Let's talk COVID-19: The race for a vaccine

Avril Benoit:

Welcome and thanks for joining us for our series Let's Talk COVID-19 which we're doing here every two weeks. I'm Avril Benoit. I'm the Executive Director of Doctors Without Borders in the United States. We're known internationally as Médecins Sans Frontières and from that we get the acronym MSF which you might hear occasionally just to save time.

Today's focus is on the global race to develop a vaccine against COVID-19 building on MSF's decades of experience with vaccine, vaccine development, vaccination campaigns and saving lives through vaccines. And we're going to focus on the challenges we continue to face when we're trying to ensure access to safe vaccines for everyone because we know that there is this global race. We've got research teams all over the world competing to be the first, and they're a lot of issues around access. I know already since we're promoting this through Facebook et cetera that there are a lot of skeptics about vaccination and we would like to address that as well because that movement needs to be taken into consideration as we try to save lives with vaccines.

So the discussion will last around 45 minutes. Wherever you're joining today, you can submit your questions, join in with the discussion. If you're watching on Zoom, you can send your questions into the Q&A option. If you're joining on Facebook or Twitch just send your comments in the comments section and we'll prioritize questions related to vaccines and this specific discussion.

In other weeks we will tackle other aspects of the response to COVID-19. So joining me today we have some experts. Kate Elder, the senior vaccines policy adviser for MSF's Access Campaign and Matt Coldiron, a medical epidemiologist at Epicenter which is an epidemiology and research satellite created by Doctors Without Borders/MSF. Welcome to both of you. Good to see you.

Matt Coldiron:

Nice to be here.

Kate Elder:

Hi Avril.

Avril Benoit:

How are you both doing? Matt, you first.

Matt Coldiron:

I'm great. Living the dream. Working from home in Brooklyn. I've been baking sourdough for a long time well before this so I haven't even had a chance to find a new hobby.

Avril Benoit:

Kate, how about you?

Kate Elder:

I'm not baking bread. I'm working really hard at home and trying to balance childcare with very long days but doing very well. Thanks, Avril.

Avril Benoit:

I'm glad you're taking the time to share your expertise with us. Let's start with you, Kate. What is your main preoccupation when it comes to this whole topic? When you think of this lodestar of it will all be over as soon as we all get the vaccine as if it's easy? What's on your mind when people like me say things like that?

Kate Elder:

I've got two big preoccupations right now. One, what COVID-19 is doing in the context for MSF work. In all of the work that we routinely do to try and vaccinate kids. It's one of the core medical services that MSF offers in the places where we work and there has been a significant interruption of the vaccination services and other child health services. I mean rightly so because we need to prepare and prevent the spread of COVID but that's having devastating effects on children and children's lives. That's my first big preoccupation.

And then of course is preparing for when we have this vaccine which everybody is eagerly awaiting. Who's going to get it? What price is it going to be at? Can we as MSF get it to vaccinate the vulnerable populations that we see? Those are the things that are keeping me up at night right now.

Avril Benoit:

And for Matt, you're looking at a lot of the research that's coming through not just for vaccines but for the sake of today's discussion, what is it you're looking for in all the literature and the news that you're following in this area?

Matt Coldiron:

Well, I think this is an epidemic a pandemic that's really... We've never seen anything like it before. MSF we deal with lots of epidemics in places around the world and sometimes they don't get as much press but here we have everyone, every single day, everywhere on the news, on Twitter, on Facebook, on everything else so I think the biggest challenge so far has been to control the quality of the evidence that's coming out. There is a lot of stuff out there, and it is just... I can't think of any other circumstance where there's been such a glut of information. Really separating through what's good and reliable from what is unreliable has been a challenge.

Avril Benoit:

Yeah, and where do you go for the reliable information.

Matt Coldiron:

I think the classic is peer-reviewed publications. Even though we know that peer-reviewed publications are not without their shortcomings sometimes, that's sort of the highest level of evidence. We're not quite there yet but often what happens when you make public policy is that you have independent groups or independent expert groups that will review all against the ensemble of evidence from peer-review publications. We're not quite to that level yet in this epidemic but that's the best place to start.

Avril Benoit:

And Kate, you focus on all of the kinds of vaccination programs that we do at MSF. With COVID-19 a lot of it has been quite disruptive. The effect of COVID-19 on our ability to bring people together for campaigns or even to look after other patients. Can you give us a bit of an overview of how COVID-19 is actually affecting other kinds of vaccination programs?

