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Alaska's public health structure was built for complications -- its size and tendency for inclement weather require it. So when it came time to start vaccinating residents, the state didn't have to build a robust public health system from scratch like some others, said Dr. Anne Zink, Alaska's chief medical officer.

A localized approach to vaccination hasn't worked everywhere, but it's worked in Alaska, Zink said. The state distributes vaccines to different regions but doesn't give directives, she said -- it's up to the communities to decide how to administer vaccines based on their needs.

Because so much power has been turned over to different regions of Alaska and the health care providers trusted in those areas, health care workers have been able to "meet people where they're at," Zink said: That means they'll deliver vaccines by boat, dog sled, helicopters and small planes, or go door-to-door in small communities to vaccinate as many community members as possible.

Vaccine eligibility in Alaska is more expansive than it currently is in most other states: Vaccines are available to anyone 55 years or older, people with certain underlying conditions, essential workers, residents of a multigenerational household, anyone who assists a senior in getting vaccinated and anyone who lives in a community where 45% of houses don't have pipes or septic tanks.

In areas where the population is mostly Alaska natives, there's a greater amount of people living in multigenerational housing. That qualifies young people who may live with an at-risk elderly person to get vaccinated, too, said Dr. Bob Onders, administrator of the Alaska Native Medical Center in Anchorage. And since 25% of rural Alaska doesn't have running water or sewage, which can heighten residents' risk for respiratory illness, it didn't make sense to exclude rural residents from the first round of vaccinations, Onders said.

Another way to alleviate that burden is to prioritize zip codes in addition to age and health status, Karmarck said. Vaccinating residents of low-income neighborhoods or areas where the majority of residents are Black, indigenous or people of color could reduce Covid-19's disproportionate impact, though backlash is likely: In Dallas, county officials axed their plan to prioritize residents in "vulnerable zip codes" after the state threatened to reduce its vaccine allocation, the Texas Tribune reported in January.

"Rather than a top-down mechanism, where someone from outside of Alaska or rural Alaska is dictating how things are going, it's much more about giving them supplies," Onders said.

Alaska asked the federal government to be treated "like a territory instead of state," so it would receive a monthly allocation of vaccines versus a weekly or biweekly lot. That made it easier to plan ahead and deliver vaccines "creatively," Zink said.

It can be costly to transport vaccines to some remote reaches of Alaska -- over $15,000 for one trip, in some cases, Zink said. To make vaccinations more cost-efficient, some areas that are less densely populated receive their entire vaccine allotment, which makes it possible to vaccinate entire communities in one go.

"We've been doing redistribution of vaccines for years," said Dr. Anne Zink, Alaska's chief medical officer. "It was pretty easy for us to stand up our existing [public health] structure."

Invest in protecting minority communities. Alaska expanded its eligibility for the first round of vaccines to include Alaska Natives and low-income residents of the state that are more vulnerable to Covid-19. While there's still work to do to alleviate that disproportionate risk, Onders said so far, it's working.

Alaska Natives have borne the brunt of Covid-19 in the state -- the Kaiser Family Foundation's Covid-19 data tracker shows that Alaska Natives make up more than a quarter of Covid-19 cases but 15% of the population, compared to White residents, who made up 38% of cases but 68% of the population.

Enlist trusted members of communities to educate. In communities where residents are hesitant to get the vaccine, particularly among Black and Latino Americans, sharing information about vaccine access is crucial to address Covid-19 racial disparities, Karmarck said.

Customize the approach. States that were lagging in vaccinations are catching up, Karmarck said, as they formalize an approach to vaccination that best fits their state. In Massachusetts, for example, large vaccination sites have opened up at Fenway Park and Gillette Stadium to accommodate more people and storage the vaccines require. It's improved the state's vaccination rates, she said.

When those countries vetted these vaccines, they made informed decisions, based on evidence about safety and efficacy released by the Chinese and Russian manufacturers — much of it also published in peer-reviewed scientific journals like The Lancet and JAMA — or after running independent trials of their own. To assume otherwise is to doubt the ability or integrity of these governments, some of which have health regulatory systems on par with those in the United States or Europe.

To some extent this is understandable. China’s and Russia’s self-serving propaganda campaigns touting their respective vaccines only increased wariness, especially abroad.

The protocols for trials vary, in other words, even for the same vaccine. Considering that, now imagine the potential for differences among results from trials for various vaccines — differences that may reveal as much about the trials’s designs as the vaccines’ performance.

The fact is that no Covid-19 vaccine has been developed or released as transparently as it should have been. And while China and Russia may have botched their rollouts more than some Western companies, that doesn’t necessarily mean their vaccines are shoddy.

Most vaccines produced in the West have already been bought up by rich countries: as of early December, all of Moderna’s vaccines and 96 percent of Pfizer-BioNTech’s, according to the People’s Vaccine Alliance, a coalition of organizations calling for wider and fairer access to vaccines worldwide.

When a vaccine is developed in and approved by a country on the W.H.O.’s trusted list, the organization usually relies on that assessment to quickly sign off. But when a vaccine maker anywhere else applies for prequalification, the W.H.O. conducts a full evaluation from scratch, including a physical inspection of the manufacturing facilities.

This CDC advisory group had previously recommended that health care workers and residents of long-term care facilities should be the first to receive a vaccine when it receives EUA. The first shipments of the vaccine will be limited, so states will have to prioritize who should receive the vaccine first.

Keeping doctors and nurses healthy will be important for the continuing fight against the virus, which will stretch on for months, even after a vaccine is authorized. But Romero said that first group includes other people working in health care institutions, like those who deliver food and perform housekeeping.

Residents of long-term care facilities like nursing homes also need the protection. So far, they account for about 40% of coronavirus deaths in the US.

"I would project by the time you get to April, it will be ... 'open season,' in the sense of anyone, even the non-high priority groups could get vaccinated," Fauci said.

"We'll be in facilities that day in states that choose to begin as soon as possible," spokesman Ethan Slavin said.

The FDA is set to make a decision on a separate vaccine candidate by Moderna in the coming days

it's possible that 20 million people could get vaccinated in the next several weeks

Army Gen. Gustave Perna, chief operating officer of the federal government vaccine initiative Operation Warp Speed, previously said he believed vaccine administration will be able to begin vaccinations within 96 hours of authorization.

Phase 1a would be followed by Phases 1b and 1c, which could include essential workers at high risk of infection, other emergency personnel and people with underlying conditions who are at a higher risk of Covid-19 complications and death.

In the meantime, it's important that people continue to wear masks and social distance. JUST WATCHEDDr. Fauci explains importance of vaccine approval processReplayMore Videos ...MUST WATCH Play</

It's important to note, however, that Pfizer's vaccine requires two doses administered several weeks apart to reach 95% efficacy. So 100 million doses would vaccinate half the number of people.

Azar said earlier this month that 6.4 million doses of Pfizer vaccine would be allocated for shipment the first week. The initial shipment would include half of the doses, followed by the second half three weeks later.

Slaoui said he believes most doses will be injected within three to four days, but after that, "I think it will take a week."

The first shipments of the vaccine departed a Pfizer plant in Michigan on Sunday morning. A total of 189 boxes of vials are expected to arrive in all 50 states Monday. Another 3,900 vials are expected to ship later Sunday to US territories. Another 400 boxes packed with about 390,000 vials are expected to ship Monday and arrive at their destinations on Tuesday.

The vaccines will then be flown across the country, and the Federal Aviation Administration has said its air traffic controllers will prioritize flights carrying the vaccines.

But Pfizer's vaccine needs to be stored at incredibly cold temperatures, making the logistics of delivery even more complicated.

According to a briefing document released by the FDA's vaccine advisory committee, the most common side effects were reactions at the point of injection on the body, fatigue, headache, muscle pain, chills, joint pain and fever.

Health authorities in the UK, where the vaccine roll out began earlier this week, said Wednesday that people with "significant history of allergic reactions" should not receive the vaccine. The advice came after two health care workers "responded adversely" following their shots.

