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Viewpoint
COVID-19: Beyond Tomorrow
May 18, 2020

Planning for a COVID-19 Vaccination Program

Author Affiliations
  • 1Division of General and Community Pediatrics, Children’s National Hospital, Washington, DC
  • 2The George Washington University Elliott School of International Affairs, Washington, DC
  • 3The George Washington University School of Medicine and Health Sciences, Washington, DC
JAMA. 2020;323(24):2458-2459. doi:10.1001/jama.2020.8711

The long-term solution to the coronavirus disease 2019 (COVID-19) pandemic, hopefully, will be a globally implemented, safe vaccination program that has broad clinical and socioeconomic benefits. Dozens of vaccines are in development, with 8 currently in phase 1 trials. Some scenarios predict the earliest, widespread availability of a COVID-19 vaccine to be in 2021.1 As launches of prior mass vaccination programs have demonstrated, careful planning to ensure readiness of both the general public and the health community for a COVID-19 vaccine should begin now.

To substantially reduce morbidity and mortality from COVID-19, an efficacious and safe vaccine must be delivered swiftly and broadly to the public as soon as it is available. However, the mere availability of a vaccine is insufficient to guarantee broad immunological protection; the vaccine must also be acceptable to both the health community and general public. Vaccine hesitancy is a major barrier to vaccine uptake and the achievement of herd immunity, which is required to protect the most vulnerable populations. Depending on varying biological, environmental, and sociobehavioral factors, the threshold for COVID-19 herd immunity may be between 55% and 82% of the population.2

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    3 Comments for this article
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    Too Early to Start Communicating?
    Luigi Roberto Biasio, MD | Contract Lecturer in Vaccinology, Rome, Italy
    How to prepare and support the start of a COVID-19 vaccination program seems to be similar to those proposed for other pandemics, such as influenza H1N1, the main differences being that steps and timelines for the development and manufacturing of the vaccine were more evident to the producers, as well to the health community, policy makers and, likely, the public.

    The authors of this Viewpoint say the health community should capitalize on an anticipated, early public enthusiasm for a COVID-19 vaccine: this seems quite complex at this time, as several vaccine projects are going on, based on different
    platforms some of which have never been authorized for mass production, nor used in immunization campaigns.

    Thus, it appears problematic to tailor a communication strategy now, presuming that the first vaccine will be available in 2021, without knowing how it will be effective and safe, and the quantity of doses the facilities will produce. Without this, it will be also difficult to understand and explain why certain individuals will be ineligible for vaccination.

    The public in particular at this time is saturated with emotions, often mistrust toward decision-makers, and is over-loaded with conflicting information from the health providers, experts, organizations, and individuals strongly active on the web and in the social media, producing conflicting opinions. These can be the reasons why only 30% would want to receive the vaccine soon after it becomes available.

    Managing the emotions, providing evidence and taking into consideration the health literacy levels of the population are three key 'tools' for the success of health communication in general and, specifically, for vaccination (1): for COVID-19 future vaccines it looks like some of these elements are still missing.

    As the authors say, the groundwork for public acceptance of a COVID-19 vaccine must be carefully started before a vaccine becomes available. This is true for all new vaccines; however, in this case it seems preferable to wait for at least some more data, hopefully available in a short time.

