COVID ARTICLE

By Rebecca L. Weintraub, Laura Subramanian, Ami Karlage, Iman Ahmad, and Julie Rosenberg

Analysis

COVID-19 Vaccine To Vaccination: Why Leaders Must Invest In Delivery Strategies Now

ABSTRACT Worldwide, leaders are implementing nonpharmaceutical interventions to slow transmission of the novel coronavirus while pursuing vaccines that confer immunity to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. In this paper, we will describe lessons learned from past pandemics and vaccine campaigns about the path to successful vaccine delivery. The historical record suggests that to have a widely immunized population, leaders must invest in evidence-based vaccine delivery strategies that generate demand, allocate and distribute vaccines, and verify coverage. To generate demand, we must understand the roots of vaccine hesitancy, engage trusted sources of authority to advocate for vaccination, and commit to longitudinal engagement with communities. To allocate vaccines, we must allow qualified organizations and expert coalitions to determine evidence-based vaccination approaches and generate the political will to ensure the cooperation of local and national governments. To distribute vaccines, we must ensure that the people and organizations with expertise in manufacturing, supply chains, and last-mile distribution are positioned to direct efforts. To verify vaccine coverage, we must identify vaccination tracking systems that are portable, interoperable, and secure. Lessons of past pandemics suggest that nations should invest in evidence- informed strategies to ensure that COVID-19 vaccines protect individuals, suppress transmission, and minimize disruption to health services and livelihoods. [Editor’s Note: This Fast Track Ahead Of Print article is the accepted version of the peer-reviewed manuscript. The final edited version will appear in an upcoming issue of Health Affairs.]

W orldwide, public health lead- ers are recommending a com- bination of nonpharmaceuti- cal interventions to slow transmission of the novel co-

ronavirus. Scientists are clear, however, that nonpharmaceutical interventions alone will not end transmission of coronavirus disease 2019 (COVID-19). A safe and effective COVID- 19 vaccine is a critical component for reducing

COVID-19-related illnesses, hospitalizations, and deaths and for restoring the global economy. To this end, governments and investors are

earmarking unprecedented investments to pre- pare billions of doses of COVID-19 vaccines. Vac- cine development for COVID-19 has progressed faster than for any other pathogen in history.We cannot yet predict the efficacy and long-term safety of these vaccines, especially since several of the leading contenders are based on new tech-

doi: 10.1377/hlthaff.2020.01523 HEALTH AFFAIRS 40, NO. 1 (2021): 1–9 ©2020 Project HOPE— The People-to-People Health Foundation, Inc.

Rebecca L. Weintraub (rebecca@globalhealthdelivery .org) is director of Better Evidence, Ariadne Labs, Harvard T. H. Chan School of Public Health and Brigham and Women’s Hospital, and an associate physician at Brigham and Women’s Hospital, all in Boston, Massachusetts.

Laura Subramanian is a senior specialist at Ariadne Labs.

Ami Karlage is a writing specialist at Ariadne Labs.

Iman Ahmad is a research assistant at Better Evidence, Ariadne Labs.

Julie Rosenberg is deputy director of Better Evidence, Ariadne Labs.

January 2021 40:1 Health Affairs 1

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nology platforms like mRNA without proven track records. Pfizer and BioNTech recently re- leased promising initial results suggesting their vaccine may be more than 90% effective,1 but three critical areas remain to be demonstrated: robust evidence of efficacy, evidence of safety with datafromthousandsofpatients,andvaccine doses manufactured consistently at the highest quality standards. The U.S. Food and Drug Ad- ministration (FDA) has stated that COVID-19 vaccines will be approved only if they are shown to reduce disease by at least 50% and to be safe in large-scale clinical trials.2 Experts recommend investing in a wider, more diversified portfolio of vaccines as they predict first-generation vac- cines will not be effective enough to end the pandemic on their own.3 Additionally, some models predict that it will probably take more than a year to produce enough vaccines to inoc- ulate the world’s 50 million medical staff, and that it could be September 2023 before we have enough doses for the world.3 Assuming safe and effective vaccines are developed, having a supply of vaccines is only the first step in ensuring that vaccines actually get delivered to populations. To ensure that COVID-19 vaccines lead to wide-

