Why vaccine production is taking so long

Illustration of a turtle carrying a vial of liquid

COVID-19 vaccine makers are under intense pressure to rev up production, but the scale of the challenge is unprecedented — and the speed of production is limited.

Why it matters: Even with help from the federal government and outside companies, vaccine-making is a complex, time-consuming biological process. That limits how quickly companies like Pfizer and Moderna can accelerate their output even during a crisis.

The big picture: With new, more transmissible variants emerging, we’re in a race to get shots into more people’s arms. What would normally take years to set up is being compressed into less than a year, leaving engineers to adapt manufacturing processes on the fly.

  • “The bottlenecks keeps moving. It keeps changing,” said Chaz Calitri, who leads the COVID-19 vaccine program at Pfizer’s Kalamazoo, Mich., facility.
  • “It’s a dream project, but at the same time, it’s the weight of the world,” he tells Axios.

Between the lines: Making vaccines is complex, and the process can be hindered at different steps.

  • “There’s a lot of science and engineering that goes into the manufacturing of any vaccine,” adds Margaret Ruesch, a vice president of Worldwide Research and Development at the company. “It’s molecular biology at a large scale.”

How it works: Axios got a deep dive into the making of Pfizer’s vaccine, a three-phase process that takes weeks from start to finish and involves three different facilities.

1) DNA manufacturing: At a plant near St. Louis, Mo., Pfizer produces DNA that encodes messenger RNA — instructions for cells to make part of the spike protein on the surface of the coronavirus. That primes the immune system to defend against future encounters with the virus.

  • The DNA is produced by bacterial cells, then purified, frozen and shipped to another Pfizer facility in Andover, Mass.

2) Making the mRNA: In Andover, the template DNA is incubated with messenger RNA building blocks in a reactor to make the mRNA. Pfizer has been making two, 40-liter batches per week — up to 10 million doses worth —but expects to double that to four batches per week.

  • After purification and quality checks, the frozen mRNA is shipped to a Pfizer plant in Kalamazoo, Mich.

3) Formulating the vaccine: In Kalamazoo, the mRNA and lipid nanoparticles (oily envelopes that deliver mRNA to cells in the body) are combined and go through a series of filtrations.

  • The bulk vaccine is then transferred to sterile vials, capped, inspected, labeled and packed into containers the size of pizza boxes. Those containers are then stored in sub-zero freezers to await shipment to vaccine distribution sites.

Where it stands: Both Pfizer and Moderna say they’re on track to meet their commitments to deliver 200 million doses each to the U.S. over the first half of the year.

  • The Biden administration yesterday announced it had secured deals for another 200 million doses, bringing the total to roughly 600 million doses, enough to fully vaccinate 300 million Americans by the end of July.
  • Pfizer and its German partner BioNTech recently upped supplies 20% by getting FDA approval to squeeze a sixth dose (instead of five) out of every vial.
  • Yes, but: Extracting a sixth dose requires the use of specialized syringes, which have their own production constraints, as Reuters explained.

The latest: The Biden administration said last week that it will use its wartime powers under the Defense Production Act to give Pfizer priority access to critical components such as filling pumps and filtration units to try to help address bottlenecks.

  • Meanwhile, Pfizer continues to tweak its processes to boost output and says it is adding more suppliers and contract manufacturers to the vaccine supply chain.
  • Novartis, Sanofi and Merck KGaA are among 10 contract manufacturers that will help the company manufacture more doses, a Pfizer spokesman tells Axios.
  • Pfizer and BioNTech will still do most of the work in their facilities, but contract manufacturers will help with specific tasks like formulating lipid nanoparticles, sterile filling, inspection and packaging.

Ordering other drug manufacturers to stand up manufacturing lines to whip up extra batches of Pfizer’s or Moderna’s vaccines is not an efficient or practical way for the federal government to quickly increase supplies, some experts say.

  • “Making vaccines is not like making cars, and quality control is paramount,” Stanley Plotkin, a vaccine industry consultant, told Kaiser Health News. “We are expecting other vaccines in a matter of weeks, so it might be faster to bring them into use.”

What to watch: Johnson & Johnson has requested emergency use authorization from the FDA for its single-dose vaccine, but is reportedly lagging in production, the NYT first reported last month.

The pandemic’s coming new normal

Photo illustration of the Freedom from Want image by Norman Rockwell with all the participants of the dinner wearing surgical masks.

As both vaccinations and acquired immunity spread, life will likely settle into a new normal that will resemble pre-COVID-19 days— with some major twists.

The big picture: While hospitalizations and deaths are tamped down, the novel coronavirus should recede as a mortal threat to the world. But a lingering pool of unvaccinated people — and the virus’ own ability to mutate — will ensure SARS-CoV-2 keeps circulating at some level, meaning some precautions will be kept in place for years.

