The Next 6 Months Will Be Vaccine Purgatory

Illustrations of a vaccine syringe
Katie Martin / The Atlantic

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With the FDA’s emergency authorization of the first COVID-19 vaccine imminent, the biggest and most complex vaccination campaign in the nation’s history is gearing into action. Planes are ferrying vaccines around the country, hospitals are readying ultracold freezers, and the very first people outside of clinical trials will soon get shots in their arms. The end of the pandemic is in sight.

But vaccines are not an off switch. It will take several months to vaccinate enough Americans to resume normal life, and this interim could prove long, confusing, and chaotic. The next six months will almost certainly bring delays in vaccine timelines, fights over vaccine priority, and questions about how immune the newly vaccinated are and how they should behave. We’ve spent 2020 adjusting to a pandemic normal, and now a strange, new period is upon us. Call it vaccine purgatory.

The biggest unknown is how long we will be left in purgatory. Operation Warp Speed officials have laid out an aggressive timeline to get nearly all Americans vaccinated by June, but this presumes several pieces going perfectly. The Pfizer vaccine, which was just recommended for FDA authorization, and the Moderna vaccine, which is expected to follow next week, cannot hit manufacturing delays, and additional vaccine candidates, from AstraZeneca and Johnson & Johnson, must earn speedy authorization from the FDA early next year. Pfizer earlier revised down the number of doses it will deliver in 2020 and separately has said it cannot supply any additional doses to the U.S., beyond the 100 million already ordered, before June. The timeline for authorizing AstraZeneca’s vaccine is up in the air after a messy clinical trial. And Johnson & Johnson’s has not yet been proved to work.

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Your experience of this purgatory may depend on where you live. While a CDC committee sets recommendations for how to prioritize initially scarce doses, each state ultimately decides how to allocate the vaccines it receives. A person who qualifies as an essential worker in Illinois might not in Indiana. One city could end up opening vaccinations to the general public before its neighbor. This system is meant to be local and flexible, but that will necessarily mean a patchwork of policies that could come off as unfair or inconsistent.

“It is such a complicated and large logistical challenge that a lot of things will go wrong. A lot of things will not go to plan,” says Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security. “The important thing is not to get hung up on that.” Hard trade-offs are ahead, as many groups have some claim to priority but they by definition cannot all be prioritized. Toner says not to lose sight of the ultimate goal: “Let’s just keep vaccinating people.”  

The decisions still being made about how to prioritize vaccines will dramatically color individuals’ experiences over the next months. But ultimately getting out of purgatory will require reaching herd immunity, which is something we can only achieve collectively. Vaccines can protect individuals, but vaccination as a public-health strategy protects a community. Every person who gets vaccinated is a small step toward herd immunity, toward bringing down the amount of circulating virus. Eventually, we can all go back to schools and dinner parties and concerts.

I. Health-care workers and nursing-home residents and staff

Vaccines will do very little to change life for the average American in 2020. The very first Americans to receive COVID-19 vaccines will be health-care workers and residents of long-term-care facilities. These priorities, set by the CDC’s Advisory Committee on Immunization Practices last week, are meant to preserve the health-care system and to save lives. People in long-term-care facilities account for many of the hospitalizations and roughly 40 percent of U.S. COVID-19 deaths, according to data from the COVID Tracking Project at The Atlantic, even though only a small fraction of the country’s population—less than 1 percent—lives in these facilities.

Because the first shipments of vaccines will not cover all 24 million people in these two groups, the CDC has recommended sub-prioritizations too. Hospital workers who are in contact with patients are first on the list—including janitorial and support staff. The CDC also asks hospitals to consider that people who have recovered from COVID-19 likely have some immunity, so they do not need to be vaccinated first, though they won’t be prevented from getting vaccinated when doses are available later. For long-term-care facilities, the CDC recommends putting skilled-nursing facilities, which have the sickest patients, before assisted-living facilities.

After vaccination begins, hospitals and nursing homes will not change overnight. Both the Pfizer and Moderna vaccines require two doses, three and four weeks apart, respectively, and even then the vaccines take time to build immunity—the companies measured 95 percent protection from COVID-19 symptoms only after one or two weeks. That will be well into 2021 for even the first people vaccinated this year. (The first dose may offer some protection after 10 days, but that likely wouldn’t be as strong or as long-lasting as the full regimen.)