spread vaccination and that 60%–70% of the population has immunity,4 governments and public health leaders need to prepare transpar- ent, evidence-based strategies to promote COVID-19 acceptance and implement equitable and effective vaccine delivery. This will require four interconnected strategies: generating de- mand for the vaccine, allocating the vaccine, dis- tributing the vaccine, and verifying coverage. Researchers have previously documented the

challenges of getting life-saving supplies or med- ications to populations and termed “implemen- tation bottlenecks” as key cause of the failure to translate known interventions into robust deliv- ery of services.5 We have studied implementation bottlenecks and strong delivery systems over the past decade.6 In this paper, we will draw on the growing public health and social and behavioral science evidence base from previous epidemics and vaccine campaigns to describe the lessons learned about successful less successful vaccine delivery. These lessons should aid leaders in de- signing COVID-19 vaccine delivery systems that lead to an immune population.

Generating Demand For Vaccine Requires Targeted Services We will ultimately fail to contain the COVID-19 pandemic if not enough people accept a vaccine. For a new vaccine developed with unparalleled speed, generating demand requires understand- ing people’s perceptions of vaccine safety and

efficacy and implementing communication cam- paigns tailored to specific populations. Since vaccination campaigns require healthy

people to seek intervention, such campaigns re- quire generating demand. Vaccine confidence was already decreasing worldwide prior to the COVID-19 pandemic for cultural, political, and personal reasons.7 The U.S. Epidemic Intelli- gence Service, which addresses public health emergencies, maintains that a pandemic is as much a communications emergency as a medical crisis. The WHO Increasing Vaccination Model acknowledges that people’s thoughts and feel- ings about vaccines, including their perceived risk, worry, confidence, trust, and safety con- cerns, can affect their motivation to get vaccinat- ed.8 Vaccine hesitancy was cited in 2019 as one of thetop 10 threats to global health.8,9 Consequent- ly, we must work proactively to mitigate global hesitancy for COVID-19 vaccines. The complexity of generating demand for

COVID-19 vaccines has increased with the rising tide of misinformation and vaccine hesitancy. One recent U.S. survey found that if a COVID- 19 vaccine were available for free before the No- vember election, only 42% of U.S. adults would get it, with reasons for hesitancies including vac- cine-specific concerns, a need for more informa- tion, anti-vaccine attitudes or beliefs, and a lack of trust.10 Public trust in government approval processes has eroded as FDA emergency use au- thorizations for hydroxychloroquine and conva- lescent plasma have been revoked (the former) or faced scrutiny (the latter).11

Strategies to stimulate COVID-19 demand must be based on perceptions, attitudes, and public trust. Inthepast, celebritiesand respected public figures have proven successful in improv- ing public attitudes, trust, and uptake of health interventions, including vaccines.12 In 1956, for example, Elvis Presley got a polio vaccination on national TV in hopes of motivating suscepti- ble teenagers to get vaccinated, and vaccination rates increased over the next six months.13

In 2003, basketball icon Magic Johnson an- nounced he was HIV positive, which led to an increased level of knowledge and curiosity about the disease and increased HIV testing.14 Social scientists have studied how influencers—cultur- al and public health leaders—help shape individ- uals’ knowledge, attitudes, behaviors, and out- comes. Influencers have been a powerful voice during the COVID-19 pandemic, with social me- dia platforms serving as a primary source for health information.15 We can leverage this power by engaging influencers in promoting COVID-19 vaccines through storytelling, information shar- ing, and other forms of public engagement— both on social media and in other communica-

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tion venues. The health care workforce also has an impor-

tant role to play in promoting vaccine accep- tance. For example, a systematic review of shin- gles (herpes zoster) vaccine acceptance among older adults showed that primary care physician recommendations consistently played a signifi- cant role in generating high demand for the vac- cine.16 Given the COVID-19 vulnerabilities for adults over the age of 65, the health care work- force could play a similar role in providing edu- cation and counsel and in building trust in the COVID-19 vaccine portfolio among vulnerable adults. Engaging grassroots and local leadership are

also essential for demand generation. Under Surgeon General Dr. David Satcher, 30 black churches partnered with the health care system to successfully increase immunization rates for all childhood vaccines among black children.17

