Control and Prevention. The FDA would then work with the ACIP to determine which selected populations might receive vaccine first, John Mascola, MD, director of the Dale and Betty Bumpers Vaccine Research Center at the National Institute of Allergy and Infectious Diseases (NIAID), said on the NAS/APHA webinar.

"You can envision people at highest risk — certainly healthcare workers, first-line workers, people in essential jobs where there's a high-density type of employment, where they are at risk," he said, adding that these discussions are already happening at federal agencies.

Richard Hatchett, CEO of a group that's accelerating COVID-19 vaccines, the Coalition for Epidemic Preparedness Innovations, told those on the NAS/APHA webinar that national authorities in most nations will oversee distribution, with guidance on prioritizing from international groups like the World Health Organization. But most countries will reserve the right to allocate according to their own schemes, he said.

If a vaccine is safe and effective, Hatchett said he anticipates that "healthcare workers would be very highly prioritized."

Berkley said he agrees that healthcare workers — and probably those at highest risk, like the elderly and essential workers — would be among the first to get a vaccine in most countries.

But he also said he envisions prioritizing vaccine to areas where the epidemic is raging.

"Our goal is to stop the pandemic and return to normal," said Berkley, adding that COVID-19 is a global, not a single nation, problem. "We are not going to be safe anywhere unless we're all safe."

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