"It is not even the beginning of the end, but it is, perhaps, the end of the beginning."
Saying this on November 10th 1942, Churchill was tempering the cheer of victory against the Nazis in the Battle of Egypt with a slab of reality. Victory in Europe would arrive two and a half years later.
On November 9th 2020, almost exactly 78 years after this speech, Pfizer announced promising results in the search for a COVID-19 vaccine – albeit in a press release rather than in the form of peer-reviewed research. This is encouraging news but there is still a long way to go. If success is the eradication or overwhelming suppression of the disease to the point that it no longer impacts our day-to-day lives, there are several challenges to overcome.
Logistics
The Pfizer vaccine needs to be stored at minus 70°C, and needs to be given as two doses a couple of weeks apart. Distributing millions of doses of vaccine, to the right places at the right time, keeping them at temperature, and delivering them to the right people, will need formidable coordination and significant logistical capacity. Production of the specialised glass vials able to withstand these temperatures must ramp up along with the medicine they contain. Other vaccines may have different storage and transportation requirements, and each will need a tailored distribution plan which fits in with the wider delivery strategy. Production capacity will likely increase over time and training of staff able to deliver vaccines will need to happen rapidly; in the initial phases, distribution is likely to be a greater rate-limiting step.
Capacity of storage and logistics networks will be challenging even in countries with well-developed infrastructure. Remote areas (including those in wealthy countries) and parts of the world with warm climates, political instability or fragmented leadership, unreliable power supplies and poor international and domestic transport links will see these challenges multiplied.
This is important because global herd immunity requires equal access to the vaccine. Rich nations should have a strong incentive to support less well-developed nations in their vaccination efforts, because this will give the best chance of global disease suppression to the benefit of all. We are not only vaccinating individuals; we are protecting our entire species. This cannot successfully happen if there remain populations in which COVID has been permitted to persist, mutate and resist the vaccines and treatments developed to fight it.
Further COVID vaccines are in the pipeline which may face different challenges and possess varying levels of efficacy. That there are more vaccines in development is encouraging – having varied approaches to some of the challenges mentioned here may allow different vaccines to fill different niches according to the needs of different populations and geographic locations.
People
The current UK government approach (as of 14 November 2020) is to prioritise vaccination for the most clinically vulnerable people and healthcare workers. Subsequent waves of vaccines will be given to less and less vulnerable groups as time goes on. While logical and certainly associated with an aura of moral justice, this may not be the most effective strategy, and policy may yet change.
People who are very elderly and clinically vulnerable may, depending on their health conditions, mount a less effective immune response to the vaccine than others. Further data on this possibility will no doubt arrive but full understanding of vaccine response is unlikely to be achieved before mass vaccinations start.
What may be more of a priority is vaccinating those most likely to spread the disease. Healthcare workers are currently in the second priority group which reflects this approach; they are likely to be in contact with vulnerable people and by limiting the chances they are infected, they are less likely to spread it to others.
However, given the logistics and other challenges, the time between the first and last patients receiving vaccinations in the UK may be measured in months or even years. This is a potentially large time lag between vaccinating those who are most vulnerable and those who spread COVID the most. If the aim is to suppress the total load of active Coronavirus in the population, it may be better to prioritise groups who are more likely to spread the disease. This could include carers, students, teachers or others whose work or lifestyle causes them to be in contact with a greater number of people than most.
This raises an ethical concern - young healthy people who ignore guidance to social distance may experience milder disease and spread it to many more people than frail elderly people who follow all COVID guidance and socially isolate effectively. "Rewarding" behaviour considered “irresponsible” with early access to the vaccine may be politically unpalatable; however governments will need to determine strategies to maximise the benefits of the vaccine to minimise loss of life and illness in the whole community.
Those making decisions on such strategies may not be able – especially in the early phases – to draw on significant bodies of evidence to justify their approach. The eventual plan may require an educated best-guess with judicious data collection, constant analysis and flexible strategies to pivot the approach as evidence and the situation on the ground develops.
Behaviour
Encouraging behaviour which keeps individuals and populations safe may become increasingly challenging as the vaccination programme advances. Subsequent spikes in infection with consequent increases in illness and death are entirely possible as people tire of restrictions on their day to day lives. The fatigue associated with following the rules may be compounded as more of the population is vaccinated and individuals feel that they are 'safe' from COVID.
Maintaining hygiene, social distancing and wearing face masks continue to have enormous value in minimising spread and must be continued until the virus is effectively suppressed or eliminated in the population. Maintaining group conformity with these behaviours may be a difficult sell for governments when people are keen to get back to normal. They may feel restrictions are unwelcome when they have a perception of safety having been vaccinated, increasing the risk of subsequent spikes in infections if group immunity is not sufficient to keep the virus' transmission under control.
Morale among those who are awaiting vaccination may suffer as large numbers of people in their community receive their doses. The wait for whole populations to be vaccinated is likely to be long as manufacturing and distribution capacity attempts to meet overwhelming demand.
This is not just a national governmental responsibility, although effective national strategy will be critical in encouraging behaviours which work towards the common goal of defeating the virus. Engaging local governmental organisations, NGOs, community groups and employers in the effort to encourage positive behaviours has significant potential to help keep the virus at bay as vaccines’ impact increases.
Facebook and media
Anti-vaccine suspicion may be magnified in social media echo chambers, amplified further by significant reporting of concerns in other media. Even with the safest medical treatments, there is a one-in-millions chance of severe or even fatal reactions for each recipient. In normal circumstances such events are tragedies which nonetheless do not tend to receive widespread media attention. Given the scale of the inoculation programme and the likely interest in its progress, more single events of serious incidents may occur in a short timeframe, leading to misplaced perceptions of a lack of safety.
As has already happened with other vaccines, a reduction in uptake can have catastrophic consequences. The disease takes hold once more, lives are lost and long-term illness in those who survive becomes a humanitarian, moral, psychological and economic burden on individuals and societies. Complacency and a failure of leadership at the point the pandemic appears to be under control risks successive waves of re-emergence of infection, all the while increasing the opportunity for the virus to mutate and resist efforts to control it.
Anti-vaccine sentiment, itself spreading in a viral way, represents a significant threat to humanity’s ability to supress COVID and risks countless lives if unchecked. Balancing free speech and lack of regulation of social media platforms against a moral imperative to minimise loss of life and human suffering may become a significant challenge not only for governments, but also for communities and organisations who are able influence discourse and messaging.
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