Sars-CoV-2 shares between 80% and 90% of its genetic material with the virus that caused Sars – hence its name. Both consist of a strip of ribonucleic acid (RNA) inside a spherical protein capsule that is covered in spikes. The spikes lock on to receptors on the surface of cells lining the human lung – the same type of receptor in both cases – allowing the virus to break into the cell. Once inside, it hijacks the cell’s reproductive machinery to produce more copies of itself, before breaking out of the cell again and killing it in the process.

Coronaviruses have caused two other recent epidemics – severe acute respiratory syndrome (Sars) in China in 2002-04, and Middle East respiratory syndrome (Mers), which started in Saudi Arabia in 2012. In both cases, work began on vaccines that were later shelved when the outbreaks were contained.

Though nobody could have predicted that the next infectious disease to threaten the globe would be caused by a coronavirus – flu is generally considered to pose the greatest pandemic risk – vaccinologists had hedged their bets by working on “prototype” pathogens.

All vaccines work according to the same basic principle. They present part or all of the pathogen to the human immune system, usually in the form of an injection and at a low dose, to prompt the system to produce antibodies to the pathogen. Antibodies are a kind of immune memory which, having been elicited once, can be quickly mobilised again if the person is exposed to the virus in its natural form.

Some of the Covid-19 vaccine projects are using these tried-and-tested approaches, but others are using newer technology.

Cepi’s original portfolio of four funded Covid-19 vaccine projects was heavily skewed towards these more innovative technologies, and last week it announced $4.4m (£3.4m) of partnership funding with Novavax and with a University of Oxford vectored vaccine project.

Clinical trials, an essential precursor to regulatory approval, usually take place in three phases. The first, involving a few dozen healthy volunteers, tests the vaccine for safety, monitoring for adverse effects. The second, involving several hundred people, usually in a part of the world affected by the disease, looks at how effective the vaccine is, and the third does the same in several thousand people. But there’s a high level of attrition as experimental vaccines pass through these phases.

There are good reasons for that. Either the candidates are unsafe, or they’re ineffective, or both. Screening out duds is essential, which is why clinical trials can’t be skipped or hurried. Approval can be accelerated if regulators have approved similar products before.

No vaccine made from genetic material – RNA or DNA – has been approved to date, for example. So the Covid-19 vaccine candidates have to be treated as brand new vaccines, and as Gellin says: “While there is a push to do things as fast as possible, it’s really important not to take shortcuts.”

It’s for these reasons that taking a vaccine candidate all the way to regulatory approval typically takes a decade or more, and why President Trump sowed confusion when, at a meeting at the White House on 2 March, he pressed for a vaccine to be ready by the US elections in November – an impossible deadline.

In the meantime, there is another potential problem. As soon as a vaccine is approved, it’s going to be needed in vast quantities – and many of the organisations in the Covid-19 vaccine race simply don’t have the necessary production capacity. Vaccine development is already a risky affair, in business terms, because so few candidates get anywhere near the clinic. Production facilities tend to be tailored to specific vaccines, and scaling these up when you don’t yet know if your product will succeed is not commercially feasible. Cepi and similar organisations exist to shoulder some of the risk, keeping companies incentivised to develop much-needed vaccines. Cepi plans to invest in developing a Covid-19 vaccine and boosting manufacturing capacity in parallel, and earlier this month it put out a call for $2bn to allow it to do so.

The problem is making sure the vaccine gets to all those who need it. This is a challenge even within countries, and some have worked out guidelines. In the scenario of a flu pandemic, for example, the UK would prioritise vaccinating healthcare and social care workers, along with those considered at highest medical risk – including children and pregnant women – with the overall goal of keeping sickness and death rates as low as possible. But in a pandemic, countries also have to compete with each other for medicines.

Because pandemics tend to hit hardest those countries that have the most fragile and underfunded healthcare systems, there is an inherent imbalance between need and purchasing power when it comes to vaccines.

Outside of pandemics, the WHO brings governments, charitable foundations and vaccine-makers together to agree an equitable global distribution strategy, and organisations like Gavi, the vaccine alliance, have come up with innovative funding mechanisms to raise money on the markets for ensuring supply to poorer countries. But each pandemic is different, and no country is bound by any arrangement the WHO proposes – leaving many unknowns.

The Democrats’ message, Schrier said, should be clear and simple: All vaccines are good. And the best thing American can do to protect themselves and their loved ones is to get a shot.

Pelosi spokesman Henry Connelly said the Speaker was simply reflecting concerns in her diverse caucus about whether minority communities were being treated equitably in the aggressive push to vaccinate all Americans.

That disparity has been attributed, in part, to the fact that the earlier Moderna and Pfizer vaccines each require two shots and colder refrigeration, complicating storage and distribution. That’s created additional barriers for getting the vaccine to poorer, historically underserved populations and rural communities.

Black&nbsp;people are nearly three times more likely to be hospitalized with COVID-19 than white people and nearly two times more likely to die from the disease; Hispanics are more than three times more likely to be hospitalized with COVID-19 than whites and 2.3&nbsp;times more likely to die.&nbsp;

White&nbsp;people have been vaccinated for COVID-19 at two times the rate of Black&nbsp;people,&nbsp;according to a New York Times analysis. The figures are worse for Hispanics.&nbsp;

The disagreement among Democrats comes during a pivotal moment in the fight against the coronavirus pandemic as states like Texas and Mississippi end their mask mandates and lift restrictions on businesses, and health experts worry about a surge in cases driven by COVID-19 variants.

Because the new Johnson &amp; Johnson vaccine requires only one shot and regular refrigeration levels, some officials like New Jersey Gov. Phil Murphy (D) have&nbsp;ordered that shipments&nbsp;of that vaccine be prioritized for harder-to-reach Black and brown communities.&nbsp;

But while Pfizer and Moderna vaccines have an overall efficacy of about 95 percent in preventing moderate to severe disease, that number for the Johnson &amp; Johnson version is just 66 percent&nbsp;— though experts point out the J&amp;J vaccine&nbsp;was being tested after more contagious variants had begun spreading in the U.S., unlike the Pfizer and Moderna versions.&nbsp;

That's led to some in those minority communities&nbsp;voicing concerns in recent days that they are being given a less-effective vaccine than more affluent, white communities.

Rep.&nbsp;André&nbsp;Carson (D-Ind.), another CBC member, noted that those suspicions have historic roots, pointing to the infamous Tuskegee syphilis study — a deadly federal research project that targeted poor Black&nbsp;people in rural Alabama in 1930s —&nbsp;as evidence of the "painful history" of biomedical mistreatment of African Americans in the United States.&nbsp;

Despite such reservations, the broad consensus in the caucus appears to favor efforts to maximize vaccinations in the shortest possible time, regardless which shot is available in a given community.

On Wednesday, Kelly is set to join Rep. Joyce BeattyJoyce Birdson BeattyDemocrats spar over COVID-19 vaccine strategy Black Caucus backs Biden's pick to head DOJ Civil Rights Division Sole GOP vote on House police reform bill says he 'accidentally pressed the wrong voting button' MORE (D-Ohio), head of the Black Caucus, in an online forum with medical experts designed to educate minority communities on best vaccine practices.&nbsp;

Rep. Anthony BrownAnthony Gregory BrownOvernight Defense: Pentagon chief to press for Manchin's support on Colin Kahl | House Dems seek to limit transfer of military-grade gear to police Democrats spar over COVID-19 vaccine strategy 140 lawmakers call for Biden administration to take 'comprehensive' approach to Iran MORE (D-Md.) said officials should monitor the distribution of vaccines to identify “patterns” that might indicate prejudices in the dispensation. But he’s also encouraging all of his constituents to get whatever vaccine is available first, and he highlighted the advantages of the one-dose&nbsp;Johnson &amp; Johnson shot, particularly in hard-to-reach populations like the homeless.&nbsp;

Security concerns, moreover, keep most information about stockpile purchases under wraps. Details about the contracts and inventory are rarely made public, and even the storage locations are secret.