Kate Elder:

Absolutely. We're seeing COVID-19 affect our immunization programs, government immunization programs and a multitude of levels. First and foremost is just the disruption of the healthcare workers in the system as countries prepare for COVID-19. So people that are typically in primary healthcare centers with a focus on immunization are being diverted to other necessary preparations. Healthcare facilities, healthcare wards. Being changed from a maternity ward for example into a COVID-19 treatment ward. So that's the first thing is just a shift in focus to this priority pandemic.

Second is can we even hold vaccination campaigns anymore? I mean in the places where MSF works we do vaccination in three different ways. One is through primary healthcare. The routine day in and day out. Kids getting their routine shots as we do here in the United States when I take my daughter for a vaccine or in Europe they also do in developing countries.

Secondly, we hold mass vaccination campaigns to prevent disease outbreaks. In the places where MSF is working measles epidemics are still raging. Immunity of kids is low so you need to hold mass vaccination campaigns to boost immunity quickly and prevent an outbreak and then thirdly we typically do actual outbreak response campaigns. There is a measles campaign. They're quickly trying to mobilize people in a couple days to vaccinate as many kids as possible. Understanding that we don't want lots of people to gather right now, that has taken away a major tool of vaccination programs that we typically do and we're seeing that level of interruption in terms of our ability to just actually vaccinate.

Thirdly, getting the vaccines to countries. I think everybody's seen the reduction of course in air travel. UNICEF said that they have seen air flights to Africa decrease by 70 to 80% meanwhile the freight charges have gone up 100 to 200% more in terms of the cost. So just getting the vaccines that we typically do to these countries has been incredibly difficult. To just maintain any services that actually can happen.

And of course, then there's the community level issues with the demand. People are scared. People have been told not to leave the house in places, so they're not coming to seek healthcare if they typically would. So that's just a few of the areas right now where we've seen immunization programs in the places where MSF works be impacted. And of course just to bear in mind the magnitude of that in a country like the Democratic Republic of Congo compared to the U.S. is significantly different. When a child is not protected against measles in DRC and if they do get measles their ability to get treatment, the rates of illnesses are much higher than in a developed country. So these are some of the concerns that our colleagues working in operations are facing right now.

Avril Benoit:

Let's focus on the new vaccine. The vaccine against COVID-19. I'm saying the vaccine as if there's just one. We're starting to get questions through the comments and the Q&A here so let's start with the first one. A vaccine against coronavirus, coronavirus is the common cold. They're in the ballpark together, and there's no vaccine against the common cold, Matt. So Dennis is asking, are vaccines even successful against Coronavirus.

Matt Coldiron:

To date, vaccines have been partially successful against other types of coronavirus. To be very clear there is not a COVID-19 vaccine yet. There are some candidate vaccines. Many of them are already doing early-stage testing but we don't have any vaccine yet. Dozens of candidates but we don't have something that we can definitely call a vaccine yet.

But yeah, it's going to be a question of managing expectations. For many vaccines, we know that efficacy is super high. If you get two doses of measles vaccines, it's going to work 98% of the time and we can sort of say for other diseases how they work. For a lot of these respiratory diseases like the flu and for some of the other coronavirus cousins that have been tried the vaccines are not probably not going to work 100% well but the question is if you can get a vaccine that works 60, 70% of the time, maybe that's a really big public health benefit and that has a massive effect.

We're probably not shooting for a vaccine that's going to be 100% effective. Definitely not the first one that's going to come out but trying to find something and can reliably prevent disease even half of the time would be really valuable.

Avril Benoit:

We're getting a lot of questions about how we seem to be rushing into this. Initially, we were told vaccine development takes five years, 10 years. Now we're going to try and do it in a year and a half and even the different models have shown how everything would have to align perfectly for something to be ready in a year and a half. Do you share the concerns that many people have that we're going to be cutting corners on safety perhaps? That it's just not going to be as secure once there is a vaccine that's validated, Matt?

Matt Coldiron:

I would say that I understand the concern. I don't say that I necessarily think that it's a... I don't see it as a major concern but I understand why people would be afraid or be scared. The way that vaccines are brought to market. The traditional classic way it would take five, 10 years from the first step all the way to sort of large scale public health use. We don't have 10 years now. This is completely... It's totally different. No one has ever seen this, so there's a massive amount of funding. There's a massive amount of goodwill, and there's a massive amount of desire and need for a vaccine so I think that some of the moving faster is because there is a massive need in front of us.

The other part of it is that because there is such a massive need there are some creative ways to look at streamlining the process. I wouldn't call it cutting corners or skipping steps but I would say streamlining. And that involves maybe doing fewer studies in animals but starting to do the studies in humans on a small number of people.