During a recent measles outbreak among the Orthodox Jewish community in New York, a group of Orthodox Jewish nurses formed a non- profit organization and became local ambassa- dors to educate the community, counter misin- formation in anti-vaccination pamphlets, and shift the trend on vaccination.18 The nurses worked with health careproviders and facilitated community discussions, including partnering with parents to demonstrate how to identify mis- information.18 The success of the initiative rein- forced the importance of both preparing the local workforce and enhancing the skills of trusted, local community influencers. Similar efforts tailored to local community needs have proven essential globally. The Meningitis Vac- cine Project’s communications efforts in sub- Saharan Africa included campaigns tailored to specific sub-populations—such as in Burkina Faso, where the project targeted adolescents via peer education, employed targeted social mo- bilization messages, gained the participation of celebrities, and organized vaccination lines for young boys only as well as vaccination cam- paigns in universities and schools.19

Vaccine industry leaders have already taken steps to promote confidence in COVID-19 vac- cines. In September, with mounting fears that the administration would fast track the approval of COVID-19 vaccines, nine pharmaceutical lead- ers released a joint statement promising to up- hold scientific integrity and to refuse to apply for approval of a COVID-19 vaccine until sufficient trial data could be aggregated.20 Selected compa- nies have also released their clinical trial proto- cols in the interest of transparency and pub- lic trust. The global community is also coming together

in a coordinated effort to promote COVID-19

vaccine acceptance. Experts in anthropology, communication, and other social sciences re- cently launched the Working Group on Readying Populations for COVID-19 Vaccines, which de- veloped recommendations on how to integrate evidence from behavioral and communication sciences, timely data, and empirically-based ad- vice to support vaccine delivery.21 They suggest further investment in research, integration of user-centric approaches such as speaking to pa- tients’ own values, and research-practitioner partnerships that engage community-based groups in the design and monitoring of vaccine delivery.21 The working group’s report also high- lights the central role of human factors—includ- ing identity, worldview, understandings of dis- ease, perceptions of risk, and social factors affecting access—in vaccine uptake.21 The report highlights the role of involving trusted commu- nity spokespeople to convey salient messages.21

The evidence base is robust: in order to gener- ate demand for COVID-19 vaccines, we need to invest in multifaceted, longitudinal engagement with communities and adapt engagement strat- egies to change attitudes and beliefs over time.20

Urgent and ongoing study of public concerns regarding the vaccine portfolio’s efficacy, safety, benefits, and initial scarcity will be essential to tailor communication efforts around COVID-19 vaccination and ensure that the vaccine leads to vaccination.22

Vaccine Demand Meets Supply: Allocating Vaccines In A Pandemic Assuming demand can be generated for COVID- 19 vaccines, the question remains about who should be first in line to receive them. Unfortu- nately, scarce resources too often go to the most privileged. Decisions about how to allocate the limited initial supply of COVID-19 vaccine doses should leverage the expertise of the biological and social sciences, with the goals of interrupt- ing transmission of the pathogen, minimizing disease burden, and maximizing societal func- tioning. Epidemiologists arescouring an arrayof disparate data sources and generating models to inform COVID-19 vaccine prioritization,23 with the assumption that many vaccine candidates will require a two-dose course. Further invest- ment is needed to bolster and aggregate global data so that leaders can understand and compare the various scenarios and plan for COVID-19 vaccines. At the global level, WHO and other stakehold-

ers have formed the ACT (Access to COVID-19 Tools) Accelerator, a global collaboration to aug- ment equitable access to COVID-19 tests, treat- ments, and vaccines.24 COVAX—led by the WHO,

