The Vaccine War

The U.S. will need to reorient its economy around vaccination until COVID is gone

The U.S. vaccination drive is not going well. 23 days after the first vaccine was approved by the FDA, only 1.42% of the U.S. population has been vaccinated. The governor of New York is threatening criminal penalties on anyone who violates the vaccine priority ordering, while simultaneously threatening to cut off vaccine supplies to any hospital that doesn’t use up its initial quota within a week. Meanwhile, a California hospital managed to give out 600 doses in 2 hours when its freezer broke, raising the question of why it didn’t do that in the first place. (When I suggested that perhaps our vaccination effort was being slowed down by a rigid priority system that our providers didn’t have the logistical capacity to implement quickly, a friend in public health angrily declared that I wanted to “give up on the sick and the aged.”)

Meanwhile, some experts are suggesting delaying the second dose of vaccine in order to give out first doses more quickly (since the first dose does appear to provide significant protection after 2 weeks or so), while government officials are considering cutting doses in half to stretch available supplies. Some other experts worry this will increase the virus’ ability to evolve resistance to the vaccines.

In other news, the President continues to completely ignore the raging pandemic and focus entirely on his efforts to overturn the election and become a dictator, thousands are dying every day, and a more easily transmissible “supercovid” virus variant is now being discovered in state after state.

So…yes, things are bad here.

But it’s important to realize that these vaccine distribution problems will be worked out. Providers will figure out how to accelerate the process. Local and state governments more intelligent than New York’s will figure out how to be more flexible about prioritization. Joe Biden will be President in two weeks, and will begin to pour much-needed resources, coordination, and leadership into the process.

At that point, however, the battle to vaccinate our population will shift. Problems in distribution will give way to bottlenecks in vaccine supply. The U.S. has only distributed 15 million first doses so far — about 5% of the amount it needs to vaccinate the entire population. With “supercovid” variants basically uncontainable and threatening to overwhelm the population, production speed is of the essence.

But in fact, the biggest threat isn’t even “supercovid” — it’s much bigger than that. As far as we know, these new variants are more contagious but are still prevented by existing vaccines (though there are some worries about the South African strain, which has more mutations to the crucial spike protein that the vaccines all target).

If the virus mutates more, however, it could “escape” both the vaccines and natural immunity. At that point we would all become susceptible to COVID again — even people who have had the virus or people who have been vaccinated. And the pandemic would start over like it was January 2020.

Usually, coronaviruses evolve slowly, but there are reasons to think this one will evolve faster. There are a LOT of COVID patients out there, which means more hosts in which to evolve and mutate. Humanity is putting evolutionary pressure on the virus with convalescent plasma, and possibly with monoclonal antibody treatments. That might eventually make the virus resistant to vaccines. Meanwhile, some worry that the one-shot or half-dose vaccine regimens could do the same. And the presence of large numbers of antivaxxers all over the world means that COVID will probably continue to have an un-vaccinated population in which to circulate and mutate for quite some time.

Thus, there seems to be a decent probability that the U.S. and other countries will find themselves in the position of having to re-vaccinate their entire populations for COVID at some point over the next year or two. This may even happen multiple times. The nightmare scenario is that each of these resurgent, vaccine-resistant outbreaks causes millions more deaths and shuts down large portions of the economy for more years, turning the pandemic year into the pandemic decade.

We obviously don’t want this to happen. But fortunately, we have a way to prevent this — mass rapid re-vaccination. If resistant COVID strains emerge, we will have to quickly modify our vaccines to protect against the new variants, and quickly re-inoculate our entire populace. Possibly several times.

This will require three things.

First, it will require a rapid approval process for tweaked vaccines. mRNA vaccines like Pfizer’s and Moderna’s are pretty easy to tweak to protect against new virus strains. But if the new vaccines have to go through the same months-long trial process we endured this year — faster than any similar approval process in history, but still not fast enough — we will be screwed.

Fortunately, our regulatory agencies seem to realize this. FDA director Stephen Hahn and Center for Biologics Evaluation and Research director Peter Marks recently stated that tweaked vaccines would have to undergo only very small rapid trials to make sure the tweaked version raises an immune response. This is similar to the approval process for new flu shots, and would allow new vaccines to be approved in a few weeks or less.

Our technology for fighting viruses has gotten pretty damn amazing.

But that’s by far the smaller of the challenges. In addition to rapid approval, we will need capacity for rapid production. We will need to be able to manufacture enough of the new vaccine to immunize the entire population within a matter of weeks.

That will be difficult. The supply chains for these vaccines are highly complex, involving stuff like shark liver oil and horseshoe crab blood. The production processes are long, delicate and complicated. We will need to secure adequate supplies of all necessary materials, and maintain enough spare production capacity to immediately ramp up to a tens of millions of doses per day. This is NOT a case where we can afford lean or just-in-time manufacturing.

Finally, the U.S. will need to maintain a rapid distribution system capable of re-vaccinating the entire population within weeks. We are currently building up a system like that, but we will not be able to afford to scale it down or dismantle it once the initial vaccination drive has been completed. We must stockpile all the necessary materials (syringes, etc.) and keep large numbers of trained workers and volunteers on standby in case rapid re-vaccination becomes necessary.

And the money has to be there. The federal government has to set up a funding policy by which tens of billions of dollars can be rapidly deployed to produce and distribute a new vaccine. Only the federal government has pockets deep enough to do this; it cannot be left to the states.

Fortunately, Biden will be massively better than the hapless, disinterested Trump. He has declared his intent to invoke the Defense Production Act, provide adequate funding, and create a federal plan for vaccination.

But just the initial effort won’t be sufficient. Given the possibility that virus may slip its chains and once again ravage the land, the United States needs to reorient much of its economy toward rapid vaccine production and distribution until COVID has ended as a threat.

We are in a war against COVID, and this vaccination drive is just one battle. As we did in World War 2, we must transform large segments of our economy in order to fight that war. If we work hard now, we can create the spare capacity and the production and distribution networks necessary to rapidly defeat any new vaccine-resistant COVID strains that emerge. We must do this. We have no other choice.

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