The way that the studies usually work. You talk about phase one, phase two, phase three and sort of phase three after that then a vaccine will become licensed. Generally, phase one you're talking about tens of participants in a trial. Phase two you're talking about hundreds of participants in a trial and phase three you're talking about thousands of participants. In terms of the safety, the very earliest it's in a very small number of participants and that's just because we want to make sure that there are no safety signals and then in none of the ways that they're talking about streamlining are those early-stage clinical trials going to be in any way streamlined or moved around. I think that the building blocks of how we evaluate vaccines is still the same.

Avril Benoit:

And Kate, the pipeline for this vaccine development. What can you tell us about how it typically would work? The challenges to actually making sure that there would be fairness in terms of who gets the vaccine and things like that.

Kate Elder:

That's an excellent question. I think never before has the world been in the position where the entire globe expects to hopefully get the vaccine at the same time. There is always, I mean we see this at MSF because many of the vaccines that are available in high-income countries are not yet available in low-income countries where we work. So traditionally because of the biopharmaceutical model, commercial model, there's a huge lag time between when a vaccine is available in high-income countries that can pay top dollar and when it's available in the poorer countries of the world that obviously have significantly lower budgets to spend on health and vaccinations.

We're in an unprecedented time of the entire world hoping that there will be a vaccine available at sufficient quantities which we know will be challenging too if there's more than seven billion people in the world and it's not necessarily going to be the case that the vaccines, the first ones that are available just require one dose. Many vaccines that MSF administer like Matt talked about before for measles, there's two doses or a couple of doses to be fully protected. So the volumes that we're also looking at are extraordinary.

So that question of the fairness. Who's going to get it is really at the top of everybody's head right now. MSF has been calling for no profits during a pandemic. We believe that this still indeed is a global public good. We're encouraged by the language we've seen by many global health leaders that indeed this is the peoples' vaccine and a common good so everybody should have access to it in a fair way as soon as possible. But then translating those big political statements into concrete mechanisms and allocation systems is the difficult bit. The devil's in the detail.

So there's some work right now being done let by the World Health Organization to develop an equitable allocation framework if you will. I think everybody agrees that healthcare workers, the people that are most vulnerable certainly deserve this vaccine first but that's going to take a lot of solidarity. That's going to take countries not hoarding the vaccine. That's going to take countries not already putting in advanced purchases for doses that aren't even available yet which is something that we're seeing with some high-income countries. So I think we're hopeful but we're practical and many steps are being taken right now by the global community to try and set those stipulations in advance. It's not going to be easy, though. It's not going to be easy.

Avril Benoit:

Is there any one regulatory body though that can make sure that the things you're talking about are upheld?

Kate Elder:

The World Health Organization would definitely be the best place for that sort of solidarity and that framework to be brokered. The challenge is A) Do countries buy in to this multilateral approach that the World Health Organization functions under? Do they have the biding mechanisms to enforce it which are challenging worldwide? But that would be the best place to do it would be WHO.

The World Health Assembly just concluded last week. The annual general assembly of all countries of the world. The first time I believe it's happened online in one day and there was one resolution on COVID-19 brokered but it's a politically dynamic sphere. Many countries are trying to pull out language that expresses solidarity, not wanting to talk about global public goods. So there's a lot of self-interest at play and it's sometimes hard to really find a consensus.

Avril Benoit:

Matt Coldiron, you're a physician and an epidemiologist and when you look at this fixation that many have on vaccine and yet what we hear from other public health experts that in fact it should be about testing and contact tracing and there's a whole different approach that we should be prioritizing. How do you balance the need for a vaccine eventually, maybe the need for treatment at some point with all the prevention work that's necessary to be able to slow down this pandemic?

Matt Coldiron:

Certainly in the absence of an effective vaccine, the best way of doing prevention is being able to do the contact tracing, isolation of people at risk and wearing your mask and washing your hands and things like that. That need for good contact tracing is not going to go away once we have a vaccine because when there are cases you will still need to do that same sort of epidemiological tracing but there is, at the same time, need for treatment for people for whatever reason are not protected by an eventual vaccine or who slip through the cracks of contact tracing or become sick even despite the contact tracing. So I think they're complementary. I don't think it's a one or another thing. It's all part of the package.

Avril Benoit:

And the testing then. There are different kinds of tests, and you've got the antibody test is a whole other issue as opposed to do you have COVID-19 or not.

Matt Coldiron:

Exactly.

Avril Benoit:

It seems also that some tests were rolled out that weren't very good, that weren't very accurate, that weren't worth it and yet they were developed and invested in and hopes were pinned on them. Is it possible that we could have a similar situation with a vaccine?