Driving the news: On Tuesday, Johnson & Johnson CEO Alex Gorsky told CNBC that people might well need a new coronavirus vaccine annually in the years ahead, much as they do now for the flu.

  • Gorsky’s comments were one of the clearest signals that even as the number of vaccinated people rises, the mutability of SARS-CoV-2 means the virus will almost certainly be with us in some form for years to come.

Be smartThat sounds like bad news — and indeed, it’s much less ideal than a world in which vaccination or infection conferred close to lifelong immunity and SARS-CoV-2 could be definitively conquered like smallpox.

  • With more contagious variants spreading rapidly, “the next 12 weeks are likely to be the darkest days of the pandemic,” says Michael Osterholm, the director of the University of Minnesota’s Center for Infectious Disease Research and Policy.
  • But the apparent effectiveness of the vaccines in preventing hospitalizations and death from COVID-19 — even in the face of new variants — points the way toward a milder future for the pandemic, albeit one that may be experienced very differently around the world.

Details: From studying what happened after new viruses emerged in the past, scientists predict SARS-CoV-2 will eventually become endemic, most likely in a seasonal pattern similar to the kind of coronaviruses that cause the common cold.

  • That’s nothing to sneeze at — literally, it will make us sneeze — but as immunity levels accumulate throughout the population, our experience of the virus will attenuate, and we’ll be highly unlikely to experience the severe death tolls and overloaded hospitals that marked much of the past year.

Yes, but: The existence of a stubborn pool of Americans who say they won’t get vaccinated — as well as the fact that it may take far longer for children, whom the vaccines have yet to be tested on, to get coverage — will give the virus longer legs than it would otherwise have.

  • “This will be with us forever,” says Osterholm. “That’s not even a debate at this point.”

What’s next: This means we can expect the K-shaped recovery that has marked the pandemic to continue, says Ben Pring, who leads Cognizant’s Center for the Future of Work.

  • With the virus likely to remain a threat, even if a diminished one, “those who are more stuck in the analog world are really going to continue to struggle,” he says.
  • Health security will also become a more ingrained part of daily life and work, which means temperature checks, masks, frequent COVID-19 testing and even vaccine passports for travel are here to stay.

The catch: That’s not all bad — the measures put in place to slow COVID-19 have stomped the flu and other seasonal respiratory viruses, and if we can hold onto some of those benefits in the future, we can save tens of thousands of lives and billions of dollars.

  • If the inequalities seen in the early phase of the vaccine rollout persist, COVID-19 could become a disease of the poor and disadvantaged, argues Mark Sendak, the co-founder and scientific adviser for Greenlight Ready, a COVID-19 resilience system that grew out of Duke Health.
  • Sendak points to the example of HIV, a disease that is entirely controllable with drugs but continues to exert a disproportionate toll on Black Americans, who take pre-exposure prophylactic medicine at much lower rates.

“If we go back to ‘normal,’ then we have failed.”

— Mark Sendak

What to watch: Whether the vaccine rollout can be adapted to reach hard to find and hard to persuade populations.

  • The Biden administration announced yesterday that it will start delivering vaccines directly to community health centers next week in an effort to promote more equity in the vaccine distribution process.
  • As the administration rolls out new COVID-19 plans, it needs to “invest in the community health care personnel” who can ensure that no one is left behind, says Sendak.

The bottom line: While SARS-CoV-2 has proven it can adapt to a changing environment, so can we. But we have to do so in a way that is fairer than our experience of the pandemic has been so far.

Most seniors aren’t vaccinated yet

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Most seniors have not gotten a COVID-19 vaccine yet, according to an analysis from the Kaiser Family Foundation.

Why it matters: There’s simply not enough vaccine available right now to take on every priority, Axios’ Marisa Fernandez writes.

  • Even as states eye the next phase of the process and additional high-risk groups clamor for access, there’s still a long way to go just in protecting most vulnerable.

By the numbers: In the first month of vaccinations, about 29% of recipients were 65 or older, per KFF.

  • The first round of vaccines was directed primarily at health care workers and the residents of long-term care facilities.

Where it stands: West Virginia has vaccinated the most seniors at 34%, thanks to a focused effort in nursing homes.

  • Nine states — West Virginia, North Carolina, Florida, Mississippi, Delaware, Texas, Michigan, New Jersey, and Wisconsin and Washington, D.C. — report vaccinating at least 20% of seniors.

Yes, but: Demographic data aren’t available in some states and cities, which will make it hard to track how well the U.S. is addressing high-risk groups as more people become eligible.

