A vaccination magic bullet?

One of the many myths being advanced by some governments, including our own, and then repeated by the media is that a vaccine will set us free from the coronavirus in 18 months. Among those promoting this false optimism is President Donald Trump, who is a veritable cornucopia of phony cures, inaccurate scientific claims and outright nonsense concerning public health. This is especially true of the nonsense he continues to spew about vaccines.

During a March 3 Cabinet meeting with pharmaceutical executives and members of the White House task force on the pandemic, Trump was asked about a timeline for a vaccine. He said:

"I don't know what the time will be. I've heard very quick numbers, that of months. And I've heard pretty much a year would be an outside number. So I think that's not a bad range. But you're talking about three to four months in a couple of cases, a year in other cases."

As seems always to be the case, Trump’s scientists had to backfill over his ungrounded fantasies. In this case, Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, immediately corrected the president:

"Let me make sure you get the ... information. A vaccine that you make and start testing in a year is not a vaccine that's deployable. So he's asking the question, when is it going to be deployable? And that is going to be, at the earliest, a year to a year and a half…”

That timeline has become very familiar to a public hoping for an end to COVID-19. Sadly, in trying to please the president, even Fauci was not getting out the real, grim facts about the likely timeline for a vaccine, or the many obstacles that a vaccine breakthrough will face.

The key issues confronting efforts to vaccinate our way out of the ongoing viral plague are: success, scope, effectiveness, duration, distribution, cost and safety.

First, is the uncertain likelihood of finding a vaccine. We have many that work, but those that do — from polio to mumps, from measles to cervical cancer — took many years or decades to discover. The Ebola vaccine went from laboratory to licensure in about 10 years. Despite 30 years of work, there is no vaccine against AIDS and only a partially effective vaccine for the flu. No one has come up with a vaccine for hepatitis C. 

Even if a promising vaccine were to be found, the scope of a worldwide plague poses an incredible challenge. Polio is nearly eradicated, and the campaign to achieve that began in 1988. Getting a vaccine rapidly to all the places where the virus might lurk and threaten to rebound — including prisons, refugee camps, failed nation-states, slums and conflict zones, not to mention to groups that are being subjected to genocide or forced into detention — is a staggering task.

And if a vaccine is found, it is highly likely not to be 100% effective. Few vaccines are. Mumps is about 80%. Rubella about 95%. Whooping cough 75%. And the flu is 40% to 60% in a good year. This means that in vaccinating either the United States or the world, tens of millions to hundreds of millions may not respond. 

Add to this the fact that vaccines against viruses work for varying periods of time and sometimes require multiple shots. The Mayo Clinic recommends renewing the tetanus shot every 10 years. Whooping cough more frequently. The flu annually. HPV and cholera require multiple doses over months. Vaccinating 330 million Americans, or billions around the world, during a pandemic with multiple shots every few months, a year or every few years is a logistical nightmare.

Will distribution go smoothly? Maybe not. Most of the vaccines sold in the United States are produced by only five large pharmaceutical companies: Sanofi S.A., Pfizer Inc., GlaxoSmithKline, Merck & Co., and Johnson & Johnson. Three of these are U.S.-based; the others are in Europe. Vaccine-manufacturing capacity has been slipping badly for decades. Other nations can and do make vaccines, including India, China and Vietnam, but many of these do not meet FDA quality manufacturing requirements. And there is no guarantee that plants in Europe will honor contracts in a crisis and ship vaccine to us or vice versa. Moreover, the world still needs the proven vaccines for other deadly diseases to be made and distributed lest Ebola or measles or polio come roaring back, so some manufacturing and shipping capacity must go to those. And since vaccines will appear gradually as they get made, the fight to get them first for the rich, for political leaders or health care workers will be vicious with few entities able to bring order to the prioritization.

In addition, how much would the vaccine cost? Some are cheap to make but some using newer technology can run into the hundreds of dollars per dose. In a worldwide plague, costs like that can keep vaccine availability down and the virus circulating for years.

Lastly, how safe ought a vaccine to be during a plague before deciding to manufacture it, especially if it proves hard to modify the manufacturing process once initiated? Would we accept dozens, hundreds, thousands or even hundreds of thousands of deaths from a vaccine that proves inherently risky or difficult to safely administer to billions? And if the vaccine did cause many deaths for any reason, how long would it take to rebuild confidence to try again in a world where many are leery of vaccines?

We need to hope a vaccine is discovered to help us defeat the plague besetting the world. And we need to anticipate and accelerate the many steps needed to get the world vaccinated as fast as we can. What we don’t need is a fantasy complete with unfounded predictions about how easy it will be to vaccinate our way out of this mess. 

Arthur L. Caplan is the director of the Division of Medical Ethics at New York University's Grossman School of Medicine. He is the co-editor of "Vaccine Ethics and Policy," published in 2017.