Former Emergent employees, government contractors, members of Congress, biodefense experts and current and former officials from agencies that oversee the stockpile described a deeply dysfunctional system that contributed to the shocking shortages last year.

Purchases are supposed to be based on careful assessments by government officials of how best to save lives, but many have also been influenced by Emergent’s bottom line

The stockpile has long been the company’s biggest and most reliable customer for its anthrax vaccines, which expire and need to be replaced every few years.

In the two decades since the repository was created, Emergent’s aggressive tactics, broad political connections and penchant for undercutting competitors have given it remarkable sway over the government’s purchasing decisions related to the vaccines

While national security officials still consider anthrax a threat, it has not received specific mention since 2012 in the intelligence community’s annual public assessment of dangers facing the country, a report that has repeatedly warned of pandemics.

Emergent bought the license for the country’s only approved anthrax vaccine in 1998 from the State of Michigan. Over time, the price per dose the government agreed to pay Emergent increased nearly sixfold, accounting for inflation, contributing to record revenues last year that topped $1.5 billion

The company, whose board is stocked with former federal officials, has deployed a lobbying budget more typical of some big pharmaceutical companies

Competing efforts to develop a better and cheaper anthrax vaccine, for example, collapsed after Emergent outmaneuvered its rivals, the documents and interviews show.

preparations for an outbreak like Covid-19 almost always took a back seat to Emergent’s anthrax vaccines

the government approved a plan in 2015 to buy tens of millions of N95 respirators — lifesaving equipment for medical workers that has been in short supply because of Covid-19 — but the masks repeatedly lost out in the competition for funding over the years leading up to the pandemic

After Dr. Frieden and others in the Obama administration tried but failed to lessen Emergent’s dominance over stockpile purchases, the company’s fortunes rose under Mr. Trump, who appointed a former Emergent consultant with a background in bioterrorism to run the office that now oversees the stockpile

“If I could spend less on anthrax replenishment, I could buy more N95s,” Dr. Kadlec said in an interview shortly after leaving office. “I could buy more ventilators. I could buy more of other things that quite frankly I didn’t have the money to buy.”

And now, as some members of Congress push for larger reserves of ventilators, masks and other equipment needed in a pandemic, a trade group led in part by a top Emergent lobbyist has warned that the purchases could endanger companies focused on threats like anthrax and smallpox by drawing down limited funds.

Last year, as the pandemic raced across the country, the government paid Emergent $626 million for products that included vaccines to fight an entirely different threat: a terrorist attack using anthrax.

“I think it’s pretty clear that the benefit of the vaccine is marginal,” he said in an interview

“They’re very vicious in their behavior toward anybody they perceive as having a different point of view,” said Dr. Tara O’Toole, a former Homeland Security official who says she ran afoul of Emergent in 2010 after telling Congress that the nation needed a newer and better anthrax vaccine.

That year, the company that would become Emergent — then known as BioPort — paid Michigan $25 million to buy the license for a government-developed anthrax vaccine and an aging manufacturing plant.

The company opened its doors with one product, called BioThrax, and one customer, the Defense Department, which required the vaccine for service members.

Emergent’s anthrax vaccine was not the government’s first choice. It was more than 30 years old and plagued by manufacturing challenges and complaints about side effects. Officials instead backed a company named VaxGen, which was developing a vaccine using newer technology licensed from the military.

Emergent’s successful campaign against VaxGen — deploying a battalion of lobbyists, publicly attacking its rival and warning that it might cease production of its own vaccine if the government didn’t buy it — established its formidable reputation. By 2006, VaxGen had lost its contract and the government had turned to Emergent to supply BioThrax.

“They were totally feared by everybody,” Dr. Philip Russell, a top health official in the administration of President George W. Bush, said in an interview. He said that he clashed with Emergent when he backed VaxGen, and that his reputation came under attack, which was documented by The Times in 2006. (Dr. Russell died this January.)

the group of federal officials who make decisions about the stockpile and other emergency preparations — known as the Phemce, for the Public Health Emergency Medical Countermeasures Enterprise — ordered up a study. It found in 2010 that the government could not afford to devote so much of its budget to a single threat.

Instead, the review concluded, the government should invest more in products with multiple applications, like diagnostic tests, ventilators, reusable respirator masks and “plug and play” platforms that can rapidly develop vaccines for a range of outbreaks.

from 2010 through 2018, the anthrax vaccine consumed more than 40 percent of the stockpile’s budget, which averaged $560 million during those years.

Emergent and the government have withheld details of the stockpile contracts, including how much the company has charged for each dose of BioThrax, but executives have shared some of the missing information with investors.

The company in 1998 agreed to charge the government an average of about $3.35 per dose, documents show. By 2010, the price had risen to about $28, according to financial disclosures and statements by Emergent executives, and now it is about $30

Over the past 15 years, the company recorded a gross profit margin of about 75 percent for the vaccine, in an arrangement that one Emergent vice president called a “monopoly.”

Emergent’s rise is the stuff of lore in biodefense circles — a tale of savvy dealings, fortuitous timing and tough, competitive tactics.

One afternoon in October 2010, Wall Street investors gathered at the Millennium Broadway Hotel in Manhattan for a presentation by Mr. Burrows. He shared with them a secret number: 75 million.That was how many BioThrax doses the government had committed to stockpiling, and it was the backbone of Emergent’s thriving business. In pursuit of that goal, the government had already spent more than $900 million, and it continued to buy virtually every dose Emergent could produce. It had even awarded the company more than $100 million to expand its Michigan factory.

“The best approach toward anthrax is antimicrobial therapy,” Dr. Anthony S. Fauci, the government’s top infectious-disease expert, told Congress as early as 2007.

In an analysis published in 2007, the firm determined that giving antibiotics immediately after a large outdoor anthrax attack was likely to reduce serious illnesses by more than 80 percent. Administering the vaccine would then cut serious illnesses only by an additional 4 percent.

Dr. Ali S. Khan, who ran the C.D.C. office managing the stockpile until 2014, said bluntly: “We overpaid.”

“A bunch of people, including myself, were sitting in a room and asking what kind of attack might happen,” said Dr. Kenneth Bernard, a top biodefense adviser to Mr. Bush, recalling a meeting in the months after the 2001 attacks.

“And somebody said, ‘Well, I can’t imagine anyone attacking more than three cities at once,’” he said. “So we took the population of a major U.S. city and multiplied by three.”

A team of Homeland Security and health officials began doing just that in 2013. The group determined, in a previously undisclosed analysis, that the government could stockpile less BioThrax and still be prepared for a range of plausible attacks, according to two people involved in the assessment. Separately, government researchers concluded that two doses of BioThrax provided virtually the same protection as three.

the National Intelligence Council, which helped draft the assessments during Mr. Obama’s second term, said in an interview that the idea of a three-city attack affecting 25 million people was “straining credulity.”

“If you talk to the head of the House Intelligence Committee,” Don Elsey, Emergent’s chief financial officer, told investors in 2011, “and you say, ‘What are you most worried about?’ he’ll say, ‘Let me see: Number one, anthrax; number two, anthrax; number three, anthrax.’”

Emergent’s sales strategy was to address that fear by promising the federal government peace of mind with its vaccine.

“There’s a political element involved,” Mr. Burrows, the company’s vice president of investor relations, said at an industry conference in 2016. “I don’t have a marketing expense. I have lobbying expense.”

Since 2010, the company has spent an average of $3 million a year on lobbying — far outspending similarly sized biotech firms, and roughly matching the outlays of two pharmaceutical companies with annual revenues at least 17 times greater, AstraZeneca and Bristol Myers Squibb

In 2015, as stockpile managers questioned the large purchases of BioThrax, the spending topped $4 million

“They were pouring it on — how poor they were and how this was going to ruin the company, and they’d have to close down factories, and America was going to be left without anthrax vaccine,”

“Their revolving door is moving at 60 miles per hour,” said former Senator Claire McCaskill, a Democrat from Missouri who had questioned spending on the vaccine while in the Senate. “There is really a lot of incestuousness because it’s such a specialized field.”