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Gavi, the Vaccine Alliance, and the Coalition for Epidemic Preparedness and Innovations (CEPI)—is a global mechanism under the ACT Accelerator to operationalize the “equitable ac- cess and allocation of COVID-19 health prod- ucts,” including vaccines. Under COVAX, partic- ipating countries will receive COVID-19 vaccine doses as follows: In Phase 1, allocation is propor- tional to countries’ populations—covering up to 20% of the population including most of the at- risk groups. In phase 2, allocation is based on risk assessments of each country’s COVID-19 threat and health system/population vulnerabil- ity.25 This allocation strategy is supported by a model indicating that an 80%–effective COVID- 19 vaccine distributed in proportion to popula- tion could prevent 61% of global deaths; if it were distributed to high-income countries first, it could prevent only 33% of deaths.26

In order to reduce mortality and protect health care workers, the WHO also released a Global Allocation Framework for COVID-19 products recommending that health care workers, elderly adults, and other high-risk groups receive high- est priority to receive a vaccine. This global framework acknowledges the need for ongoing flexibility due to the evolving pandemic trajecto- ry and portfolio of products available and recom- mends a global access mechanism that meets the needs of all countries.27

Despite this evidence-based guidance, COVID- 19 pandemic preparedness has been thwarted for months by politics—including vaccine nationalism—as some countries are procuring vast quantities of doses even before the comple- tion of clinical trials.28 The World Health Orga- nization and 181 countries have put their diplo- matic weight behind the COVAX initiative to pool investment and promote global vaccine access. However, as of October 2020, the United States, Russia, and India have opted out of the plan.29

This nation-first strategy is not new. Soon after the WHO declared H1N1 a pandemic in 2009, high-income countries—specifically Australia, Canada, and the United States—purchased ini- tially scarce vaccine supplies for their own citi- zens, leaving little vaccine supply for low- and middle-income countries (LMICs) that also needed it.30 The WHO responded by implement- ing a formal global process for vaccine allocation involving, among other tactics, the donation of up to 10% of high-income countries’ vaccine supplies to LMICs.31 However, the WHO faced formidable barriers to ensuring equitable global vaccine allocation, most notably the lack of a global regulatory framework to enforce it.30

Thus, high income countries only made dona- tions to LMICs once their own vaccine needs were satisfied, leaving LMICs with a vaccine

shortage.30

Because pandemics exacerbate existing in- equalities, a vaccine must be allocated on the basis of what it will take to stop transmission and protect everyone (not just those who can pay for vaccines) in order to maximize impact. These goals for allocation are relevant at the

local level as well as at the global level. The Na- tional Academies of Science, Engineering, and Medicine (NASEM) published recommenda- tions about who should have priority in the US for vaccines.32 They recommend that Operation Warp Speed (the Trump administration’s public- private effort to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics) allocate vaccine doses proportionally to states based on population and that states then hold 10% for hotspots and adopt a phased approach to alloca- tion.32 The CDC has also released a prioritization framework in its COVID-19 vaccination program interim playbook.33 Meanwhile, U.S. states are submitting COVID-19 vaccination plans to the CDC that include phased allocation strategies.34

For example, Maryland’s plan prioritizes first responders, health care workers, nursing home residents and staff, and other essential work- ers.35 States can use a COVID-19 vaccine alloca- tion planning tool to assist with operationalizing their allocation plans.36

These recommendations are similar to alloca- tion procedures for the 2009 H1N1 pandemic, in which each U.S. state received population-based allocations of H1N1 vaccine supply, and local governments were then tasked with allocating vaccine supplies within communities based on priority group recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP).37 The ACIP priority groups for vaccina- tion (health care workers, pregnant women, children) were identified with the goals of mini- mizing the burden of illness, protecting health care system functions, and targeting key groups responsible for large amounts of disease trans- mission.38 While the ACIP recommendations had the benefit of standardizing allocation at multi- ple levels, local variation in applying these rec- ommendations led to some confusion among the public about eligibility for H1N1 vaccines, which can interfere with demand.39

The example of H1N1 highlights the potential bottlenecks in implementing allocation strate- gies at the global, national, and local levels as well as the need for careful planning and coordi- nation to ensure consistency of allocation strat- egies at every level. With the early, limited sup- plies of H1N1 vaccines purchased by high- income countries rather than allocated to all countries with high rates of transmission, vac-