Scientists also do not yet have the data to confirm that the vaccines actually prevent people from spreading the coronavirus asymptomatically in addition to preventing COVID-19 symptoms. This is likely, but data on this won’t be available until early next year. For now, a vaccine can clearly offer some protection to the recipient—but that person can’t be fully confident about not spreading the disease to others. A nurse might feel safer at work but still worry about bringing the virus home to their family.

Moreover, “even with a vaccine that is 95 percent effective, you don’t know if you are in the 5 percent,” Marci Drees, the infection-prevention officer at ChristianaCare and a representative on the CDC advisory committee, points out. Health-care workers who come in contact with COVID-19 patients will continue to need full personal protection equipment. Drees says she doesn’t anticipate any changes in PPE or quarantine-after-exposure policies in the near term.

Slowly, though, small corners of the world could start to change. In nursing homes where every staff member and resident gets vaccinated—essentially reaching building-wide herd immunity—some restrictions could be loosened. Residents could increase their very limited socializing with one another. Jason Belden, the director of emergency preparedness for the California Association of Health Facilities, says the buildings might eventually open to some visitors, but symptom checks and masking will continue. With everyone inside vaccinated, the risk from unknowingly letting in a visitor who is infected is diminished, but not zero.  

States, hospitals, and nursing homes are still dealing with a lot of unknowns right now though. For one, Operation Warp Speed keeps changing the number of doses that will be initially available to each state. Kris Ehresmann, the director of the Minnesota health department’s infectious-disease division, told me that the numbers have changed so many times just in the past week, “I had this slide that I showed to the governor on Thursday. Then when I gave an update Monday, I used the same slide and had to cross things out. And I gave an update [Wednesday], and I crossed even more things out.”

States also have no sense of how regularly shipments will come, so they are unable to plan beyond the first few weeks. Hospitals, for example, might be able to vaccinate only a quarter of their staff in the first wave. Without knowing more, they will then be unable to reassure their staff about when the rest will get the shots—will it be in one or four or eight weeks? This uncertainty is one of the biggest challenges for hospitals right now, says Azra Behlim, a senior director at the health-care-services firm Vizient. “There’s a little bit more panic when I don’t know when I’ll be getting anything else.”

The inclusion of nursing-home residents in the first priority group by the CDC advisory committee also came as a bit of a surprise to states, which did not expect it when they drew up vaccine plans earlier this year. The federal government has contracted with CVS and Walgreens to help vaccinate nursing-home residents, but this division of responsibility between the federal and state levels has also introduced confusion. Ehresmann says she’s been told to reserve some number of her state’s 183,000 initial doses for nursing homes, even though the nursing-home vaccination program won’t be ready to start for a few more weeks. In California, Belden says, facilities in the association are still waiting to find out which ones will get how many doses when. “All of our members are reaching out every day. Am I going to be first? Am I going to be second? What's it going to look like? None of those questions have been answered,” he told me. “But I do suspect we’ll get answers very soon.”

Pfizer and Moderna expect to have 35 million to 40 million doses of their vaccines ready by the end of the year, which is almost enough to cover hospitals and nursing homes at two doses per person. By early 2021, states will be getting ready for the next priority group.

II. Essential workers and adults at risk for COVID-19

In some ways, the very first group is actually the easiest to vaccinate. Health-care workers and residents of long-term-care facilities are relatively well-defined groups, and they are already concentrated in hospitals and nursing homes. “The real test will be what comes after that,” says Saad Omer, a vaccinologist and the director of the Yale Institute for Global Health. It only gets harder from here.

The first hard choice is a stark one: Who should come next, essential workers, or adults over 65 or with comorbidities? The question boils down to which strategy to prioritize, Omer says: reducing transmission out in the community, by vaccinating essential workers interfacing with the public, or reducing deaths, by vaccinating the people most at risk of dying of COVID-19.

The CDC advisory committee has indicated that it will recommend essential workers next, though the National Academies and the World Health Organization have recommended the opposite. None of this guidance is binding. The decision is ultimately up to the states, though they have historically followed the CDC.

Essential workers are also a nebulous category, and again, states get to set their own definitions. “There are an awful lot of interest groups that are lobbying states and lobbying feds to get their members or their constituents vaccinated sooner,” Toner told me. Should bank tellers count as essential workers? Teachers? Exterminators? And how should states prioritize different groups of essential workers? One study found that 70 percent of American workers can be defined as essential workers and 42 percent as frontline workers who directly interact with the public.