Ms. DeLorenzo, the Emergent spokeswoman, said the lobbying was necessary because government investment “in biodefense and other public health threats has not been as strongly prioritized as it should be.”

Over the past 10 years, Emergent’s political action committee has spread almost $1.4 million in campaign contributions among members of both partie

The move followed a yearslong pattern of retaining a bipartisan lobbying corps of former agency officials, staff members and congressmen, including Pete Hoekstra of Michigan, Tom Latham of Iowa and Jim Saxton of New Jersey.

“You have people coming and saying, ‘There’s no market for this — nobody’s going to produce this unless you buy enough of it to keep the production line open,’” he said. “It’s an absolutely appropriate argument to make.”

Emergent’s campaign proved effective. Despite the 2015 recommendation by the stockpile managers, Senate overseers made clear they opposed the reduction, and the government went ahead and bought $300 million worth of BioThrax.

Emergent executives, meanwhile, warned that there could be job losses at the factory in Lansing, Mich. — the capital of a swing state at the center of a contentious presidential campaign between Mr. Trump and Hillary Clinton.

Because Emergent was the sole manufacturer of a product deemed critical to national security, the company has played what one former executive described to The Times as “the we’re-going-to-go-bankrupt card.”

Dr. Hatchett said the idea gave him pause. But, he explained in an interview, “if there’s only one partner that can provide a product and only one customer for that product, the customer needs the partner to survive.”

Just a year later, Emergent spent about $200 million in cash, and made other financial commitments, to acquire Sanofi’s smallpox vaccine and GlaxoSmithKline’s anthrax treatment, two products with established pipelines to the stockpile. The purchases expanded Emergent’s hold over the reserve.

Ms. DeLorenzo said the acquisitions did not suggest the company was better off than it had claimed, but Dr. Bright said he and others involved in the bailout felt used.

a plan five years earlier to create an emergency supply of N95 respirators was simply not funded. A team of experts had proposed buying tens of millions of the masks to fill the gap during an outbreak until domestic manufacturing could ramp up, according to five officials involved in the assessment, which has not been previously disclosed.

By the time the novel coronavirus emerged, the stockpile had only 12 million of the respirators. The stockpile has since set a goal of amassing 300 million.

Dr. Kadlec, the Trump administration official overseeing the stockpile, said he used the previous administration’s mask recommendation to raise alarms as early as 2018.

Dr. Annie De Groot, chief executive of the small vaccine company EpiVax, spoke about the need to break Emergent’s lock on research dollars at a biodefense forum in 2015.

“Politicians want to look like they’ve addressed the problem,” she said. “But we need to actually listen to the scientists.”

Over the last five years, Emergent has received nearly a half-billion dollars in federal research and development funding, the company said in its financial disclosures.

“We know ahead of time when funding opportunities are going to come out,” Barbara Solow, a senior vice president, told investors in 2017. “When we talk to the government, we know how to speak the government’s language around contracting.”

The company used federal money to make improvements to BioThrax, and also found a way to earn government money from a competing anthrax vaccine it had excoriated. After the demise of VaxGen in 2006, Emergent bought the company’s unfinished vaccine and in 2010 persuaded the federal government to continue paying for research on it

By the time the research contract was canceled in 2016, Emergent had collected about $85 million, records show. The company then shelved the vaccine. “If the U.S. government withdraws funding, we re-evaluate whether there is any business case for continuing,” Ms. DeLorenzo said.

For more than 30 years, the government had been encouraging the development of a BioThrax replacement. In 2002, the Institute of Medicine had concluded that an alternative based on more modern technology was “urgently needed.” By 2019, there were three leading candidates, including one made by Emergent, known as AV7909.

Emergent’s candidate was hardly the breakthrough the government was seeking, former health officials said. AV7909 was essentially an enhanced version of BioThrax. The competitors were using more modern technology that could produce doses more rapidly and consistently, and were promising significant cost savings for the stockpile.

To qualify for emergency authorization, a vaccine must be at an advanced stage of development with no approved alternatives. Emergent acknowledged in its financial disclosures that there was “considerable uncertainty” whether the new vaccine met those requirements.

The election of Mr. Trump as president was good news for Emergent.

Dr. Lurie, the senior health official in the Obama administration who had tried to scale back BioThrax purchases, was out. Mr. Trump’s pick to replace her was Dr. Kadlec, a career Air Force physician and top biodefense official in the Bush administration who was fixated on bioterrorism threats, especially anthrax, current and former officials said

Soon after entering the Trump administration in 2017, Dr. Kadlec took a series of actions that he characterized as streamlining a cumbersome bureaucracy but that had the effect of benefiting Emergent.

He assumed greater control of purchasing decisions, diminishing the authority of the Phemce, the oversight group that had proposed buying less BioThrax. And in 2018, he backed a decision to move control of the stockpile to his office in the Department of Health and Human Services and away from the C.D.C., which is based in Atlanta and prides itself on being insulated from the influence of lobbyists.

Dr. Frieden, the former C.D.C. director, was strongly opposed. The move, he said, “had almost as an explicit goal to give the lobbyists more say in what got purchased.”

That July, the government made the announcement Emergent had been banking on, committing to buying millions of doses. Separately, it said it would stop funding Emergent’s competitors.

The decision to side with Emergent did not surprise Dr. Khan, the former C.D.C. official overseeing the stockpile.“Again and again, we seem unable to move past an old technology that’s bankrupting the stockpile,” he said.

Last month, as the death toll from Covid-19 neared a half-million, Mr. Kramer, the company’s chief executive, told analysts there had been no “evidence of a slowdown or a delay or a deprioritization,” and echoed a statement he had made in April when asked whether the pandemic might interrupt Emergent’s sales to the stockpile.“It’s pretty much business as usual,” he said then.

Even in normal times, mass-vaccination campaigns involve many moving parts within a vast network of suppliers, transporters and middlemen.

Nine other candidates are also in the final stage of testing. If any of those win approval from the F.D.A., that will reduce the importance of Pfizer’s vaccine but also introduce new questions, such as which hospitals and people get the different vaccines.

Pfizer has said it expects to be able to produce 50 million doses this year.

“We’re working very closely, in the U.S., in particular, with Operation Warp Speed to identify those distribution points,” Ms. Alcorn said, referring to the federal initiative to produce and distribute Covid-19 vaccines. “We don’t have them today.”

Representatives of UPS and FedEx said they had been planning to play a major role in distributing vaccines and were ready to go.Once the Pfizer coolers reach their destinations, hospitals or pharmacies will have a few choices of how to store the vaccine. The easiest option is using ultracold freezers, but not many sites have them. Otherwise, the facilities can stash the trays in conventional freezers for up to five days. Or they can keep the vials in the cooler for up to 15 days, so long as they replenish the dry ice and don’t open it more than twice a day.

Pfizer does not yet know where the government wants the vaccine sent or who will be first in line to receive it, said Ms. Alcorn, the supply-chain executive.

“If you’re talking about 12.5 million people, you’re going to have to make some very tough-minded decisions about who this goes to,” said J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, a research firm. “It’s a pretty small number of doses that are going to be distributed.”

For all the difficulties of making and distributing the vaccine, public health experts said the hardest part of the process could soon be complete.

One of the biggest early challenges may be distributing the vaccine in rural areas, which may not be able to administer doses quickly enough before they go bad. It isn’t clear how states with large rural populations are going to deal with this.

f Pfizer receives authorization for its vaccine from the Food and Drug Administration in the coming weeks, as expected, the company in theory could vaccinate millions of Americans by the end of the year, taking advantage of months of planning and decades of experience

So it was cause for celebration this week when Pfizer announced that an early analysis showed its vaccine candidate was more than 90 percent effective.

The effort will hinge on collaboration among a network of companies, federal and state agencies, and on-the-ground health workers in the midst of a pandemic that is spreading faster than ever through the United States.

