‘The year of the vaccine’

What comes after the year of Covid?

A few seconds after rolling up the sleeve of her bright blue t-shirt, emblazoned with a penguin donning a Santa hat and scarf above the text ‘Merry Christmas’, Margaret Keenan asked nurse May Parsons “all done?” to rapturous applause.

At her local hospital in Coventry, central England, the then-90-year-old became the first person in the world to receive the Pfizer Covid-19 vaccine outside of a trial at 6.31am on December 8, before being wheeled down a corridor to a guard of honour.

The grandmother-of-four marked the historic occasion with a plea: “Please go for it, that’s all I say.”

“If I can do it, so can you.”

Twelve months feels like a long time in a pandemic – when lockdowns have blurred weeks and months together, and special occasions have been postponed or cancelled – but it is no time at all when it comes to developing a vaccine.

The journey from identifying the need for a vaccine to getting a licensed product is a massive undertaking – one that typically takes years, if not decades, and costs billions of dollars.

But the rulebook has been rewritten in the face of the pandemic, and all eyes are on 2021 as “the year of the vaccine”.

On March 16, three months after the first cases were notified to the World Health Organisation (WHO), the first vaccine candidate – produced by Boston-based biotech company Moderna – entered human trials.

Nine months later, in the space of three weeks in November, three frontrunners released preliminary findings from phase 3 clinical trials – the final, most difficult, expensive and time-consuming stage – each touting efficacy rates between 90 and 99 per cent.

As hundreds of vaccine candidates began developments and trials, countries scrambled to join waitlists. In September, New Zealand announced it was throwing $27 million at the COVAX facility’s efforts to create a vaccine. (COVAX is a global arrangement to pool resources and equitably distribute vaccines.) This was just the beginning of the bidding.

By October 12, another agreement - the cost of which is yet to be disclosed - secured 1.5 million doses of the Pfizer and BioNTech vaccine candidate, enough for 750,000 people.

On November 9, Pfizer announced preliminary findings which placed the vaccine at over 90 per cent effective. Seven days later, Moderna announced its candidate was 94.5 per cent effective.

On December 2, the UK became the first country in the world to approve the Pfizer/BioNTech vaccine – less than a month after preliminary findings were released.

Britain ordered 40 million doses in one fell swoop, enough to vaccinate 20 million people, and began its mass vaccination campaign within a week. Canada and the US promptly followed suit.

On December 17, the Government announced it had secured enough vaccines for the whole of New Zealand

It will vaccinate border workers from the second quarter of 2021, and the rest of the country from mid-year, inking two new agreements for millions of two-dose vaccines from AstraZeneca and Novovax.

The Government would also purchase enough vaccines for New Zealand-realm countries Tokelau, Niue and the Cook Islands, as well as neighbours Tonga, Samoa and Tuvalu if they want to take up the offer.

The speed at which this is happening is dizzying. Historically, the fastest vaccine ever developed still took four years to go from collecting viral samples to licensing.

The Pfizer vaccine - based on a completely new technology using mRNA to activate the immune system against the virus - took only 10 months to go from concept to reality, bounding through steps which typically take 10 years.

But the break-neck speed is necessary.

Hundreds of thousands of people continue to contract the virus around the world each day, and more than 1.6 million people - equivalent to the population of Auckland - have died worldwide to date.

A vaccine is being revered as a panacea, a ‘silver bullet’ that will see our lives return to some semblance of normal. But as we look ahead to 2021 - the year of the vaccine - experts warn there are challenges still to come.

In 1963, American microbiologist Maurice Hilleman’s daughter Jeryl Lynn came down with the mumps.

Hilleman took a swab and retreated to his lab, eventually forming the basis of the mumps vaccine still used today. The process took 4-5 years – the fastest in history.

Vaccine development was traditionally a “very, very long process”, University of Auckland associate professor and vaccinologist Dr Helen Petousis-Harris says.

Nearly six decades on from Hilleman’s work on the mumps vaccine, progress had remained “slow”, largely owing to the “huge bureaucracy involved” in developing a vaccine – until now.

In the wake of the Ebola epidemic (2014-16), which devastated west Africa and killed more than 11,000 worldwide, and the recognition “we would be in trouble” if a new disease emerged, the Coalition for Epidemic Preparedness Innovation was founded in 2017 - a global alliance for financing and coordinating vaccine development for emerging infectious diseases.

The outlook had historically been “terrible” for low income countries with diseases that don’t affect developed nations, and there was an “enormous problem” getting vaccines for neglected diseases and emerging infectious illnesses.

“We had ourselves in a bit of a corner,” Petousis-Harris says.

But when Covid-19 reared its ugly head, work was already underway to streamline the process, including the use of new technologies utilised by a number of Covid front-runners.

“We were fortunately in a slightly better position when this happened than we could have been five years ago … we are seeing now what is actually possible.”

The race to find a Covid-19 vaccine is likely to forever shake-up the way vaccines are developed.

“I don’t think vaccine-land is going to look the same again, it can’t look the same again. We can’t go back,” Petousis-Harris says.

