A vastly faster vaccine rollout

One key limitation for vaccines is supply, as others have noted. That certainly doesn't explain everything, but it does explain a lot. 

This obstacle was, of course, completely foreseeable, and we proposed a simple way to deal with the problem, which we presented to policymakers and even posted on Lesswrong [LW · GW], by the end of April. 

Thus beings our story.

Unfortunately, we couldn't get UK policymakers on board when we discussed it, and the US was doing "warp speed" and Congress wasn't going to allocate money for a new idea. 

We were told that in general policymakers wanted an idea published / peer reviewed before they'd take the idea more seriously, so we submitted a paper. At this point, as a bonus, Preprints.org refused to put the preprint online. (No, really. And they wouldn't explain.) 

We submitted it as a paper to Vaccine May 20th, and they sent it for review, we got it back mid-june, did revisions and resubmitted early July, then the journal changed its mind and said "your paper does not appear to conduct original research, thus it does not fit the criteria." After emailing to ask what they were doing, they relented and said we could cut the length in half and re-submit as an opinion piece.  

We went elsewhere, to a newer, open access, non-blinded review journal, and it was finally online in October, fully published: https://f1000research.com/articles/9-1154

A response from @politicalmath, based on Smallpox: The Death of a Disease by  DA Henderson:

1) There were no phases, it was just "show up, get poked"
2) There were plenty of vaccines to go around. Countries typically had millions of smallpox vaccine doses ready to go just in case
3) with no lockdowns, they could go to schools / churches / offices & line people up
4) the smallpox vaccine was incredibly heat-stable. There were batches that were still efficacious after being stored for a year at 113F
5) the public health infrastructure had a lot of practice with mass vaccinations (they did them all the time in other countries)
And it did cause a city-wide panic. Smallpox has like a 20% fatality rate so people were pretty motivated to get the vaccine. All this is from this book
https://www.amazon.com/Smallpox-Disease-Inside-Eradicating-Worldwide-ebook/dp/B002FU5O54/

Do they have to fill out a lot of paperwork to recruit them

A medical worker who tried to sign up for vaccine administration recruitment was confronted with needing 21 pieces of paperwork showing that they had completed various trainings, many of which have nothing to do with vaccination.

My cursory reading has indicated that every part of the process is fractally like this. We are in a liability liquidity trap of some sort as a civilization.

This NYT article is from the 10th of January as well:

https://www.google.com/amp/s/www.nytimes.com/2021/01/10/nyregion/new-york-vaccine-guidelines.amp.html

It states that the state as a whole has received 1.2 million doses. NYC is about half the population of the state and has administered about half the doses. So estimate that it’s received about 600,000 doses, while NYC had received 4 million doses during the smallpox crisis. That accounts for maybe 80% of the disparity.

I believe Dryvax was the vaccine administered for smallpox in 1947 NYC, and it was made 50 years before that. So there was time to gain trust and produce enough to vaccinate 4 million people without any question of queues.

Despite the righteous anger at this process, what we’re trying to accomplish is a flippin’ scientific and logistical miracle: going from “new disease” to “global vaccine rollout” in less than a year. Could they have done that in 1947?

A few observations:

1. Compared to 1947, there are many fewer things that you can do without permission, and many more people from whom you must seek permission. This naturally inhibits quick action.
2. Institutional incentives are all pointed towards caution, conservatism, and proceduralism. Undertaking decisive action to deal with a new situation is discouraged, and therefore these institutions are full of people without the disposition to even try.

I don't have citations for these, but cf. Zvi's entire series on moral mazes.

To these, we add a corona-specific factor, that we do not have enough vaccine doses to vaccinate everyone, so we have to ration and prioritise our doses. This, in turn, opens up vaccine prioritisation to political input, which means that the two factors mentioned above come to dominate, and we wind up with a vaccine plan which is maximally cautious, procedural, and bureaucratic. If we had enough doses to actually vaccinate everyone, it would be much easier to sell a policy of just vaccinating whoever walks through the door.

I think there are significant differences in manufacturing and transportation.  My understanding is that cowpox was common enough that vaccines for smallpox were made somewhat locally, and there was no constraint about how many doses could be available.  For COVID-19 vaccines, the necessity of distant manufacturing and limited doses added a LOT of politics in who gets it first.   And this political truth led to massive restriction in how it's delivered.