Before Pfizer can begin shipping its vaccine, federal and state governments must tell it where to send how many doses. McKesson, a major medical supplier, will have to provide hospitals and other distribution sites with the syringes, needles and other supplies necessary to administer the vaccine.

The vaccine, developed with the German company BioNTech, has to be stored at around minus 70 degrees Celsius (minus 94 Fahrenheit) until shortly before it is injected

If an analysis planned for next week confirms the vaccine’s safety, the company is likely to ask the F.D.A. this month for emergency authorization to distribute its vaccine. In that case, limited doses will most likely be shipped to large hospitals and pharmacies to be provided to health care workers and other vulnerable groups.

Then there is the thorny question of who will receive vaccines first. That will be up to state governments.

The chief executives of Pfizer and BioNTech have suggested that half of those may go to the United States. Since each person needs two doses, about 12.5 million Americans could be vaccinated.

Over the past four decades, governments have slashed budgets and privatized basic services. This has two important consequences for public health

First, people are unlikely to trust institutions that do little for them.

second, public health is no longer viewed as a collective endeavor, based on the principle of social solidarity and mutual obligation. People are conditioned to believe they’re on their own and responsible only for themselves.

an important source of vaccine hesitancy is the erosion of the idea of a common good.

compared with white Americans, communities of color do experience the American health care system differently. But a closer look at the data reveals a more complicated picture.

Since the spring, when most American adults became eligible for Covid vaccines, the racial gap in vaccination rates between Black and white people has been halved. In September, a national survey found that vaccination rates among Black and white Americans were almost identical.

Other surveys have determined that a much more significant factor was college attendance: Those without a college degree were the most likely to go unvaccinated.

Education is a reliable predictor of socioeconomic status, and other studies have similarly found a link between income and vaccination.

It turns out that the real vaccination divide is class.

“People are thinking, ‘If the government isn’t going to do anything for us,’” said Elden, “‘then why should we participate in vaccines?’”

during the 1950s polio campaigns, for example, most people saw vaccination as a civic duty.

But as the public purse shrunk in the 1980s, politicians insisted that it’s no longer the government’s job to ensure people’s well-being; instead, Americans were to be responsible only for themselves and their own bodies

Entire industries, such as self-help and health foods, have sprung up on the principle that the key to good health lies in individuals making the right choices.

Without an idea of the common good, health is often discussed using the language of “choice.”

there are problems with reducing public health to a matter of choice. It gives the impression that individuals are wholly responsible for their own health.

This is despite growing evidence that health is deeply influenced by factors outside our control; public health experts now talk about the “social determinants of health,” the idea that personal health is never simply just a reflection of individual lifestyle choices, but also the class people are born into, the neighborhood they grew up in and the race they belong to.

food deserts and squalor are not easy problems to solve — certainly not by individuals or charities — and they require substantial government action.

Many medical schools teach “motivational interviewing,”

the deeper problem:

Being healthy is not cheap. Studies indicate that energy-dense foods with less nutritious value are more affordable, and low-cost diets are linked to obesity and insulin resistance.

Another problem with reducing well-being to personal choice is that this treats health as a commodity.

This isn’t surprising, since we shop for doctors and insurance plans the way we do all other goods and services

mothers devoted many hours to “researching” vaccines, soaking up parental advice books and quizzing doctors. In other words, they act like savvy consumers

When thinking as a consumer, people tend to downplay social obligations in favor of a narrow pursuit of self-interest. As one parent told Reich, “I’m not going to put my child at risk to save another child.”

Such risk-benefit assessments for vaccines are an essential part of parents’ consumer research.

Vaccine uptake is so high among wealthy people because Covid is one of the gravest threats they face. In some wealthy Manhattan neighborhoods, for example, vaccination rates run north of 90 percent.

For poorer and working-class people, though, the calculus is different: Covid-19 is only one of multiple grave threats.

When viewed in the context of the other threats they face, Covid no longer seems uniquely scary.

Most of the people we interviewed in the Bronx say they are skeptical of the institutions that claim to serve the poor but in fact have abandoned them.

he and his friends find reason to view the government’s sudden interest in their well-being with suspicion. “They are over here shoving money at us,” a woman told us, referring to a New York City offer to pay a $500 bonus to municipal workers to get vaccinated. “And I’m asking, why are you so eager, when you don’t give us money for anything else?”

These views reinforce the work of social scientists who find a link between a lack of trust and inequality. And without trust, there is no mutual obligation, no sense of a common good.

The experience of the 1960s suggests that when people feel supported through social programs, they’re more likely to trust institutions and believe they have a stake in society’s health.

While the reasons vary by country, the underlying causes are the same: a deep mistrust in local and international institutions, in a context in which governments worldwide have cut social services.

In one Syrian city, for example, the health care system now consists of one public hospital so underfunded that it is notorious for poor care, a few private hospitals offering high-quality care that are unaffordable to most of the population, and many unlicensed and unregulated private clinics — some even without medical doctors — known to offer misguided health advice. Under such conditions, conspiracy theories can flourish; many of the city’s residents believe Covid vaccines are a foreign plot.

In many developing nations, international aid organizations are stepping in to offer vaccines. These institutions are sometimes more equitable than governments, but they are often oriented to donor priorities, not community needs.

“We have starvation and women die in childbirth.” one tribal elder told us, “Why do they care so much about polio? What do they really want?”

In America, anti-vaccine movements are as old as vaccines themselves; efforts to immunize people against smallpox prompted bitter opposition in the turn of the last century. But after World War II, these attitudes disappeared. In the 1950s, demand for the polio vaccine often outstripped supply, and by the late 1970s, nearly every state had laws mandating vaccinations for school with hardly any public opposition.

What changed? This was the era of large, ambitious government programs like Medicare and Medicaid.

The anti-measles policy, for example, was an outgrowth of President Lyndon Johnson’s Great Society and War on Poverty initiatives.

Research shows that private systems not only tend to produce worse health outcomes than public ones, but privatization creates what public health experts call “segregated care,” which can undermine the feelings of social solidarity that are critical for successful vaccination drives

Only then do the ideas of social solidarity and mutual obligation begin to make sense.

The types of social programs that best promote this way of thinking are universal ones, like Social Security and universal health care.

If the world is going to beat the pandemic, countries need policies that promote a basic, but increasingly forgotten, idea: that our individual flourishing is bound up in collective well-being.

Scientists are also using different strains of another virus, adenovirus, as a vector or a missile to deliver genes that code for these same spike proteins and that also provoke an immune response. The vector has been engineered in the lab to be replication-defective; that is, the vector is able to deliver the spike gene into humans but once it’s done its job, the vector cannot replicate any further. At least three groups are testing these vectors.

The science is paying off. Novavax, a Maryland-based company working on this type of vaccine, recently reported the results of its Phase 1 trial. The levels of antibodies generated were stunning, about four times higher than those in individuals who are recovering from a COVID-19 infection.

Nine vaccine candidates have now entered Phase 3 human trials, the final step before regulatory approval. The fact that entirely different approaches to vaccine development are all yielding promising early results is highly encouraging.

My optimism doesn’t stop with these early results, although they are key. I’m also encouraged because at least five very different approaches (I’ve walked through only three above) are being explored to make a vaccine. As we say in Canada, if you want to win, you have to take many shots on goal.

Equally important is the unprecedented global collaboration among scientists around the world, as well as the high degree of cooperation between scientists and clinicians, biopharmaceutical companies, government, philanthropic funders, and regulators. They are all working together toward the common goal of developing as quickly as possible a safe and effective vaccine against COVID-19.

the encouraging news is that all of the vaccine candidates that have entered trials in humans so far are safe and have elicited high levels of antibodies against COVID-19. Some have also been shown to activate the cellular arm of our immune system, another crucial component of our defenses against foreign pathogens.

the mandate that the approval process be above any political considerations and solely based on data from the clinical trials. Anything else risks losing the public’s confidence in a vaccine or, in a worst-case scenario, might result in a vaccine that is less effective than those that might be approved later, or the widespread administration of a vaccine that turns out to have serious adverse side effects. That would be a public-health tragedy.

