Vaccine administration: What went wrong, and can the pandemic be stopped solely using vaccination?

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In late December, the idea that safe, effective vaccines against COVID-19 had been created in less than a year seemed miraculous—a triumph of science and American ingenuity. It took only six weeks to tarnish that image. Pride in the remarkable feat has been replaced by confusion, accusations of unfairness, frustrating waits and the nightmare of vaccine vials gathering dust while tens of thousands of people die of what is now a preventable disease.

A laundry list of issues slowed the vaccine rollout ranging from unrealistic public expectations and a lack of communication to overwhelmed software. The prior administration did an admiral job of delivering millions of vaccine doses to loading docks. However, states and localities were expected to take over from there with little support, guidance or money. However, a broader mandate is needed by the federal government, helping states organize their vaccination efforts and get doses the "last mile" into the hands of vaccinators and the shoulders of eager Americans.

Multiple issues have marred vaccine rollout:

The amount of vaccine states receive weekly fluctuates wildly, and there's no clear explanation why.

States were not immediately prepared to distribute at the scale the public demanded, even when they did get expected amounts of vaccine.

Appointment-scheduling programs crashed under overwhelming demand, leading to chaos as people tried to get in line. Digital-scheduling systems advantaged people who are internet-savvy and had hours to spend waiting for their turn.

Full-scale manufacturing didn't start until late last year; though 100 million doses were promised by the end of the year, 20 million were available in December and 30 million in January.

Hospitals were thought to be a good place to start administering vaccinations because of their expertise. But just as vaccine became available in late December, the holidays arrived, reducing staffing. Hospitals were overwhelmed by the highest rate of COVID-19 infections since the start of the pandemic, filling beds, taxing workers and stretching finances in a desperate year.

States struggled to ramp up their vaccination efforts. Health department workers and budgets were spread thin over the course of the pandemic. Many didn't have the resources to plan a large-scale vaccination effort. In addition, states have struggled with constantly fluctuating amounts of vaccine, making planning extremely difficult. Officials said they request the same amount of vaccine each time and have no idea why there's so much variation. Computer systems have been a huge challenge for states, each of which is left to develop programs on its own for tracking vaccine distribution and signing people up for shots. Stories abound of people spending hours online or on hold, trying to make appointments only to have systems crash or phone connections cut.

Barring disaster, vaccination efforts will ramp up over the coming weeks and months.

Three additional vaccines (AstraZeneca, Johnson+Johnson and Novavax) are nearing the finish line, and more are on the horizon. The new administration invoked the Defense Production Act to make raw materials needed for manufacturing COVID-19 vaccines more available, including vials and syringes, and changed rules to allow retired doctors and nurses to deliver shots, as well as have FEMA to bring in portable vaccination facilities with logistic help by the National Guard.

More detailed data about how many doses are available are regularly released to the media to increase the flow of information to the public. To do much more, the administration will need help from Congress, including passage of a “American Rescue Plan.”

Among other things, the extra funds would support public health systems and enable the administration to launch mass vaccination clinics across the country. Federal officials are pushing states to speed up COVID-19 vaccinations and announced major changes to distribution. Amid the efforts, the flow of vaccinations is improving. Recently 1.3 million people in the U.S. were vaccinated in one day and 10 million in one week. To get past the pandemic, those totals must keep climbing to double those amounts. On a more laudable note, recently a millstone was reached in the U.S. as more people have been vaccinated than have been infected during the entire pandemic. The administration will allow major pharmaceutical companies to start administering vaccines by Feb. 11, which can increase daily vaccine administrations by 1 million per day and allow for additional doses included in each vaccine vial. However, capturing these additional doses from a vaccine vial will require more expensive modern syringes and expertise of the vaccinator? The question also remains: Will vaccine production and availability keep pace with increasing vaccine administration? To that end, Pfizer recently reported that it can reduce the time needed to produce 1 to 3 million doses from 90 to 60 days.

So far, only one human disease—smallpox—has been officially eradicated; that is, reduced to zero cases and kept there long-term without continuous intervention measures. Smallpox was stamped out thanks to a highly effective vaccine and the fact that humans are the only mammals that are naturally susceptible to infection with the variola virus that causes the disfiguring, sometimes deadly disease. Humans are the only known reservoir of poliovirus, yet it still spreads in a few countries, causing paralyzing disease, despite the widespread use of effective immunizations and a 32-year-old global eradication effort. SARS-CoV-2 is thought to persist in nature in bats and has been known to infect minks, cats, gorillas and other small animals. Wiping out the virus would require banishing it from every susceptible species, which isn’t feasible.