Where the pandemic has been deadliest

Image result for Ratio of COVID-19 deaths to population Map: Michelle McGhee and Andrew Witherspoon/Axios

In the seven states hit hardest by the pandemic, more than 1 in every 500 residents have died from the coronavirus.

Why it matters: The staggering death toll speaks to America’s failure to control the virus.

Details: In New Jersey, which has the highest death rate in the nation, 1 out of every 406 residents has died from the virus. In neighboring New York, 1 out of every 437 people has died.

  • In Mississippi, 1 out of every 477 people has died. And in South Dakota, which was slammed in the fall, 1 of every 489 people has died.

States in the middle of the pack have seen a death rate of around 1 in 800 dead.

  • California, which has generally suffered severe regional outbreaks that don’t span the entire state, has a death rate of 1 in 899.
  • Vermont had the lowest death rate, at 1 of every 3,436 residents.

The bottom line: Americans will keep dying as vaccinations ramp up, and more transmissible variants of the coronavirus could cause the outbreak to get worse before it gets better.

  • Experts also say it’s time to start preparing for the next pandemic — which could be deadlier.

“I got the vaccine…now what can I do?”

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A family member in her 70s called with the great news that she received her first dose of the COVID vaccine this week. She mentioned that she was hoping to plan a vacation in the spring with a friend who had also been vaccinated, but her doctor told her it would still be safest to hold off booking travel for now: “I was surprised she wasn’t more positive about it. It’s the one thing I’ve been looking forward to for months, if I was lucky enough to get the shot.” 

It’s not easy to find concrete expert guidance for what it is safe (or safer?) to do after receiving the COVID vaccine. Of course, patients need to wait a minimum of two weeks after receiving their second shot of the Pfizer or Moderna vaccines to develop full immunity.

But then what? Yes, we all need to continue to wear masks in public, since vaccines haven’t been proven to reduce or eliminate COVID transmission—and new viral variants up the risk of transmission. But should vaccinated individuals feel comfortable flying on a plane? Visiting family? Dining indoors? Finally going to the dentist?
 
It struck us that the tone of much of the available guidance speaks to public health implications, rather than individual decision-making. Take this tweet from CDC director Dr. Rochelle Walensky. A person over 65 asked her if she could drive to visit her grandchildren, whom she hasn’t seen for a year, two months after receiving her second shot. Walensky replied, “Even if you’ve been vaccinated, we still recommend against traveling until we have more data to suggest vaccination limits the spread of COVID-19.” 

From a public health perspective, this may be correct, but for an individual, it falls flat. This senior has followed all the rules—if the vaccine doesn’t enable her to safely see her grandchild, what will? It’s easy to see how the expert guidance could be interpreted as “nothing will change, even after you’ve been vaccinated.”

Debates about masking showed us that in our individualistic society, public health messaging about slowing transmission and protecting others sadly failed to make many mask up.

The same goes for vaccines: most Americans are motivated to get their vaccine so that they personally don’t die, and so they can resume a more normal life, not by the altruistic desire to slow the spread of COVID in the community and achieve “herd immunity”. 

In addition to focusing on continued risk, educating Americans on how the vaccinated can make smart decisions will motivate as many people as possible to get their shots.

Disparities may worsen as vaccine eligibility widens

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Early data on vaccine distribution by race and ethnicity show a mismatch between those population groups receiving the vaccine, and those that have been hardest hit by the pandemic. As the graphic above shows, Black and Hispanic Americans have thus far been vaccinated at considerably lower rates in many states compared to their share of population as a whole—and these disparities are likely to worsen as states shift focus to senior populations for priority access, moving away from prioritizing essential workers, who tend to be more racially diverse.

The White population skews older, which stands to widen disparities in the near-term. Another compounding issue: vaccine hesitancy.

A recent Morning Consult poll found that, despite an overall increase in overall vaccine willingness, Black Americans remain the most hesitant, with only 48 percent willing to get the vaccine.

Meanwhile, Black and Hispanic Americans continue to be disproportionately impacted by COVID, with hospitalization and death rates nearly three to four times greater than those of White Americans.

Hesitancy will become an increasingly urgent problem as larger swathes of the population become eligible for vaccination, especially given that communities of color tend to be younger, as shown above.

Turning the tide in the battle against the virus

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The national COVID indicators all continued to move in the right direction this week, with new cases down 16 percent, hospitalizations down 26 percent, and deaths (while still alarmingly high at more than 3,000 per day) down 6 percent from the week prior.

More good news: both nationally and globallythe number of people vaccinated against COVID now exceeds the total number of people infected with the virus, at least according to official statistics—the actual number of coronavirus infections is likely several times higher.