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cine delivery failed to end the global pandemic precipitously, as vaccines helped contain the H1N1 epidemics in high-income countries but did not reach developing countries until several months later. Avoiding a similar situation for COVID-19 vaccines will require global coordina- tion and political will. Political will is essential to implementing

allocation guidelines. As an example, in the Meningitis Vaccine Project, key multilateral, NGO, and public sector stakeholders worked to- gether, including hosting a high-profile vaccine launch ceremony, in the presence of key African political leaders and partners. News of the launch was covered around the globe and gener- ated interest in rolling out the MenAfriVac vac- cine in sub-Saharan Africa.19 The Global Polio Eradication Initiative also benefited from strong political will; Rotary International and UNICEF engaged heads of state and political bodies,40

which translated into powerful efforts to procure and allocate vaccine where it was most needed. Equitable vaccine allocation will require glob-

al institutions to generate enough political will within nations to implement and monitor allo- cation guidelines. As all nations will face an ini- tially scarce vaccine supply, a global allocation mechanism will be vital to efficiently and effec- tively decreasing transmission.

Vaccine Supply: Distributing Vaccine Where It Is Needed GAVI currently estimates that we will need bil- lions of doses of vaccines in order to successfully establish herd immunity to COVID-19.41 Ensur- ing that high-quality vaccine doses can be man- ufactured and efficiently transported to the priority populations will require responsive sys- tems keeping pace with changes in transmission. Over the last two decades, GAVI has supported 496 vaccine programs in the 73 poorest coun- tries and helped supply them with 600 million vaccine doses every year.42 While GAVI’s central focus is expanding access to new and under-used vaccines for vulnerable children, it has sup- ported countries to provide vaccines for people of all ages for epidemic-causing diseases such as yellow fever and meningitis. The supply-chain challenges we face with

COVID-19 are hardly new.43 For example, the WHO process for managing the tens of millions of donated smallpox vaccine doses was long and complicated early in the smallpox eradication efforts.WHO was responsible for receiving sam- ples of all dose batches, sending them for exten- sive testing at a single laboratory, then coordi- nating with the producer to have those vaccine batches delivered to recipient countries.43

In 1967, the WHO established the Intensified Smallpox Eradication Program and made several changes to the testing and distribution system. These included creating regional reference labo- ratories, requiring periodic sampling instead of universal testing, creating a central donated vac- cine processing and storage facility in Geneva for rapid dispatch, and encouraging local vaccine production in endemic countries.43 Even with all these measures in place, stocks of donated vaccines frequently ran low; however, by 1980, this novel distribution model enabled the eradi- cation of smallpox from the world.43

Vaccine distribution must be responsive and efficient in order to successfully interrupt a pan- demic. This means putting the vaccine and the necessary data into the hands of people who can make distribution happen. With smallpox, that meant making the WHO a centralized distribu- tor. For COVID-19, it will require leveraging the know-how of manufacturing and supply-chain experts, organizations well versed in overcom- ing “last-mile distribution” challenges, and others with relevant experience to design, acti- vate, and improve our distribution systems for vaccines. For a COVID-19 vaccine, the supply chain

challenges—getting the right product at the right temperature to the right person at the right time—will be complicated by and must be re- sponsive to allocation decisions. Experts have reminded us that there will likely be an insuffi- cient supply of vials, stoppers, and other neces- sary products to package and transport the vac- cine.44 We must upgrade our supply chain and distribution strategies now with digital advances to plan, track, and monitor vaccine delivery.

Vaccine Supply: Verification Of Immunization Verifying that the appropriate people and pop- ulations have received a COVID-19 vaccine will be critical in tracking global progress toward herd immunity, informing allocation, and tailoring strategies to generate demand among the appro- priate people and populations. When vaccine supplies are scarce, giving one person an extra dose of vaccine means denying it to another; similarly, misdirected vaccine represents a missed opportunity to interrupt virus transmis- sion and protect at-risk populations. It will re- quire a dedicated investment to build and imple- ment a functional verification system for COVID- 19 vaccines. Identity of individuals receiving a product or

service is the foundation of any verification sys- tem.45 However, personal health information, including vaccination records with personal