Efforts to suppress an outbreak need to result in zero new cases of a disease or infection in a defined area over a sustained period. There’s no official definition of how long that should be. During pandemic, sustaining elimination of any infectious disease nationwide is challenging, if not impossible, because of the threat of the virus re-entering the country from infected international travelers.

It’s not known what proportion of the population needs to have immunity to stop the coronavirus from circulating, or whether even the most potent vaccines will be able to prevent it from spreading. One study estimated that to stop transmission, 70% to 82% of the population would need to have immunity, which can be achieved either by recovering from an infection or through vaccination. Still, there’s reason to believe mass inoculations will have a more powerful effect because vaccines appear to elicit stronger and more durable protection than a prior infection. In addition, mass vaccinations could slow the development of new variants, and persons that had a prior COVID infection developed a significant boost in antibody response after the first dose of vaccine infection, indicating they had developed a durable level of antibody and T-cell producing memory cells after the initial infection.

There’s good evidence that the shots made by Pfizer and Moderna are very effective—as much as 95%—at preventing recipients from developing clinical disease against the original SARS-COV-2. However, data haven’t been released on their ability to prevent people from developing asymptomatic infections or transmitting the virus to others. Antidotal evidence from Moderna and AstraZeneca have reported that their vaccines can reduce virus transmission by 70%. The gold standard in vaccinology is to stop infection as well as disease, providing so-called sterilizing immunity.

Vaccines don’t have to be perfect to have a public health benefit. Rotavirus and chickenpox are examples of diseases that have been “virtually eliminated using vaccines that are very good at preventing severe disease, quite good at preventing any disease, but that do not completely prevent infection in everyone.” Since SARS-CoV-2 spreads through respiratory particles from an infected person’s throat and nose, a vaccine that reduces the amount of virus in the respiratory tract or reduces the frequency an infected person coughs may decrease the likelihood of it being transmitted to others and lower the effective reproduction number (Re), which is the average number of new infections estimated to stem from a single case. The head of the World Health Organization’s emergencies program, told reporters Jan. 25 that rather than focusing on eliminating SARS-CoV-2, success should be seen as “reducing the capacity of this virus to kill, to put people in the hospital, to destroy our economic and social lives.” Recent data have shown that the top commercially available vaccines can provide at least 80% protection against serious illness (hospitalizations and deaths) from all isolated variants.

The WHO has stated, “It appears the destiny of SARS-CoV-2 is to become endemic.” Viruses that are endemic continuously circulate in the community, often causing periodic spikes when disease characteristics and human behavioral patterns favor transmission. Examples include norovirus, the notorious cause of gastroenteritis on cruise ships, and the myriad of viruses, including four coronaviruses, that cause the common cold, especially over the winter.

It’s unknown how things will evolve, but researchers have begun to spin out scenarios. People who have survived COVID-19 and those vaccinated against it will probably be protected against the disease for some time, however, the exact length of time will depend on how well existing vaccines protect against newly emerging, highly transmissible variant viruses, one of which recently isolated from South Africa has shown to be an neutralizing escape mutant. No doubt the SARS viruses will continue to mutate and rapidly spread across the globe eventually replacing the original SARS-CoV-19 virus. This will necessitate the continual development and administration of new vaccines, at what rate as yet to be determined. 

As more and more people develop immunity through natural exposure or vaccination, the virus will need to find those who are not yet immune. That will mean that people who can’t get vaccinated—because their immune systems are compromised; they have allergies to vaccine ingredients; they are too young (none of the vaccines authorized in Western countries have been approved for children less than 18 years of age); or refuse to be vaccinated—will remain vulnerable. Therefore, present mitigations and improved testing and contact tracing will need to be in place for the foreseeable future.

About Joseph Giambrone:
Joseph Giambrone is a professor emeritus in Auburn University’s Department of Poultry Science with a joint appointment in the Department of Pathobiology in the College of Veterinary Medicine. During his graduate research career at the University of Delaware, he was part of a research group that developed the first vaccine against an antigenic variant of an avian coronavirus. During a sabbatical leave during his tenure at Auburn, he was part of a research group in Australia that sequenced the entire genome of antigenic variant of a coronavirus of chickens. During his 42-year research career as a molecular virologist, immunologist and epidemiologist, he has made critical advancements in understanding the ecology of viral pathogens, led efforts to improve detection and surveillance of viral diseases and developed new and effective vaccines and vaccine strategies to protect commercially reared chickens as well as pathogens, such as avian influenza viruses, which have spilled over into human populations. His research has had a profound impact on practices used today to reduce the incidence and severity of viral diseases of commercially reared poultry as well in human populations.

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