Matt Coldiron:

The short answer is yes and I think that's not necessarily a bad thing. As I was explaining before we're not expecting the first vaccine to be a perfect vaccine and I think that sometimes when people have... And there's no test that's a perfect test either. It's a fact. I think that an imperfect vaccine could be an extremely useful tool. If you're able to decrease the number of cases of COVID by 50%, no one would say oh, well your vaccine didn't do us any good because it didn't work half the time. You'd say well you have 50% fewer cases. 50% fewer deaths due to COVID.

If one looked at it from a public health point of view even a perfect or an imperfectly protecting vaccine is still an extremely valuable tool. I think as Kate was talking about there's sort of an urge to move fast. Where I'm a little bit afraid about that is if one country has the vaccine they push to move it out in their populations. To roll it out very fast. I think that's a potential risk and I think it's going to be about that race mentality. The horse race mentality.

Avril Benoit:

For those who are part of the anti-vaccination movement, though, they will say actually the biggest risk is that this vaccine or these vaccines that are proposed will do more harm than good. How does the scientific research process avoid that?

Matt Coldiron:

Through rigorous application of protocols. Through rigorous oversight. Through independent review and through continued follow-up even after licensure. What I was explaining before about the way that you go from animal studies to small studies in humans to larger studies in humans and then to very large studies in humans. That is done to mitigate any possible risks. If there are any potential risks with any vaccine, drug, device, anything you want to be looking at the smallest group possible first and generally healthy people as well. You don't want to have an 85-year-old person with multiple comorbidities in a phase one safety trial. You want to look at it in a healthy population similar to you're not going to look at pregnant women or children in those trials. You're going to look at a healthy young adult population.

And then I think one of the things that's difficult with the anti-vaccine movement is that there are sometimes rare side effects from vaccines. There are rare side effects from drugs. That's just a fact. The problem is that even if you did a massive scale clinical trial with a hundred thousand people in it, which is larger than almost any clinical trial you've ever seen. If you have a rare side effect from any drug or vaccine that maybe happens to one in three million people, you're never going to even see that in the clinical trial so after the clinical trial process if over what happens is that there's post-licensure monitoring of any drug or vaccine or therapeutic. And that's just a part of the cycle. It's regulated by researchers. It's regulated by scientific people. It's regulated by ethics committees. It's regulated by drug regulators and it's just a process.

Kate Elder:

Can I jump in there Avril?

Matt Coldiron:

Please.

Avril Benoit:

Yeah, go ahead.

Kate Elder:

Just to underscore the importance of some of the points that Matt's saying. Every single vaccine regardless of where it's produced goes under the same level of scrutiny. There is not a huge number of vaccine producers around the world. It's actually a relatively small group of producers and the level of regulation... Because if these vaccines are being given to healthy people, we're injecting a substance in a healthy person. The bar of safety is incredibly high. There's no such thing as generic vaccines actually. Every single vaccine, whether it's produced by a company in France, here in the United States, in Brazil, in India, go through the same robust clinical procedure that Matt is talking about. It has to go through every same step. There's no such thing as bioequivalence as you seen in a medicine field with generics.

So just to underscore, there's no such thing as a generic vaccine. Every single one of them where they're coming from goes under the same level of extreme regulatory steps and also the World Health Organization has a program called the Prequalification Programme where they look at all of the data from regulatory agencies and give their stamp of approval as well these are indeed safe. All of the vaccines that MSF buys have received WHO prequalification too. So just to underscore what Matt's saying. These are very safe when they finally get to people.

Avril Benoit:

Question from Jessica though which links to something that you mentioned in passing Matt that you wouldn't do the clinical trials with pregnant women for example. So how then when the vaccine is rolled out would you know that it's safe to give it to pregnant women?

Matt Coldiron:

Let me clarify. I would not do the very first phase one trial and that's the trial where you're doing it in tens of people. So 10, 20, 30 people. I would not want to include pregnant women in that trial. I think it's extremely important, and we've seen this in the Ebola epidemics and in all sorts of other vaccine development to make sure that pregnant women are offered the chance to participate in these trials. Participation in a trial is not something that's forced on anyone. It's something that's proposed to people and they have a back and forth talking about the risks and the benefits and if they decide they want to participate it's their voluntary choice. So I think there's a very important role to include pregnant women in these trials but just not at that very first stage like the 10, 20 person trial.

Avril Benoit:

Another question that comes to mind is that if somebody participates in the trial at a certain point you want to know if they're still carrying the antibodies or they're still protected by the vaccine. I recall participating myself in the vaccine trial for the Ebola vaccine when I was working with Doctors Without Borders in Eastern Democratic Republic of Congo. So that was a year, year and a half ago. Am I still somewhat protected? How will we know? What will be the aftermath of having participated in a trail let alone once an approved vaccine is actually given to the wider population?

