VAX: Breaking thru the vaccination bottlenecks…

“Requires some dramatic, untested, and controversial strategies.”

That’s the conclusion in a recent Atlantic article that argues:

Building herd immunity requires vaccinating 75 percent of the U.S. population.

Doing so by summer  would require hundreds of millions of doses by June.

To achieve those levels we need to  vaccinate the most Americans we can right now and ramp up quickly to 3 million shots per day.

Doing so requires that we break the existing bottlenecks.

Specifically, the author identifies four main bottlenecks to accelerating vaccinations are:

  1. Authorization: You can’t receive a vaccine that the FDA hasn’t authorized or approved.
  2. Supply: Even with several vaccines authorized, you can’t get vaccinated if there’s a critical shortage of shots.
  3. Distribution: Even with lots of vaccines available, we still need to distribute them to states, cities, hospitals, and clinics and create eligibility rules that people can understand.
  4. Demand: Even if the public-health establishment does everything right, that won’t matter if Americans don’t want a vaccine.

So, how to break the bottlenecks?


Let’s work thru the bottlenecks in order, starting with the authorization bottleneck…

1. Speeding authorizations

The unstated premise is that the currently authorized vaccine manufacturers (Pfizer & Moderna) are already operating at full throttle,  maximizing their output.

They can’t build new plants quickly (and long-run economics might not justify them anyway) , so any increases in output will come from marginal efficiency tweaks that will help but not solve the immediate supply shortage.

The remedy: Add additional big “chunks” of supply by expediting the authorization of the on-deck vaccine manufacturers.

Specifically, the Atlantic author recommends immediate authorization of the AstraZenaca vaccine that has already has been authorized for emergency use in the U.K. and the European Union.

What’s the hang-up?

Reportedly, the FDA is “concerned” that AstraZenaca’s clinical trials were “a bit messy” … and the CDC is legitimately concerned by  evidence from Europe that the vaccine is least effective and more risky for vulnerable older people.

That’s a bad combination, but …

The answer might be to authorize the AstraZenaca vaccine but target (or restrict) its use to younger people.


The Atlantic author doesn’t mention my favorite bottleneck-breaker: the 1-shot J&J vaccine.

See J&J officially applies for FDA approval !

For the life of me, I don’t understand why the FDA is dragging its feet on the J&J authorization.

Surely, J&J has been working with the FDA for months, funneling clinical results as they became available.

I’d bet the ranch that J&J will be authorized in a couple of weeks.

So, why not take some risk, cut the bureaucratic i-dotting & t-crossing and issue the authorization.

Worst case, the authorization gets pulled back if unforeseen (and unlikely) issues crop up

That move alone could double the rate of fully-vaccinated people starting immediately.


2. Stretching available doses

Boiled down, the author advocates “First Doses First”.

That is, using available vaccine doses to give as many COVID-vulnerable people a first shot … and defer the second shots until vaccine availability is substantially increased.

We’ve covered this idea in prior posts:

See: F.D.A.’s guidelines for second doses is misguided. and CDC updates guidance re: 2nd shots… and Uh-oh: If you haven’t already scored your 1st vax shot…

In math-speak, the underlying premise for First Shots First:

Having 100% of a group protected 70% is better (at this stage of the pandemic) than having 50% of a group protected 95% … especially if the 2nd shot is eventually given … and can always be expedited for the most urgent vulnerable cases.

Translated into conversational English:

Economics writer Tim Harford puts it memorably:

The two-shot mRNA vaccines aren’t like bicycles, which are great with two wheels but useless with one.

They’re more like car headlights: Two are better, but at night you’d rather most cars on the road have one headlight than some two and some none.

The contrary argument from “the science” is that delayed 2nd dosing hasn’t been adequately evaluated  in appropriately designed, large-scale clinical trials.

The obvious risk:

“if you give somebody an insufficient dose of vaccine or don’t boost them in enough time, then you will lose the robustness of the immune response [and] you’ll have to re-vaccinate them, which means ultimately using more vaccine.”

Yep, there’s a risk.

Is it a risk worth taking?

Based on my informal, non-projectible survey of friends, there’s a sharp segmentation of views:

  • Those who are still hunting for their 1st shot think First Shots First is a brilliant idea.
  • Those who have gotten their 1st shots and are already scheduled for their 2nd shots think it’s a fundamentally stupid idea.
  • Those who have had both shots can’t be reached for answers since they’re golfing, shopping or dining out.

As a colleague of mine used to say: “Where you stand depends on where you’re siting.”


3. Simplifying eligibility & scheduling

The underlying premise: “Americans who are eager to get vaccinated face glitchy websites … and eligibility requirements that are too fussy, too confusing, and too difficult to operationalize.”

We’ve covered this topic in prior posts:

See What do lawyers, prisoners and ‘the media” have in common? and Eat, drink, smoke … and move to the front of the line.

Like music to my ears, the Atlantic author advocates replacing the current eligibility schemes, for now, an easy to implement age-based eligibility sequence …  perhaps complemented with a birthdate flow management process (e.g. start with folks over 75 who were born in, say, October … then do over 75ers born in, say, March … and so on)

See Start sequencing vaccinations from oldest to youngest … period! and So, why is West Virginia kicking other states butts?

But, what about essential workers, rural access and   “equity”

The vast majority of unequivocally-deemed essential workers (e.g. medical personnel in direct contact with  COVID-infected patients) have already been offered vaccines.

Rural access will boosted soon when Walmart ramps-up since the majority of their stores are in underserved “secondary markets”.

“Equity” can continue to be supported by over-allocating doses to specific locales and strategically locating vaccination sites.


4. Converting the “reluctants”

Looking forward, the ultimate constraint to building herd immunity may be insufficient willingness of many people to get vaccinated.

See Do we have a supply problem or a demand problem?

By some estimates, 40% or more of Americans are reluctant to get vaccinated:

  • Some are hard core anti-vaxers
  • Some are vaccine reluctant (e.g only half of the population gets annual flu shots)
  • Some, based on history,  are generally distrustful of government administered vaccination programs.
  • Some have been convinced that a “Trump vaccine”  developed under Operation Warp Speed can’t be trusted.

The point: we’ve got to get ahead of the curve by initiating powerful communication programs — sooner rather than later!



I really liked the bottleneck structure that the author used to disaggregate the problem and sort the recommendations.

I think he overlooked a big issue area: the overly complex distribution network that has been rushed into service.

Not to worry, we’ll be addressing that topic in some future posts.


DISCLAIMER: I’m not a medical professional or scientist — just a curious, self-interested guy.  So, don’t take anything that I say or write as medical advice. Get that from your doctor!

One Response to “VAX: Breaking thru the vaccination bottlenecks…”

  1. Is herd immunity by the end of April possible … or pure folly? | The Homa Files Says:

    […] For more detail see VAX: Breaking thru the vaccination bottlenecks… […]

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