    REFERENCE

    (1) -LR Biasio et al - Health literacy, emotionality, scientific evidence: Elements of an effective communication in public health - Human Vaccines & Immunotherapeutics, 2018, 14:6, 1515-1516, DOI: 10.1080/21645515.2018.1434382
    CONFLICT OF INTEREST: None Reported
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    The System Needs to Improve Vaccine Access
    Shawn Baca, MD, FACR | Rheumatology Associates of South Florida, Past President Palm Beach County Medical Society, Affiliate Professor Schmidt School of Medicine, Florida Atlantic University
    What is apparent is that even during "normal times" vaccine distribution has become difficult for physicians. Most physicians no longer vaccinate in their offices due to the confluence of of big chain pharmacies and payers creating monopolistic barriers for some patients. These self created monopolies push aside hard working primary care physicians and specialists who feel they can no longer vaccinate patients in their offices due to poor reimbursement and supply chain issues. Local pharmacy chains and grocery stores often have vaccines available for sometimes one or two months prior to doctors who take care of the most vulnerable. This especially affects those patients who have difficulty with transportation and ambulation by having to travel to additional locations when then should be able to receive their vaccinations at their normal doctor's visit. Hopefully when the Covid 19 Vaccine does become available the AMA will work with payers and point out monopolistic barriers to make sure that physicians and facilities on the front line will be able to vaccinate and improve access to their patients in a more efficient and expedient fashion.
    CONFLICT OF INTEREST: None Reported
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    Getting Human Beings To Accept COVID-19 Vaccination
    Stephen Green, M.D. | University of Sheffield & University of Plymouth, United Kingdom
    DeRoo et al’s article was both very thoughtful & pragmatic. It certainly recognized the great difficulties that lies ahead of us even if a good vaccine or two do eventually emerge.

    More recently, Usher in the Lancet argued for the worldwide availability of effective vaccines if & when they eventually emerge. (1) It is heartening to see that already widespread goodwill, & a degree of financial commitment, are coming into being to ensure such vaccines would be made available & affordable worldwide, while important players in the international political community already appear to be prepared to support such
    a vital initiative. (2)

    However, as discussed by DeRoo et al, delivering the vaccine to some in the wider population is likely to be rather less straightforward than a simple “offer & acceptance” scenario.

    Achieving adequate levels of herd immunity is definitely a key factor if a vaccination program is to be successful. However, there are already concerns that future preventative COVID-19 vaccine initiatives may fail to achieve the impact they could & should be capable of, as a consequence of non-medical factors.

    Indeed, pre-coronavirus, “vaccine hesitancy” had a long history (3) & already COVID-19 vaccines have not been immune from attention of this type (4,5).

    It is also important to note that even when, in the past, highly effective vaccines able to prevent the spread of one or other particular infectious disease have become available, the worldwide impact on the prevalence of the target infectious disease has sometimes been disappointing. For example, although good commercial hepatitis B vaccines have been available since 1981, worldwide the virus still affects 0.25 billion human beings. (6) Furthermore, despite their being vaccine-preventable to varying extents, dangerous infectious diseases such as polio, rabies, cholera, measles, mumps, rubella, yellow fever & tuberculosis continue to remain significant global scourges.

    Everyone wants to be rid of COVID-19. However if an effective vaccine does eventually come along, persuading people - including those who are skeptical - that vaccination is an acceptable response to the COVID-19 crisis & that they & their offspring would benefit from consenting to having it administered to them, is the next critical challenge. In fact, the success or failure of any eradication program may well depend pretty well entirely on that.

    We must, for all of our sakes, make as certain as we can that all around the world COVID-19 vaccines are used in a maximally efficacious way, but we have to recognize that relying entirely on evidence-based science might not win the day.

    Accordingly, this will not be an issue for the healthcare fraternity alone, but also a matter for politicians, lawyers, businessmen & other leaders to stand side by side with their fellow professionals from the worlds of healthcare & science - & take things forward.

    Authors: S.T. Green & L. Cladi.

    REFERENCES

    1. Usher AD. Lancet 2020; 395: 1822-1823. DOI:10.1016/S0140-6736(20)31354-4
    2. Paton J. Bloomberg, 5 May 2020. https://www.bloomberg.com/news/articles/2020-05-05/nations-back-pushfor-universal-access-to-covid-19-vaccines
    3. Drew L. Nature 2019; 575: S58-60. DOI:10.1038/d41586-019-03642-w
    4. Ball P. Nature 2020; 581: 251. DOI:10.1038/d41586-020-01423-4
    5. Srikanth A. The Hill, June 3, 2020. https://thehill.com/changing-america/well-being/prevention-cures/501020-anti-vaxxers-are-organizing-even-
    6. World Health Organization. July 18, 2019. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b
    CONFLICT OF INTEREST: None Reported
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