Matt Coldiron:

This is where we're working on multiple fronts at once. One of the things that we talk about in terms of evaluating vaccines is immune correlates of protection, and that's a big fancy-sounding phrase but it basically says we know what to look for in someone's blood that says if they have this antibody or if they have this type of cell then they're definitely going to be protected. You don't know that yet for COVID-19. With the testing we're looking for antibodies we can say that that means that they have been exposed. We can say for sure that they've had it but it doesn't necessarily mean that they're going to be protected in the future. So we don't know this immune correlate protection against COVID-19 yet. So it does make it a little bit more difficult to do some of these early-phase vaccine studies because we can look for some antibodies but we don't know if the presence of the antibodies will actually confer actual immunity.

Classically in larger-scale trials of vaccines that would be what would be seen. The people who are planning these trials now are forward-thinking. They're saying well, we're doing the small safety studies now. The phase one. The phase two trials now but if the vaccine looks promising then we need to do it in thousands of people. They're already planning those trials now and getting them on the ground and it will be important to do some of these larger trials in places where there is active transmission because that's going to be the easiest way to see if the vaccine works is if you go into a city or a county where there is a widespread transmission and you're vaccinating some people you can compare to see who gets and who doesn't get.

Avril Benoit:

You're watching a live stream from Médecins Sans Frontières/Doctors Without Borders, an international medical organization that is responding to COVID-19 and today we're taking a deep dive into vaccinations and the COVID-19 vaccine. The promise of it to get us out of this pandemic. Now, Kate Elder, you're a senior vaccines policy advisor with our Access Campaign and we have a question here that's come in from the audience how does MSF work with other organizations, other actors at different stages of the development or testing of a vaccine?

Kate Elder:

That's a great question. MSF is involved in vaccine development almost across the entire spectrum I would say. Way upstream so to speak when the money is being allocated, we're following that right now. Who's giving the money to develop COVID-19 vaccines? How much are they giving and what strings are coming attached to make sure that the end product...? If this company has a successful product are available to as many people as possible. So I would say we really watch it from the very inception of when this happens that we're doing right now. Trying to trace the money so to speak and make sure there are conditions attached to that money.

MSF sometimes gets involved in clinical trials itself. We have research arm of MSF, Epicenter that Matt works for and so we participate in many of the places where MSF works, we need to know about the potential success of these vaccines and we're ultimately the ones that also use them. So sometimes MSF actually participates in the clinical trials run by pharmaceutical companies. Further down the line, the Access Campaign, a small arm of MSF that works to ensure affordability and accessibility of medical tools to the people that MSF serves as well as beyond. We follow the access element.

So what prices are being set? What sort of policies are governing how these tools are being allocated? What do the products even look like? We're talking right now about trying to get a vaccine. We're all eagerly waiting for the first vaccine. The second, the third vaccine but then actually getting that vaccine and distributing it and using it in communities is a very different context in which MSF works in high-income countries. We deal with things called cold chains. You've got to keep the vaccine cold. How do you do that in a place that doesn't have electricity? Many of the vaccines as I said before require multiple doses. Some of them are not in multi-dose vials. You just have one dose. There's one vial. That seems easy. That's what we have in the States but that means you need so much more cold chain refrigeration capacity to get it to these places.

We're also following what the product characteristics if you will are of these vaccines to try and make sure that they're easy to use in developing country contexts. But we're following it I would say from every single step and we're doing it as you said, Avril, in collaboration with other civil society and NGO partners. There is a huge access to medicine community right now that is following the development of these vaccines very closely because they want to make sure that they're accessible to all.

I would say in more than a dozen years of working in immunization and vaccination policy I have never seen such interest from the civil-society community in the outcomes of one vaccine. If there's a silver lining for me it's that the access to medicine community is so interested in this vaccine whereas before immunization I would say hasn't really had a huge advocacy constituency in the civil-society community. At least it's not as much as I would like but of course, I spend all day working on vaccines. But right now, the access to medicine community is watching this closely which is great because we're going to have to hold governments and pharmaceutical companies to account when the first vaccines are available.

Avril Benoit:

Let's jump right back into another topic in the questions and this one's for you Matt. Will mutation of this COVID-19 virus affect vaccine development?