The world will need billions of doses and many billions of dollars to produce and disseminate the vaccine. My main concern in this whole process is that governments will not spend enough on manufacturing the vaccine to administer it to every adult on the planet

Ensuring equitable access to a vaccine is imperative, and not just a generous gesture by wealthy nations. It’s also in their best interests. If the virus is anywhere, it’s everywhere.

The United States, the wealthiest nation in the world and historically the first among nations in its generosity and leadership, has yet to contribute to the various multilateral initiatives established to purchase vaccines for the developing world. To date, 75 industrialized nations have agreed to finance vaccine purchases for 90 lower-income countries. But the U.S. is not yet one of them.

The cost of manufacturing enough doses to vaccinate every adult on the planet will be in the hundreds of billions of dollars. But compared with the trillions of dollars that governments are now spending to assist individuals who have lost their jobs and to prop up their economies, $100–200 billion is a bargain and an insurance policy that developed countries cannot afford not to buy.

If people everywhere—regardless of their gender, citizenship, ethnicity, skin color, or ability to pay—have equal and timely access to a safe and effective vaccine against COVID-19, the world will come out of this pandemic stronger than it went in

Misinformation has complicated efforts by some states to reach out to Black and Hispanic residents, particularly when health officials have provided special registration codes for vaccine appointments. Instead of a benefit, in some cases the codes have become the basis for new false narratives.

Anti-vaccine activists have drawn on historical examples, including Nazi doctors who ran experiments in concentration camps, and the Baltimore hospital where, 70 years ago, cancer cells were collected from Henrietta Lacks, a Black mother of five, without her consent.

The state figures vary widely. In Texas, where people who identify as Hispanic make up 42 percent of the population, only 20 percent of the vaccinations had gone to that group. In Mississippi, where Black people make up 38 percent of the population, they received 22 percent of the vaccinations

According to an analysis by The New York Times, the vaccination rate for Black Americans is half that of white people, and the gap for Hispanic people is even larger

Research conducted by the nonprofit Kaiser Family Foundation in mid-February showed a striking disparity between racial groups receiving the vaccine in 34 states that reported the data.

An experiment conducted in 1943 on nearly 400 Black men in Tuskegee, Ala., is one of the most researched examples of medical mistreatment of the Black community. Over four decades, scientists observed the men, whom they knew were infected with syphilis, but didn’t offer treatments so that they could study the disease’s progression. When the experiment came to light in the 1970s, it was condemned by the medical community as a major violation of ethical standards.

While Tuskegee averaged several hundred mentions a week on Facebook and Twitter, there were several noticeable spikes that coincided with the introduction of Covid-19 vaccines, according to Zignal Labs, a media insights company.

Last month, a poll by the NORC Center for Public Affairs Research found that 23 percent of Republicans said they would “definitely” not get vaccinated, while 21 percent said they “probably” would not get a coronavirus vaccine.

Native American groups have been battling vaccine fears in their communities, and doctors have reported that some of their Chinese-American patients have been bringing in articles in Chinese-language media outlets questioning vaccines made in the United States.

Many Black and Hispanic people were already struggling to make appointments and reach vaccination sites that are often in whiter, wealthier neighborhoods

Misinformation about who is allowed to receive the vaccine, when it is available and how it was safety tested has added even more difficulty, Ms. Mitchell, said.

dislikes the term breakthrough case, which evokes a barrier walling humans off from disease. “It’s very misleading,” she told me. “It’s like the virus ‘punches’ through our defenses.”

Immunity is not a monolith, and the degree of defense roused by an infection or a vaccine will differ from person to person, even between identical twins. Some people might have underlying conditions that hamstring their immune system’s response to vaccination; others might simply, by chance, churn out fewer or less potent antibodies and T cells that can nip a coronavirus infection in the bud.

An ideal response to vaccination might create an arsenal of immune molecules and cells that can instantaneously squelch the virus, leaving no time for symptoms to appear. But sometimes that front line of fighters is relatively sparse

Should the virus make it through, “it becomes a race [against] time,” Ellebedy told me. The pathogen rushes to copy itself, and the immune system recruits more defenders. The longer the tussle drags on, the more likely the disease is to manifest.

The range of vaccine responses “isn’t a variation of two- to threefold; it’s thousands,”

“Being vaccinated doesn’t mean you are immune. It means you have a better chance of protection.”

The number of post-vaccination infections is also contingent on “the ongoing transmission situation,” Omer told me. “It depends on how much people are mixing.”

he circumstances of exposure to any version of the coronavirus will also make a difference. If vaccinated people are spending time with groups of unvaccinated people in places where the virus is running rampant, that still raises their chance of getting sick. Large doses of the virus can overwhelm the sturdiest of immune defenses, if given the chance.

under many circumstances, vaccines are still best paired with safeguards such as masks and distancing—just as rain boots and jackets would help buffer someone in a storm.

Even excellent vaccines aren’t foolproof, and they shouldn’t be criticized when they’re not. “We can’t expect it’s going to be perfect, on day one, always,” Borio said.

The numbers for asymptomatic infections are still crystallizing, but they’re likely to be lower.

“Whenever someone tests positive, the real question is, are they sick, and how sick are they? That’s a big difference.”

Efficacy, a figure specific to clinical trials, also doesn’t always translate perfectly to the messiness of the real world, where there’s immense variability in how, when, where, by whom, and to whom shots are administered

The vaccine’s performance under these conditions is tracked by a separate measure, called effectiveness. Studies rigorously examining vaccine effectiveness are challenging, but early data suggest that the Pfizer-BioNTech and Moderna shots are living up to their initial hype.

Vaccination is actually more like a single variable in a dynamic playing field—a layer of protection, like an umbrella, that might guard better in some situations than others. It could keep a lucky traveler relatively dry in a light drizzle, but in a windy maelstrom that’s whipping heavy droplets every which way, another person might be overwhelmed.

A vaccine with a recorded efficacy of 95 percent, for example, doesn’t give everyone who’s vaccinated a 5 percent chance of getting sick. Not all of those people will even encounter the virus

The key is how vaccination changes the outcome for those who are meaningfully exposed: Among 100 individuals who might have fallen ill without the vaccine, just five symptomatic cases might appear.

The White House on Tuesday said that the pause will not have a significant effect on the country’s vaccination campaign, which has accelerated in recent weeks as a rise in new virus cases threatens a fourth possible surge.

“Over the last few weeks, we have made available more than 25 million doses of Pfizer and Moderna each week, and in fact this week we will make available 28 million doses of these vaccines,” Jeff Zients, the White House Covid-19 response coordinator, said on Tuesday.

As of Monday, 36 percent of the country’s total population has received at least one shot of a vaccine, and 22 percent are fully vaccinated, according to data from the C.D.C.

Even though the reaction to the Johnson &amp; Johnson shot is rare, any questions about the safety of the shots could bolster vaccine hesitancy.

Nearly seven million people in the United States have received Johnson &amp; Johnson shots so far, and roughly nine million more doses have been shipped out to the states, according to data from the C.D.C. The six women who developed blood clots were between the ages of 18 and 48.

“I know there are people who have gotten the vaccine, who are probably very concerned. For people who got the vaccine more than a month ago, the risk to them is very low at this time,” Dr. Schuchat said.

On Friday, Gov. Andrew M. Cuomo said that New York expected to receive 34,900 Johnson &amp; Johnson shots, a decrease of 88 percent from the previous week

Dr. Zucker, New York’s health commissioner, said that the state would honor appointments made at state-run mass vaccination sites for the Johnson &amp; Johnson vaccine by giving people the Pfizer-BioNTech vaccine instead.

Mayor Bill de Blasio of New York City said that the city would do the same, rescheduling appointments at city-run vaccine sites.“Every site has been told this morning to stop giving the J&amp;J shots,” he said at a news conference.

Both Mr. Cuomo and Mr. de Blasio received the Johnson &amp; Johnson vaccine at separate appearances last month, which they framed as an effort to boost confidence in that vaccine’s efficacy rate and to address vaccine hesitancy.