There are two parts to the 50x difference - number of doses available to doctors/nurses, and percentage of those doses actually injected (vs still in storage or stuck in the supply chain).  From what I can tell, many big cities have injected ~25% of the doses they have received.  I don't know how this compares to smallpox, as JIT manufacturing could be modeled as delivering 100% of available doses, or less than 1%.

edit: not local or JIT manufacturing, it seems.  But still no supply limits.  I find it easy to believe that the limited supply of vaccine is driving all of the slowness, both directly and indirectly.  Directly because we don't have enough, and indirectly because the fact that some people have to wait adds the politics and perception problems of "fairness" and "optimization" that hugely slows things down.

Am I being naive in thinking that most of the 50x comes from manufacturing the vaccine? In 1947 they had 650k vaccines ready to go, then got 7 pharma companies across the country to work round the clock to get them the rest. They were aiming to vaccinate 6.35 million, we are aiming to vaccinate 328 million just in the US (57x more doses needing to be manufactured). We'd expect to have more total capacity today of course but we have fewer companies doing the manufacturing.

I guess the mRNA vaccines are also more difficult to manufacture. Based on the cost the P/B is 5x more expensive than O/A viral vector. The latter is planning on producing more than twice as many in 2021 (I don't know how the size and number of facilities compare but Pfizer are the bigger company).

Say we were giving every dose procured by the US evenly spread across the country - how many would we be doing a day in NYC?

New York has apparently distributed 35% of the vaccine that it has. Maybe they are focusing on other bottlenecks? Though my naive guess would be that the main problems are that the staff at US agencies are more numerous, less-competent, more regulated, as part of the aging process of any bureaucracy, compounded by the declining prestige of governmental jobs.

My assumption is that the smallpox vaccination was first-come-first-served, and that they weren’t attempting to identify and vaccinate small, targeted subpopulations first. It’s the difference between spraying your lawn with weed killer and selectively hand-pulling weeds. It’s not surprising to me that the former is many times faster than the latter.

After spending months saying that social distancing is very important, the current vaccination efforts happen against the backdrop of social distancing. It's valuable to do vaccination in a way that doesn't result in crowded waiting rooms in which people get infected with COVID-19.

What I'd expect to see to scale up getting needles in arms (off the top of my head):

• All major population centers with multiple vaccination centers (temporary tents, school gyms, etc)
  • Should go without saying that these places should be very strict about masks, distancing, ventilation, etc.
• Drop-in vaccinations allowed, forcing appointments shouldn't be a high priority
  • but make it easy to see delays
  • delays mean you probably don't have enough vaccination centers
  • quickly built appointment and tracking systems will themselves fail enough to slow down vaccinations; keep it simple and low-tech
• Don't worry so much about "fairness"
  • the goal is to get needles in arms, as quickly as possible (it doesn't much matter that the most vulnerable don't strictly come first if you're quickly vaccinating the majority of people)
  • handle vulnerable or non-mobile populations separately, by bringing the vaccine to them
  • cheaters (people jumping the queue) don't matter that much if you're vaccinating many quickly
• Don't worry so much about tracking who's been vaccinated or not
  • assume people aren't so stupid as to get vaccinated multiple times; likely not a major problem
  • you can't force people to get vaccinated, so don't worry about it; make it easy for those that want it

That we're not seeing these sorts of things (in Canada, where I am) feels like the people making these decisions aren't really prioritizing vaccinating people. Maybe that'll change in a couple of months, but we've had a long time to prepare for actually having vaccines available, so again feels like a failure to really prioritize (as in "does this thing make it easier or harder to get vaccinated now?"). There are risks (of the "unknown unknown" variety) that can happen just by being so slow (e.g., yet-another-variant that requires yet-another-vaccine)

Of course not having enough vaccine on hand makes things slower, but even then I think vaccinating with as little overhead as possible is preferable, since until the actual case numbers come down, vaccinated or not, people need to be careful, and being vaccinated doesn't really affect your life much until then.

What I find silly and embarrassing is that with all the time to prepare, we're still so bad at this (in Canada, but doesn't seem much better than USA). Israel seems like the country to emulate at the moment. And if you hear about doses expiring, that is pure incompetence: just give it to anyone that wants it at that point.