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identifiers, is typically harder for the U.S. gov- ernment to access and manage due to privacy laws,state authority, and system interoperability challenges.46

Immunization information systems (IIS) or centralized registries can play an important role in vaccine verification for the pandemic re- sponse. During the 2009 H1N1 pandemic, states utilized their IIS to track inventory at provider sites, to communicate with providers (sending reminders for a second dose for certain popula- tion groups or alerts of recalled vaccines), and to aid with dosing regimens (determining who was eligible for one dose or two doses).47

Reporting into IIS systems,however, is uneven and not always mandatory. States and projects reporting to IIS suggest thereareissues with data quality related to patient identification in the absence of unique patient identifiers. These in- clude variations in a patient’s name or missing addresses, which lead to duplication issues or inappropriately merged records.48 In Septem- ber 2020, the Trump administration issued emergency guidance to allow pharmacists and pharmacy interns to order and administer COVID-19 vaccinations, which could add to the challenge of tracking vaccination given as not all states require pharmacies to participate in the ISS.49

It is possible to do vaccine verification well, but it will require investment in systems engineering to address the technical complexities (adequate data storage, interoperability of data systems) and to ensure privacy. Concern for the handling and sharing of health-related data is legitimate and warranted. Privacy concerns surrounding the sharing of personal medical histories in the US are, for the most part, still governed by the Health Insurance Portability and Account- ability Act (HIPAA). But, in March, the Centers for Medicare & Medicaid Services (CMS) an- nounced the adoption of the Interoperability and Patient Access final rule that sets technical standards and will allow app developers to con- nect digitally with health facilities and pull data.50

If properly designed and integrated, biometric vaccine registries that can record vaccine receipt (for COVID-19 and routine vaccines) and func- tion as a health record could be interoperable, portable, and secure. There is work ahead to set interoperability and privacy standards to ensure these systems can connect to foundational ID programs as coverage expands over the next decade. Policymakers are also discussing the idea of

COVID-19 “immunity passports”—documents verifying proof of immunity that allow a person to move freely through society.While vaccination

certificates only incentivize vaccination, immu- nity passports that can be attained after illness or vaccination can incentivize infection.51,52 The WHO does not currently recommend immunity passports for COVID-19, given the lack of evi- dence about what level of antibodies confer im- munity and for how long. However, some coun- tries are already exploring the use of immunity passports; the pros/cons should be considered carefully. Another option that could facilitate verifica-

tion is the policy lever of vaccination mandates.53

While it’s unlikely that public health emergency laws would be used to require population-wide vaccination (no U.S. jurisdiction did this during the H1N1 pandemic), some U.S. health care em- ployers did implement 2009-H1N1 vaccination mandates for their workforce54 and commonly mandate seasonal influenza vaccination.55 A mandated vaccination approach requires health care employers to verify that their employees have received the flu vaccine, for example, by administering vaccines directly to their staff or by requiring employees to document that they received the vaccine elsewhere. There is work ahead to ensure that vaccine verification will not impinge on equity, but instead will ensure that vulnerable populations have access to the vaccine and that it will serve as a means to learn, adapt, and improve delivery systems. Global stakeholders must convene, collabo-

rate, and collectively tackle the problem of veri- fying vaccine coverage. Investing in global standards and modular, secure, biometrically supported digital health technologies that can not only deliver COVID-19 vaccines but also serve as longitudinal tracking systems for routine im- munizations is a valuable step that will pay dividends long after the world’s attention has shifted.