Regulators in Europe and elsewhere are concerned about a similar issue with another coronavirus vaccine, developed by AstraZeneca and Oxford University researchers.

Scientists call these two shapes the prefusion and postfusion forms of the spike. Antibodies against the prefusion shape work powerfully against the coronavirus, but postfusion antibodies don’t stop it.

they discovered a way to keep the protein locked in a tulip-like prefusion shape. All they had to do was change two of more than 1,000 building blocks in the protein into a compound called proline.

All three of the vaccines that have been authorized so far in the United States — from Johnson &amp; Johnson, Moderna and Pfizer-BioNTech — use the 2P spike.

Other vaccine makers are using it as well. Novavax has had strong results with the 2P spike in clinical trials and is expected to apply to the Food and Drug Administration for emergency use authorization in the next few weeks. Sanofi is also testing a 2P spike vaccine and expects to finish clinical trials later this year.

Dr. McLellan’s ability to find lifesaving clues in the structure of proteins has earned him deep admiration in the vaccine world. “This guy is a genius,” said Harry Kleanthous, a senior program officer at the Bill &amp; Melinda Gates Foundation. “He should be proud of this huge thing he’s done for humanity.”

The potency of the vaccine brought an extra benefit: The researchers needed fewer viruses for an effective dose. A single egg may yield five to 10 doses of NDV-HXP-S, compared to one or two doses of influenza vaccines.

once Dr. McLellan and his colleagues handed off the 2P spike to vaccine makers, he turned back to the protein for a closer look. If swapping just two prolines improved a vaccine, surely additional tweaks could improve it even more.

The winner contained the two prolines in the 2P spike, plus four additional prolines found elsewhere in the protein. Dr. McLellan called the new spike HexaPro, in honor of its total of six prolines.

The structure of HexaPro was even more stable than 2P, the team found. It was also resilient, better able to withstand heat and damaging chemicals. Dr. McLellan hoped that its rugged design would make it potent in a vaccine.

the University of Texas set up a licensing arrangement for HexaPro that allows companies and labs in 80 low- and middle-income countries to use the protein in their vaccines without paying royalties.

The first wave of authorized Covid-19 vaccines require specialized, costly ingredients to make. Moderna’s RNA-based vaccine, for instance, needs genetic building blocks called nucleotides, as well as a custom-made fatty acid to build a bubble around them. Those ingredients must be assembled into vaccines in purpose-built factories.

The way influenza vaccines are made is a study in contrast. Many countries have huge factories for making cheap flu shots, with influenza viruses injected into chicken eggs. The eggs produce an abundance of new copies of the viruses. Factory workers then extract the viruses, weaken or kill them and then put them into vaccines.

In March, he joined forces with two fellow University of Texas biologists, Ilya Finkelstein and Jennifer Maynard. Their three labs created 100 new spikes, each with an altered building block. With funding from the Gates Foundation, they tested each one and then combined the promising changes in new spikes. Eventually, they created a single protein that met their aspirations.

PATH then connected the Mount Sinai team with influenza vaccine makers. On March 15, Vietnam’s Institute of Vaccines and Medical Biologicals announced the start of a clinical trial of NDV-HXP-S. A week later, Thailand’s Government Pharmaceutical Organization followed suit. On March 26, Brazil’s Butantan Institute said it would ask for authorization to begin its own clinical trials of NDV-HXP-S.

n vaccine maker Avi-Mex as an intranasal spray. The company will start clinical trials to see if the vaccine is even more potent in that form.

And now there are significant data about the reliability of the Chinese and Russian vaccines. (It’s still too early to tell for Covaxin.) Trial results in the U.A.E. in early December placed the efficacy of the Sinopharm vaccine at 86 percent; others, in China, at 79 percent.

The fact is that no Covid-19 vaccine has been developed or released as transparently as it should have been. And while China and Russia may have botched their rollouts more than some Western companies, that doesn’t necessarily mean their vaccines are shoddy.

Some doctors and activists have put forward proposals to increase the delivery worldwide of vaccines produced in the West. These calls are well-intentioned, but they, too, assume that vaccines from Western countries are the only ones worth having — and waiting for.

There is a simpler solution, already at hand: It’s time to start trusting other countries’ vaccines.

It found that nearly 75 percent of Americans are now wearing masks when they leave their homes.

What changed her mind?“The Biden administration, returning to listening to science and the fantastic stats associated with the vaccines,” she replied.

But the grim reality of the pandemic — with more than 200,000 new cases and some 3,000 deaths daily — and the wanness of this holiday season are perhaps among the biggest factors

A barrage of feel-good media coverage, including rapt attention given to leading scientists and politicians when they get jabbed and joyous scrums surrounding local health care workers who become the first to be vaccinated, has amplified the excitement, public opinion experts say.

The divide between women and men has become pronounced, with women being more hesitant. Black people remain the most skeptical racial group, although their acceptance is inching up: In September, a Pew Research poll said that only 32 percent of Black people were willing to get the vaccine, while the latest poll shows a rise to 42 percent. And though people of all political persuasions are warming to the vaccine, more Republicans than Democrats view the shot suspiciously.

A brighter indication, he said, is that two-thirds of the public say they are at least somewhat confident that a coronavirus vaccine will be distributed in a way that is fair, up from 52 percent in September.

The most pronounced pockets of resistance include rural residents and people between the ages of 30 and 4

Timothy H. Callaghan, a scholar at the Southwest Rural Health Research Center at Texas A&amp;M School of Public Health, said that rural residents tend to be conservative and Republican, characteristics that also show up among the vaccine hesitant

. They also include immigrants and day laborers, many of whom do not have college degrees or even high school diplomas and so may be more dismissive of vaccine science.

The resistance also springs from their hampered access to health care in remote areas. In addition, the need to take off several hours of work from the inflexible demands of farming for travel and recovery from vaccine side effects makes the shots seem even less compelling, he added.

About 35 percent of adults between 30 and 49 over all expressed skepticism about the vaccine, according to the Kaiser poll. Dr. Scott C. Ratzan, whose vaccine surveys in New York with the City University of New York Graduate School of Public Health echo findings similar to the national polls, noted that this group doesn’t keep up on flu shots either. They are well out of the age range for routine vaccines.

Another group that has been uncertain about taking the vaccine is health care workers, who typically have high rates of acceptance for established vaccines.

But other hospitals say that staff time slots for the vaccine are becoming a hot commodity.

For months, Tina Kleinfeldt, a surgical recovery nurse at Long Island Jewish Medical Center, a hospital in the Northwell Health network, had absolutely no intention of getting the vaccine until long after the science and side effects had been established.

Then she realized that doses were still so scarce that she might not get another opportunity soon. So she said yes. She became the first nurse on her unit to get the shot.

Afterwards , she felt some muscle soreness at the site of injection. But she also felt elated, excited and relieved.

Speaking on “CBS This Morning” on Monday, Alex M. Azar II, the secretary of the Department of Health and Human Services, reiterated that distribution would begin quickly after the expected approvals of the Pfizer and Moderna vaccines. “We could be seeing both of these vaccines out and getting into people’s arms before Christmas,” he said.

Meanwhile, federal officials have urged Americans returning from Thanksgiving travel to reduce unnecessary activity.

Moderna has received a commitment of $955 million from the U.S. government’s Biomedical Advanced Research and Development Authority for research and development of its vaccine, and the United States has committed up to $1.525 billion to buy 100 million doses.

Asked about the role of states in the distribution process, Mr. Azar said that doses would be shipped out through normal vaccine distribution systems, and governors would be “like air traffic controllers” determining which hospitals or pharmacies receive shipments.

But generally, “Be thinking people in nursing homes, the most vulnerable, be thinking health care workers who are on the front lines,” he said.

More than 70 vaccines are being developed around the world, including 11 that, like Pfizer’s and Moderna’s vaccines, are in large-scale trials to gauge effectiveness.

If authorization is granted, the first shots could be given as early as Dec. 21.