Matt Coldiron:

Maybe. That's the short answer. We don't know. There's been documented small mutations of this virus that's circulating in the community now that don't seem to have clinical impacts on patients that get COVID. For now, it doesn't seem to have any impact on the vaccine targets. I don't want to get too deep into how a vaccine is made but often the vaccine targets a specific part of the germ, in this case, the COVID-19 virus and there haven't been any significant mutations in the part of the virus that many of the vaccines are being mounted against.

That said, you can look at things like the flu where every year there are mutations and there are differences in what happens and it can affect vaccine efficacy. So it's possible that that happens for COVID-19. I wouldn't say that it's probable at this point or highly likely at this point but it's definitely possible and it's something that researchers and the scientific community will have to keep an eye on.

Avril Benoit:

And many of us have heard that there are strains. That you can tell where the vaccine came from. So for example the strain of the virus that has afflicted the northeast of the United States, New York State in particular for example, came from Europe. They can say that came from Europe. Is that a mutation or is that a strain? What is the difference between the two?

Matt Coldiron:

It is the result of a small number of mutations that are not clinically relevant or not clinically different. You can sort of take the whole genome of this virus and if there's... I don't know how many genes there are in this virus but if there's two million different little strands of DNA or two million different pieces of DNA, there might be three or four, five or six that are slightly different and you can look at those slight differences on a genomic level, on a molecular level and say that this is different. But then in terms of what you actually see, there's not a difference in terms of the clinical picture or in terms of the transmissibility or anything like that. It's something to watch and maybe in the future, there could be some sort of mutation that would make a difference in clinical presentation or transmissibility. That's not the case yet and for now, it's an epidemiological tool that we're able to look and see on a molecular level who's spreading where.

Avril Benoit:

All right. Another question for you Matt. Explain how this herd immunity concept which has flocked in a few countries, maybe is still being tried in other countries, is a question mark, is controversial but how long does it take for a community to have the herd immunity that you would look for in order to diminish the risk of these terrible apexes of cases arriving in intensive-care units in hospitals for example?

Matt Coldiron:

Again we don't know the answer to that question yet. There are hypotheses that maybe you need about 50 or 60% of the population in any given community. 40, 50, 60%. But we just don't know the answer to that question yet. The concept is that you want to have... If you get enough people in a given community, you are protected against the disease even if the disease is introduced into that community it doesn't really have the chance to spread and to propagate and that is biological. It's also a mathematical concept. You can sort of look at it the numbers way. We have ideas and hypotheses but we don't know for sure yet.

But that herd immunity right now is being gained hopefully be people who have been infected and who we hope are protected. We don't know yet, but we hope we will be protected against infection at least for a year or two. And eventually, this vaccine would be able to contribute to providing that herd immunity so you could gain either by natural infection or by vaccination. We'll have to see what that magic number is. Whether it's 50%. Whether it's 75%. It's probably not going to be 90% like it is for some diseases that you need but if we can get to an acceptable level then that would have a big effect.

Avril Benoit:

Let's jump in to how long it would take... Let's say we had some notion of which were the vaccines that would succeed through the various hoops that they have to go through for the clinical trials and you start the manufacturing process early. You're tooling up your factories to be able to manufacture and let's say that process is starting in a timely way. How long would it take to vaccinate enough people in the world to create that sense of herd immunity? I don't know which one of you would want to speculate on that.

Matt Coldiron:

I can start and say that it takes a lot longer to vaccinate a million people in the Democratic Republic of Congo than it takes to vaccinate a million people in New York City and I think that the question of time is very important because it's one to vaccinate a densely populated urban areas but it's another to vaccinate in some of the places where we work every day in MSF.

Avril Benoit:

Kate Elder?

Kate Elder:

And with globalization like a lot of people have been saying and it certainly rings true, nobody is going to be without borders. This virus is without borders. With the globalization, with how quickly people travel around right now the idea of countries taking a very nationalistic approach which we do see in some places, that's really a fool's errand right. What are you going to do? Shut down travel indefinitely. People are always going to be traveling into your country, out of your country. This virus as we saw in practice will spread very quickly. We're still bracing for what's going to happen in many of the countries where MSF works. Maybe just the surveillance isn't strong enough yet to really give a clear indication of what's actually happening in a lot of developing countries.

The availability of the vaccine in terms of what it can do scientifically, medically is a very good question. We can only answer that as well if we actually have the doses available. Are the doses available? Are countries getting them? How quickly are countries getting them? Are they just going to stay these golden tools that only a few have? The people that can pay the highest dollar. The people that can get in the line first. Those are the sorts of questions right now that we need to be preparing for.