Conclusion Considering the speed of COVID-19 vaccine de- velopment, it is likely there are only months left to plan for the rollout of COVID-19 vaccination programs. Previous pandemics remind us that our inability to expeditiously vaccinate at-risk populations and end transmission was due to implementation bottlenecks. Global cooperation around COVID-19 vaccines

is already being thwarted by nationalistic ten- dencies. If this continues, we will see ineffective vaccine delivery strategies play out, much like those we arestill experiencingin the distribution of personal protective equipment, testing, and COVID-19 treatments. The COVID-19 vaccine portfolio requires ur-

gent, unprecedented investment in the delivery

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strategies and systems needed to generate vac- cine demand and facilitate vaccine allocation, distribution, and verification of coverage. Na- tions, states and local municipalities will need tools to build actionable—and equitable—plans for vaccine distribution. This will ensure the vac-

cine protects individuals, suppresses transmis- sion, and minimizes disruption to health ser- vices and livelihoods. We need to align the aims of our systems to protect our populations against our common threat, the virus, and lever- age responsive systems across borders. ▪

Rebecca Weintraub is a managing director of the Draper Richards Kaplan Foundation. The authors would like to acknowledge and thank David Jones,

Atul Gawande, Marc Lipstich, and Prashant Yadav for their review and advice. Thank you Liz McGovern and Vilas Dhar for your ongoing

encouragement. [Published online November 19, 2020].

NOTES

1 Pfizer [Internet]. New York (NY): Pfizer. Press release, Pfizer and BioNTech announce vaccine candi- date against COVID-19 achieved success in first interim analysis from Phase 3 study; 2020 Nov 9 [cited 2020 Nov 12]. Available from: https://www.pfizer.com/news/ press-release/press-release-detail/ pfizer-and-biontech-announce- vaccine-candidate-against

2 U.S. Food and Drug Administration [Internet]. Silver Spring (MD): FDA. Press release, Coronavirus (COVID- 19) Update: FDA Takes Action to Help Facilitate Timely Development of Safe, Effective COVID-19 Vaccines; 2020 Jun 30 [cited 2020 Sep 18]. Available from: http://www.fda.gov/ news-events/press-announcements/ coronavirus-covid-19-update-fda- takes-action-help-facilitate-timely- development-safe-effective-covid

3 McDonnell A, Van Exan R, Lloyd S, Subramanian L, Chalkidou K, La Porta A, et al. COVID-19 Vaccine Predictions: Using Mathematical Modelling and Expert Opinions to Estimate Timelines and Probabilities of Success of COVID-19 Vaccines [Internet]. Washington (DC): Center for Global Development; 2020 Oct 1 [cited 2020 Nov 5]. Available from: https://www.cgdev.org/ publication/covid-19-vaccine- predictions

4 World Health Organization. Episode 1—Herd Immunity [Internet]. Geneva: World Health Organization; 2020 Aug 28 [cited 2020 Oct 12]. Available from: https://www.who .int/emergencies/diseases/novel- coronavirus-2019/media-resources/ science-in-5/episode-1

5 Kim JY, Farmer P, Porter ME. Re- defining global health-care delivery. Lancet. 2013;382(9897):1060–9.

6 Global Health Delivery Project. Case Collection [Internet]. Cambridge (MA): Harvard University; c 2020 [cited 2020 Sep 18]. Available from: https://www.globalhealthdelivery .org/case-collection

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8 World Health Organization. Im- proving vaccination demand and addressing hesitancy [Internet]. Geneva: WHO; c 2020 [cited 2020 Jul 6]. Available from: https:// www.who.int/immunization/ programmes_systems/vaccine_ hesitancy/en/

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10 Fisher KA, Bloomstone SJ, Walder J, Crawford S, Fouayzi H, Mazor KM. Attitudes Toward a Potential SARS- CoV-2 Vaccine: A Survey of U.S. Adults. Ann Intern Med. 2020 Sep 4. [Online ahead of print].

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14 Casey MK, Allen M, Emmers- Sommer T, Sahlstein E, Degooyer D, Winters A, et al. When a celebrity contracts a disease: the example of Earvin “Magic” Johnson’s an- nouncement that he was HIV posi- tive. J Health Commun. 2003;8(3): 249–65.

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17 House of Representatives. Vaccines—finding the balance be- tween public safety and personal choice; hearing before the Commit- tee on Government Reform, 106th Cong., 1st sess. [Internet]. Washington (DC): House of Repre- sentatives; 1999 Aug 3 [cited 2020 Nov 5]. Available from: https:// www.govinfo.gov/content/pkg/ CHRG-106hhrg62560/html/CHRG- 106hhrg62560.htm

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