The government has arranged to buy vaccines from both Moderna and Pfizer and to provide it to the public free of charge.

F.D.A. scientists will examine the information, and the application is likely to undergo a final review on Dec. 17 by a panel of expert advisers to the agency, Mr. Bancel said, adding that he expected the advisers to make a decision within 24 to 72 hours. The F.D.A. usually follows the recommendations of its advisory panels.

In response to a question about how officials can guard against people using money or connections to jump the proverbial line, Mr. Azar vowed to “call out any inequities or injustices that we see.”

The first shots of the two vaccines are likely to go to certain groups, including health care workers, essential workers like police officers, people in other critical industries and employees and residents in nursing homes. On Tuesday, a panel of advisers to the Centers for Disease Control and Prevention will meet to determine how to allocate initial supplies of vaccine.

The first injections may be given as early as Dec. 21 if the process goes smoothly and approval is granted, Stéphane Bancel, the company’s chief executive, said in an interview.

Moderna’s application is based on data that it also announced on Monday, showing that its vaccine is 94.1 percent effective, and that its study of 30,000 people has met the scientific criteria needed to determine whether the vaccine works. The finding from the complete set of data is in line with an analysis of earlier data released on Nov. 16 that found the vaccine to be 94.5 percent effective.

The drugmaker Moderna said it would apply on Monday to the Food and Drug Administration to authorize its coronavirus vaccine for emergency use.

According to Transportation Safety Administration data, about 800,000 to one million people passed through T.S.A. checkpoints each day in the days before and after the holiday — far lower than the same period last year, but likely far higher than epidemiologists had hoped to see.

There were 91,635 current hospitalizations as of Nov. 28, according to the Covid Tracking Project, almost twice as many as there were on Nov. 1, and triple the number on Oct. 1.

California on Sunday became the first state to report over 100,000 cases in a week, according to a New York Times database.

The US has lost more than 529,000 people to the virus, Johns Hopkins University data shows. It's more than the number of Americans killed in World War I and World War II combined. And the death toll is rising by the thousands each week.

Now, the country is at a pivotal point.

"While these trends are starting to head in the right direction, the number of cases, hospitalizations and deaths still remain too high and are somber reminders that we must remain vigilant as we work to scale up our vaccination efforts across this country," Walensky said.

So far, almost one in 10 Americans have been fully vaccinated -- a number that is still too low to suppress the spread of the virus. And some experts have warned another possible surge could be weeks away, fueled by a highly contagious variant spreading across the country.

"We must continue to use proven prevention measures to slow the spread of Covid-19," Walensky added. "They are getting us closer to the end of this pandemic."

For Americans who have been fully vaccinated, the new guidance released by the Centers for Disease Control and Prevention earlier this week marks a small first step toward a return to pre-pandemic life, the agency's director and other colleagues wrote in a JAMA Viewpoint article published Wednesday.

"What we have seen is that we have surges after people start traveling. We saw it after July 4, we saw it after Labor Day, we saw it after the Christmas holidays," Walensky said in the briefing. "Currently 90% of people are still unprotected and not yet vaccinated. So we are really looking forward to updating this guidance as we have more protection across the communities and across the population."

"With high levels of community transmission and the threat of SARS-CoV-2 variants of concern, CDC still recommends a number of prevention measures for all people, regardless of vaccination status," they wrote.

"As vaccine supply increases, and distribution and administration systems expand and improve, more and more people will become fully vaccinated and eager to resume their prepandemic lives," Walensky and CDC officials Drs. Sarah Mbaeyi and Athalia Christie wrote.

More than 62 million Americans have received at least one dose of a Covid-19 vaccine, CDC data shows. Roughly 32.9 million are fully vaccinated.

As vaccination numbers climb, more state leaders are loosening the requirements for who can get a shot.

At least 47 states plus DC are allowing teachers and school staff to receive Covid-19 vaccines. By next Monday, teachers will be eligible in all 50 states.

In Georgia, officials announced the state will expand its vaccine eligibility starting March 15 to include people 55 and older as well as individuals with disabilities and certain medical conditions.

"Provided supply allows, vaccine eligibility is expected to open to all adults in April," Gov. Brian Kemp's office said in a statement.

Other states also announced expanded vaccine eligibility this week, including Alaska, who took it the furthest by making vaccines available to everyone living or working in the state who is at least 16. It's the first state in the nation to do so.

The guidance allows for indoor visitation regardless of the vaccination status of the resident or visitor, with some exceptions.

For example, visitations may be limited for residents with Covid-19 or who are in quarantine or for unvaccinated residents living in facilities where less than 70% of residents are fully vaccinated, in a county that has a Covid-19 positivity rate greater than 10%.

"CMS recognizes the psychological, emotional and physical toll that prolonged isolation and separation from family have taken on nursing home residents, and their families," CMS Chief Medical Officer Dr. Lee Fleisher said in a statement.

"That is why, now that millions of vaccines have been administered to nursing home residents and staff, and the number of COVID cases in nursing homes has dropped significantly, CMS is updating its visitation guidance to bring more families together safely."

"Vaccine hesitancy is a big problem for all of us,"

Up until now, the nationwide vaccine campaign has seen demand outstrip supply, but Mokdad says he believes that will soon change. By May, he believes, "We will have more vaccines than people willing to take the vaccine."

The numbers who may refuse the vaccine remain potentially too high to contain a respiratory virus such as SARS-CoV-2, which requires a large segment of the population to be immune.

But the fall and winter could be a different story. Scarpino says he believes that more contagious variants such as the one first reported in the U.K. will dominate the fall and winter COVID-19 season, raising the herd immunity threshold. Variants with higher transmissibility may require a larger share of the population to be immune before they can be contained.

"What most of us want is a safe return to something that looks more normal," says Samuel Scarpino, who models the coronavirus outbreak at Northeastern University. "That to me means 80% to 85%, probably, vaccinated."

And roughly 20% of the population are children under the age of 16, who are not yet eligible to receive a vaccine — making it even more crucial that adults do get vaccinated.

Nobody knows exactly how large, but based on other diseases, researchers believe it is far above the current 32% of the U.S. population that's gotten at least one shot to date.

"It's very hard to convince people to take the vaccine in summer, when everything is going good,"

Scarpino and Mokdad say the problem will not be immediately apparent. Both scientists expect COVID-19 cases to drop over the summer months when a combination of vaccinations and warm weather will dramatically slow the virus down. Mokdad says he thinks the improved conditions will paradoxically make vaccination more difficult.

Moderate rates of vaccination will prevent a nationwide crisis such as that seen during the winter of 2020 and 2021, he says. But he worries regional outbreaks could still overwhelm hospitals, close schools and force local governments to reinstitute restrictions in different parts of the United States, especially in areas where vaccination rates are low.

The reasons for saying "no" to a vaccine are often complex.

"I don't think there's one particular group," says Tara Kirk Sell, a senior scholar at the Johns Hopkins Center for Health Security. "I don't think that it works to classify people who are vaccine hesitant all having the same reason for being vaccine hesitant."

Koltai says that misinformation is proliferating right now, often tailored to different groups with different grievances

"You need to speak to these different groups: the minority groups, the Republicans and the other people who feel like they have some distrust in science," she says. Often the best way to do so, she says, is through groups and leaders at a local level who are in favor of vaccination.

Last week, the Biden administration launched a major initiative to try and encourage vaccination by enlisting faith groups, unions and even NASCAR to promote getting vaccinated. It's the kind of broad, grassroots effort experts say can help.

The question is, will it be enough? "We need to vaccinate as much as possible right now, stop the circulation of this virus in the U.S. and elsewhere," Mokdad says. "Then we can control it."

Two colleges, St. Edward's University in Austin, Texas, and Nova Southeastern University (NSU) in Broward, Florida, have gone a step further, requiring students and all campus employees to be vaccinated.

After NSU's announcement on April 1 DeSantis signed an executive order stating that vaccines are available but not mandated. Crucially the order prohibits any government entity or business from requiring a vaccine passport. NSU said Thursday that it is reviewing the executive order.