The decision to prioritize essential workers also has to do with reaching working-class Black and Latino communities that have been disproportionately hit by the coronavirus. But these are the same communities that may be hardest to reach—because of distrust in the government and language barriers. As part of their vaccine planning, state health departments are planning to connect with churches, nonprofit groups, and other leaders in those communities. Without this effort, vaccines will go only to people who come asking for it. “The people who are capable of advocating for themselves in these situations are sometimes people who are less in need of the services than those who are not advocating for themselves,” says Kelly Moore, an associate director of the Immunization Action Coalition. These communities might take longer to reach, which means the overall vaccination might proceed a bit slower. There can be tension, Toner adds, between vaccinating as many people as quickly as possible and actually reaching priority groups.

States and the CDC are still working out who will qualify as adults at high risk for COVID-19. Again, there’s a trade-off: Requiring proof will make getting the vaccines out harder, but forgoing it might mean someone who doesn’t strictly qualify gets a vaccine. “I don’t think we should get mired in documentation,” Toner said. “I don’t feel like they should have to show their medical record to prove that they’re diabetic. Or if they say they’re 65, but they’re only really 64, I wouldn’t have them bring a birth certificate. I think to some extent, we would have to trust people.”

III. The general public  

Five months into the future, the plans get even fuzzier.

When vaccines become available to the general public depends on a few unknowns. First, how many other vaccine candidates, like AstraZeneca’s and Johnson & Johnson’s, will actually also get authorized? These companies have already ramped up manufacturing, so doses can be ready to go as soon as the FDA gives the green light. Second, will they run into manufacturing delays? The mRNA vaccines from Pfizer and Moderna rely on a new technology that has never been used in an approved vaccine, let alone produced at the scale needed now. During manufacturing of the more routine H1N1 swine-flu vaccine during the 2009 pandemic, the U.S. ran out of “fill and finish” facilities that package bulk vaccines into vials. The government set up a program to prevent this bottleneck in the future, but other unforeseen snags may come up.

The last stage of purgatory will be getting vaccines to the general public. Some parts of the country may allow everyone to get the vaccine sooner than others. In 2009, says Moore, who was running Tennessee’s immunizations program at the time, demand for the swine-flu vaccine in priority groups varied across the state. Some vaccine providers had doses for priority groups sitting unused, while members of the general public were asking about shots. Moore let those providers begin giving the vaccine to anyone who asked. This dynamic is very likely to play out between cities and between states with the COVID-19 vaccine, where doses are currently being allocated by census population but demand may vary.

This decision is tough because it’s likely to be criticized either way. “Visualize the frustration … if Georgia and Tennessee and Alabama all have different groups being allowed to be vaccinated at different times. But if you don’t, if you try to make everyone in the whole country do these groups in lockstep, then you can imagine that that also is terribly unfair,” Moore says, if “there are lots of willing people who could be protected, and vaccine is being withheld.”

Vaccine hesitancy is, of course, also a more general concern across the country. But Americans’ willingness to take a COVID-19 vaccine has risen as data on the vaccines’ efficacy have come out, and experts expect it to keep rising if early vaccination goes well. Many people have said they are more comfortable waiting a few months to get the vaccine, which is in effect what will happen.

Eventually, our social lives can start getting back to normal. It won’t happen in a moment, but stepwise, in small ways and then larger ones. Omer says small gatherings like dinner parties and game nights might be safe if everyone in the group is vaccinated. School reopenings and mass gatherings will likely happen only when widespread vaccination—along with masks and social distancing through the winter and spring—pushes COVID-19 rates to low levels.

Public-health experts stress that vaccines work in tandem with other measures: The start of a vaccination campaign cannot be an excuse to abandon the measures that are working right now. Moore likens vaccines to another slice on a pile of Swiss cheese, where each slice is an intervention that is by itself imperfect (masks, social distancing, even vaccines) but they drastically reduce risk when stacked together. Rochelle Walensky, President-elect Joe Biden’s pick for CDC director, made this analogy on Twitter: “If I have a cup of water, I can put out a stove fire. But I can’t put out a forest fire, even if that water is 100% potent. That’s why everyone must wear a mask. As a nation, we’ll recover faster if you give the vaccine less work to do when it’s ready.”

There will likely be many frustrating and imperfect things about the vaccine rollout in the next few months. But the goal is to get the country—and, really, the world—back to normal, and that happens not when you as an individual are vaccinated but when enough people all over are vaccinated. It might take longer than we like, but we get there together.

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