On Jan. 26, my parents texted me the welcome news that they had received the first shot of the Moderna vaccine and made an appointment for their second dose, on schedule, in a few weeks. While I am overjoyed that my parents are on their way to being protected against COVID-19, my enthusiasm is tempered by the fact that many other people across the nation have been unable to follow suit because of issues with both supplies and distribution of those vaccines. The vaccines are the light at the end of the tunnel, but it’s a very long tunnel.
In December, we learned that both the Pfizer/BioNTech and Moderna vaccines outperformed expectations for efficacy by a large margin. The news about the vaccines has been overwhelmingly good, right up to Monday’s report that, despite some loss in neutralizing capacity, antibodies elicited by the Moderna vaccine still effectively neutralize emerging SARS-CoV-2 variants of concern. Adding to this good news, President Joe Biden stated on Monday that vaccines will be available on demand in the spring, and “we’re going to be well on our way to, heading toward, herd immunity” by the summer. However, not all estimates are as optimistic. Despite the Biden administration’s efforts to secure an additional 200 million doses, goals of vaccinating 1.5 million people per day remain largely aspirational, and vaccine rollouts have been hampered by federal allocations being smaller than expected, or simply not arriving at all. We can’t rely solely on the hope of a better future through vaccination to overcome the obstacles presented by distribution and supply.
We are a long way from being able to pop the Champagne and raise a toast to a job well done. Last week, Anthony Fauci acknowledged that the Biden administration needed to build substantially on the distribution activities that began under the Trump administration. Nationwide, logistical problems with distribution have been reported since the Pfizer and Moderna vaccines were authorized by the FDA. Distribution efforts have been plagued by reports of inequitable access. An overreliance on technology to schedule vaccine appointments has forced high-risk patients to navigate a complex, buggy labyrinth of websites and apps. Those without access to reliable internet access or less comfortable with technology have been left behind, often with no recourse. There have also been reports of wealthy people without priority paying to cut in line. And these problems with distribution don’t even begin to contend with the issues about vaccine supplies.
Allocated supplies of vaccines to individual states have been vastly insufficient to meet the demand. From the moment the vaccines were authorized for emergency use by the FDA, the question of supply has loomed large in the mind of both public health professionals and the general public. Almost immediately upon approval, proposals appeared to delay, halve, or eliminate vaccine doses altogether, despite minimal evidence to support these strategies. Unfortunately, policymakers listened in the U.K. and Quebec, and began recommending delayed booster doses with no evidence to support doing so. However, even if we gave a half-dose single shot, supplies would still be insufficient to vaccinate millions of the highest risk people. The only way to effectively do this would be to increase supply.
While Biden plans to invoke the Defense Production Act to increase vaccine supply, it’s unclear how much authority he ultimately has to compel private manufacturers to ramp up production. Centers for Disease Control and Prevention Director Rochelle Walensky stated last week that the administration is currently trying to determine what supply bottlenecks even exist. In addition, clinical-grade mRNA vaccines are complex products to manufacture, repurposing existing facilities for vaccine production takes time and substantial resources, and the nature of the free market prohibits the government from simply ordering manufacturers, who are already mostly operating at capacity, to just make more vaccine. And while Sanofi, which shelved its own vaccine candidate under development earlier this year, has approached Pfizer with an offer to produce 100 million doses under a licensing agreement, this will not occur overnight.
In many parts of the U.S., case numbers are finally in decline. However, though they are lower than they were several weeks ago, they are not actually low; in fact, cases remain higher than throughout most of 2020. States are anxious to relax restrictions, at least where restrictions have been implemented in the first place. Transmission is occurring at levels too high to be countered with vaccination alone, given the issues with supplies and distribution. This week, a model by scientists at Columbia University predicts that vaccination alone will not be sufficient to control spread, even if vaccine distribution and uptake were substantially improved. The lag in vaccine availability in the face of rising transmission was predicted in a policy paper authored by Walensky and colleagues last fall. Relying exclusively on vaccines is like throwing a ball of wet yarn at a raging forest fire. Even if we could magically untangle the myriad knots in the vaccine distribution and supply knot, it will do nothing to extinguish the encroaching flames.
For this reason, we absolutely must continue to look to the horizon and the long-term promise of the vaccines. We must look ahead with hope for what the vaccines offer, but we must not be so overwhelmed by our yearning for an end that we forget the crisis that continues to unfold around us. Biden’s declaration that “science is back” is indeed welcome news, but we should not be so swept up in our scientific accomplishments that we ignore data about the less glamorous logistical issues and the still-uncontrolled pandemic.
To its credit, the Biden administration has admitted that there are enormous challenges ahead and is proactively addressing them. Invoking the Defense Production Act and securing more vaccines from manufacturers are necessary steps forward, and I look forward to hearing more about the plan to improve distribution. In particular, the Biden administration deserves praise for its attention to addressing inequities in vaccine access, as the same communities that have been disproportionately affected by the pandemic have also been left behind when it comes to vaccines. Ultimately, widespread vaccination will allow us to contain the pandemic for good.
But we also can’t sugarcoat reality: While these vaccines are the greatest scientific triumph of my lifetime, we are at a critical juncture. Without continued vigilance and increased dedication to reducing transmission as we resolve the existing vaccine distribution and supply issues, we are destined to fail in our efforts to bring the pandemic to heel. We must remember that risk reduction is additive: Whenever possible, we should focus on masking, social distancing, staying home when leaving the house is not essential, avoiding gatherings outside our household, avoiding enclosed spaces, ventilating when possible, washing our hands, and disinfecting high-touch surfaces. We must persist in this struggle just a few months more.