On the manufacturing side, I think it's a great question, Avril because the way pharmaceutical companies typically invest in scaling up their production is... They do it based upon spreadsheets. Budget. How much do they need to produce to make this much money for these shareholders essentially? So they make investments when they're very sure about a market case if you will. In many places where we work as MSF, there are medical tools, there are vaccines that have been around for more than a decade so far and we still can't buy them because the pharmaceutical companies don't think that it's worth their while to produce enough doses to sell to us at a lower price. It's really shameful.

So what are we doing right now differently as a global community to prepare that? To start putting in place the wheels to manufacture at a huge scale in advance so that when we do have the first ones out of the gate we can produce as quickly as possible. It's also important to note that all of these different vaccine candidates right now that are being developed can in human trials right now, they're all working on different platforms. I think, correct me if I'm wrong Matt, I think there's about eight different vaccine development platforms that they're using right now to develop future COVID-19 vaccines. Some of them are vaccine development platforms that we've used for decades. Some of them are completely cutting-edge. They have never once produced a successful human vaccine. I think people are reading about these things. mRNA, DNA vaccines are totally new.

Each of those platforms has different implications for how long it takes to develop the vaccine. The product development lifespan and at what scale. How many doses you can produce too. So it's very vaccine-specific but regardless of which ones are out of the gate first, the global community needs to come to an agreement of who's going to get them and what level of priority. This is incredibly important right now especially when you refresh your browser every day, and you see a new merger acquisition from a pharmaceutical company buying up the little guys.

Merck just bought up a small company recently.

Matt Coldiron:

Big one today.

Kate Elder:

Big one today. So what does that mean? The companies are the ones that ultimately because unfortunately we have not dealt with intellectual property and we're not doing anything different than we typically do. That means that sadly that these are proprietary tools. They're not truly in the public domain. So the companies get to decide what scale they're producing them. How many doses, what they're pricing at and who they're selling to first.

Avril Benoit:

We have a question from Dave about transparency. Kate, will information sharing between these big pharmaceutical companies accelerate the development? Will it go faster if they are more transparent with one another?

Kate Elder:

Absolutely. It's a great question from Dave. Absolutely. And I do not want to be all doom and gloom. I definitely want to give credit to the unprecedented level of scientific collaboration that we're seeing right now. WHO is doing a very good job of convening the developers and encouraging sharing of information because indeed it does benefit everybody. It does accelerate on innovation. It does produce a faster COVID-19 vaccine. We have enough scientific barriers alone to lengthen the timeframe but if we can share information yes it will certainly accelerate the availability of these tools.

Not only sharing information. I think it's also an important point about then sharing the ability to produce it too. Not only in the scientific process but once we actually have a vaccine can we think of a new way to produce it at a huge scale that has the public's interest in mind? Can we not just give the pharmaceutical companies the ability to make these decisions unilaterally? I think that's what people are trying to plan for right now and see what sort of tools we have to push companies to act in a different way than they traditionally do.

Matt Coldiron:

Just to jump in or to follow on that point, I think that the question of quantity of production is very important because there is a bricks and mortar implication of this. The machinery, the technology that you must have in a physical place. The vats that you have to produce this vaccine, there are limited numbers of those right now and they cost money to make and this question of where you put them, how you make them, what are you not making if you're using this specific vat for this vaccine. So it's a super important question.

Kate Elder:

Have you heard there's a global run on glass? I'm sorry Avril.

Avril Benoit:

Yeah, there's a run on PPE and the plastic for face shields. Every part of this COVID response seems to a run on supplies of some kind, but we're focused on the development of the vaccine that will prevent the transmission of COVID-19 and Adam is asking, how do we guarantee a true cross-cultural testing process? I guess this is a clinical trial stage to maybe take into consideration that often with clinical trials it's white men of a certain age span and others are excluded and you never quite know. So how do we address those issues of race and class and location of the perspective people? Matt?

Matt Coldiron:

This is in my wheelhouse. This is what we do at Epicenter and at MSF. We run these trials in places where trials are not run and it's super important and I think the nest example that I can give is the trial we did of a novel rotavirus vaccine. It's heat stable. We ran it in Niger which is a country where up to a third of childhood deaths are due to diarrhea and this is a vaccine that stays stable at room temperature for up to two weeks at a time. It's a game-changing tool. And we were able to do it in a population that didn't have access to this vaccine, wasn't participating in trials and it actually turned out that this vaccine did so much better than the other previous vaccines in African populations.