On the vaccine front, Johnson & Johnson filed with the Food and Drug Administration (FDA) for an Emergency Use Authorization for its single-dose COVID vaccine, which could become the third vaccine approved for use in the US following government review later this month. The J&J vaccine is reportedly 85 percent effective at preventing severe COVID disease, although it is less effective at preventing infection than the Pfizer and Moderna shots.

Elsewhere, TheLancet reported interim Phase III results for Russia’s Sputnik V vaccine trials, showing it to be 91 percent effective at preventing infection, and a new study found the Oxford-AstraZeneca vaccine to be 75 percent effective against the more-contagious UK virus variant.

Amid the positive vaccine news, the Biden administration moved to accelerate the vaccination campaigninvoking the Defense Production Act to boost production and initiating shipments directly to retail pharmacies. With the House and Senate starting the budget reconciliation process that could eventually lead to as much as $1.9T in stimulus funding, including billions more for vaccines and testing, it feels as though the tide may be finally turning in the battle against coronavirus.

While the key indicators are still worrisome—we’re only back to Thanksgiving-week levels of new cases—and emerging variants are cause for concern, it’s worth celebrating a week that brought more good news than bad.

Best to follow Dr. Fauci’s advice for this Super Bowl weekend, however: “Just lay low and cool it.”

How soon can we achieve immunity through vaccinations?

Over the weekend I realized that my son Henry, born in June 2019, has lived more than half of his life in the pandemic era. He’s too young to be cognizant of it, of course, but my wife and I are acutely conscious of the experiences his older brother had already enjoyed by the time he was Henry’s age, things that are impractical or impossible in the moment.

He’s not alone in that, of course. Most Americans are experiencing some ongoing deprivations because of the pandemic. (Most of those for whom the pandemic is not imposing unusual restrictions are, ironically, probably contributing to the pandemic’s extent and duration.) Just about everyone in the United States is eagerly scanning the horizon for signs of normalcy — as we have been for months, occasionally spotting oases that too often turn out to be mirages.

So when will we return to some semblance of normal? It’s hard to say with certainty. The best tool we have to reach that point, though, is the broad deployment of the vaccines approved for emergency use by the government. But even the existence of those vaccines can’t completely answer the question.

For example, the rate at which the vaccines are deployed makes a massive difference. A pace of 2 million shots per day as opposed to 1 million seems like a subtle distinction but, obviously, means achieving immunity for recipients twice as fast.

What level of immunity is necessary is a question of its own. Do we need 70 percent of the country to have been immunized? Or, as infectious-disease expert Anthony S. Fauci has recently said, is the figure closer to 80 or 85 percent?

When doing this calculation, do you include the 26 million Americans who have already had coronavirus infections? What about young people? The vaccine trials included only those age 16 and over. Those younger have constituted about a 10th of the total infections. And what vaccine are we talking about? The Pfizer and Moderna iterations require two shots; the vaccine from Johnson & Johnson requires only one.

All of these factors affect how we can figure out when the country might hit the herd-immunity mark. If we assume that young people will be included among those needed to be vaccinated — a complicated question on its own — the calculator below will allow you to figure out when immunity might be achieved at various immunization rates.

At this rate, the country would reach 70 percent herd immunity through vaccinations by Nov. 10

How we calculate this:
There are about 330 million Americans, meaning that we need 231 million to be resistant to the virus to hit 70 percent immunity. We can take out the 5.8 million Americans who’ve already been vaccinated. That leaves 211.3 million people to be vaccinated.

From there the math is straightforward: doing two-shot vaccinations at a rate of 1.5 million shots per day means it will take 282 days to complete the job.

Bear in mind that sliding the little bar to determine how quickly shots are administered is far easier than actually scaling up the infrastructure to do so. President Biden’s original target for daily vaccinations was 1 million; he recently increased it to 1.5 million. At that rate, we’re still months from resolution. But because administering the vaccine is more complicated and requires more tracking than vaccinations such as that for the seasonal flu, it’s necessarily trickier to scale up.

At this point, the more urgent concern is the efficacy of the vaccine against any variants of the virus that might emerge. Manufacturers have already noted that the vaccine works less well against a virus variant first identified in South Africa, though the vaccines are still broadly effective, particularly at protecting the recipient from severe illness or death after infection.

Well, that and the fact that a fifth of Americans said in a recent Kaiser Family Foundation poll that they won’t get the vaccine or would do so only if it was required. Happily, more Americans are now saying they’re eager to get a vaccine.

The faster we get people immunized, the better we protect against the emergence of new mutations that prove less able to be controlled by the vaccines. The faster we get shots in arms, as the phrasing has it, the faster we get back to normal.

Which would be nice for all of us, including my 1-year-old.