“We’ve already now furthered these technologies way beyond where they were before … [there] won’t really be an excuse anymore not to be able to produce [a vaccine] when there is a need.”

Petousis-Harris says a huge amount of logistical work is going into organising how to get vaccines to those who need it, amid the challenges posed by needing to be kept at -70 degrees.

But there is another issue which will pose a “real challenge” worldwide.

As soon as you start vaccinating lots of people, you are going to see adverse events happening, she says. These may, or may not be related to the vaccine, except by virtue of happening after a vaccine was given.

“This is something we need to be prepared for.”

Sitting opposite Auckland City Hospital, Petousis-Harris says ‘events’ happen every day, so “we’re going to have to work very hard to be able to communicate what we should be expecting as we monitor this carefully” in a mass campaign.

A Covid-19 vaccine won’t be a silver bullet, but it will enable us to see things start to change, Petousis-Harris says.

“[2021] is going to be a year full of challenges, but more certainty.

“It’s going to be the year where we start knocking this thing back.”

Thinking back to life before Covid-19 or to a future without it feels a bit like grasping at smoke.

Late November saw the first decline in newly-reported cases globally since September, WHO Director-General Dr Tedros Adhanom Ghebreyesus announced, linked to “difficult but necessary” measures put in place in Europe.

While it was “welcome news” it must be interpreted with “extreme caution”, he warned.

“Gains can easily be lost … There is no time for complacency, especially with the holiday season approaching in many cultures and countries.”

Ghebreysus says the WHO is sure it can “defeat” the pandemic using existing tools and vaccines in the pipeline.

“The most important thing is we need to have hope, and not only hope but solidarity to work together.

“The pandemic will end – and we all have a part to play in ending it.”

WHO’s press office told Stuff that while we might be tired of Covid-19, “it is not tired of us”.

Studies show the “vast majority” of the population is still susceptible to the disease, and we must do “everything we can” to prevent infections and save lives.

It would not take much to throw New Zealand back into the grips of the virus, either.

Infectious diseases modeller Dr Michael Plank says it could take only one case to start another major outbreak.

“Things can change very, very easily. We really have to stay alert,” he says.

A vaccine is the first step in opening New Zealand back up to the world, but it is not the only step.

In November, Covid-19 Response Minister Chris Hipkins said some travel restrictions would likely remain in place for another 12-18 months, while Prime Minister Jacinda Ardern revealed New Zealand would need to have a certain level of herd immunity to the virus before any significant alterations are made to border restrictions.

It has not yet been stated exactly what immunity level would be required before any decisions are made, but Ardern has said people would need to be able to safely go about their day-to-day lives before quarantine rules were eased.

She said the question is: "What will it take us to get, through immunisation, up to that herd immunity [level]?"

Once that question had been answered, she said New Zealanders would be able to be less worried about what is happening at the border.

Hipkins earlier said that work is underway to decide how much of the population would need to be vaccinated before travel restrictions could be eased.

"It doesn't necessarily have to be 100 per cent - we may never get to 100 per cent."

The Ministry of Health would not say if it was setting a target for vaccination coverage among at-risk groups or the general population.

At a media briefing in December, Chief Science Advisor for the Ministry of Health, Professor Ian Town said we “just don’t know enough at this point” about how the vaccine could inform what happens next.

We don’t yet know how long a vaccine protects a person or whether it stops them potentially infecting others.

What is clear is the virus may never go away entirely.

Eradication - the complete reduction of a virus to zero - may not happen anytime soon or at all, which is why New Zealand, and many other like-minded countries, opted for elimination instead.

Only two diseases have been declared by the WHO as officially eradicated, and only one in humans: smallpox. Rinderpest, the “cattle plague” was also eradicated. Polio is on the cusp.

In November, after promising results of various vaccine candidates were released, Bloomfield delivered a sobering reminder.

“I can tell you that the first reports of influenza were in the 12th Century. So it’s been around with us for centuries.”

Covid-19 is on track to becoming an endemic disease – established and ever-present, like the other four coronaviruses which cause respiratory infections, epidemiologist Professor Michael Baker says.

“Ultimately, vaccines are going to be the thing that allow us to manage the threat.”

A Covid-19 vaccine “will change things hugely”, and could help other countries in eliminating the virus rather than learning to live with it at great cost.

But this likely wouldn’t happen overnight, he says: “I think it will be by degrees.”

Baker says there is one clear message from the fallout of the pandemic: Governments and people need to get far more sophisticated at managing collective threats. Whether that is a virus, or climate change.

“The pandemic is a transient threat. It is horrible, and it is killing a lot of people, but it will stop in the next 2-3 years largely,” he says.

“But all the CO2 we’re putting into the atmosphere, that’s there for generations. That will ultimately be far more disruptive if we don’t manage it.”

It’s not about returning to life as it was before Covid-19 as quickly as possible, he says.

“We have to use this opportunity to take a different direction, quite a fundamentally different direction.”

Regardless of what happens with the development of a vaccine or effective treatments for Covid-19 in coming months or years, 2020 will forever be marked as the year a novel disease brought the world to its knees.