So it's super important that any intervention, whether it's a vaccine or a drug, could be tested in a populations where it's going to be used. And that's what we do regularly and there are plans being made for some of these trials of COVID-19 vaccine candidates to be done in Africa. Already with one of the vaccines that's being developed at Oxford, there's plans to run inclusions in Kenya, in Kilifi along the coast. CEPI, the Coalition for Epidemic Preparedness, they're already planning to do these trials in Africa. So it's super important and I think personally that it's a very important thing for MSF to support and participate in because it is an equity question just as we need access to the vaccines we need to make sure that the right people are being able to participate in the trials and whatever candidate is being evaluated in the right population.

Avril Benoit:

We are coming up to time, but there are a couple of really good questions that I want to get to so we'll try to keep the answers relatively concise. This one I guess is for you Matt, you mentioned earlier that probably the vaccines that are developed won't be perfect. They won't provide 100% coverage. They'll be maybe good enough if I can paraphrase. We've received several questions about whether a partially effective vaccine could really help reduce the severity of COVID-19. So even if you are exposed and you get the virus that actually it helps you to weather it a little better.

Matt Coldiron:

It's a great theory and it's a great idea and we've seen it happen with other vaccines before. With other vaccines and other diseases, if you've been vaccinated and even if you get the disease afterwards maybe you have a less severe form. Certainly the flu and maybe measles as well. Definitely precedent for that. We don't know if that would be the case yet for any of these vaccines in COVID but it would certainly be great particularly in the most vulnerable populations.

Avril Benoit:

Kate, this one's for you. Flu shots are voluntary, and I have always rolled up my sleeve for the annual flu shot because I feel it's my responsibility not to expose others to my flu especially vulnerable elderly people who might not get the vaccine et cetera. So I'm one of those who will volunteer but do you think the COVID vaccine will be mandatory for some people? Will it be voluntary? What do you think?

I'm not hearing Kate. That means you're going to have to take this one Matt.

Matt Coldiron:

I can jump in and answer that. Yes, I think that it will certainly be mandatory for healthcare professionals as is the case for several other diseases right now. Flu shots, Hepatitis B vaccinations are mandatory for healthcare professionals so I think that that would certainly be the case. I remember when I was a resident and one the novel flus came out they literally brought the cart around the hospital. Anyone that was wearing scrubs. Nurse, doctor, respiratory therapist got the jab in their arm as soon as it was ready. So I think that that will certainly be the case for this vaccine that comes out both to protect the healthcare workers who are at very high risk but then also to protect the others that they're taking care of from going on and transmitting.

Avril Benoit:

Right, have we got your mic back on there Kate?

Kate Elder:

Yeah, sorry about that.

Avril Benoit:

No problem. Matt jumped in and now I'm going to leave you with the final question from Laurie. Kate, Laurie wants to help. On a practical level what can be done and how can those who are watching help on the access to affordable medicine vaccine front for this COVID-19 vaccine?

Kate Elder:

That's a great question Laurie, and I'm very glad that you asked because recalling what I said before in terms of the need for civil society and everybody individually to take a role to demand that these future vaccines are available we're going to need your voice. We're going to need your voice to push politicians. We're going to need your voice to push pharmaceutical companies that I said are really going to be unfortunately the ones in the driving seat of determining how these vaccines are priced. We didn't even get to talking about the price, but that's a big concern too and who's getting them first.

So I would ask you, Laurie, to please check back at MFS websites to keep in touch with us because we will be asking for your support in many different ways in the future to push and use your voice to make sure that everybody really benefits from these tools that indeed actually are a global public good.

Avril Benoit:

Wonderful and a great ending for us. Thanks everyone for joining us for this COVID talk. We have had the pleasure of listening to Kate Elder, senior vaccines policy advisor for MSF’s Access Campaign, and Dr. Matthew Coldiron, at Epicentre which is an epidemiology and research satellite created by Médecins Sans Frontières/Doctors Without Borders. So thanks to both of you for being here and apologies if I didn't get to your question. We tried to fit in as many as we could but we will be back here, same place, same time in another couple of weeks for a discussion of the challenges that we as MSF are facing as we strive to deliver medical care in many of the places where there are all kinds of restrictions caused by COVID-19.

This pandemic has had a massive effect on our operations so that'll be June 11th, 01:00 P.M. Eastern Daylight Time. That's correct. I'm getting the time zone correct. This time. Registration is also on our website for this one and for upcoming events so you can just go to our website www.doctorswithoutborders.org and msf.org. You can follow us on Facebook in different languages including msf.english. Twitter is @MSF_USA and of course, you can find us on Instagram at doctorswithoutborders.

So please do stay in touch with us. We love to hear from you, and we appreciate and thank you for all your financial support. All the donations are making our operations possible so thank you. I'm Avril Benoit and we'll see you in a couple of weeks. Bye for now.

Kate Elder:

Thanks Avril.