Johnson & Johnson vaccine deepens concerns over racial and geographic inequities

Decisions to send the shots to harder-to-reach communities make practical sense, because Johnson & Johnson’s single-shot vaccine is easier to store and use. But they could drive perceptions of a two-tiered vaccine system, riven along racial or class lines — with marginalized communities getting what they think is an inferior product.

The issue came up on a recent call between governors and Biden administration officials coordinating the country’s coronavirus response. Gov. Charlie Baker, a Massachusetts Republican and former health insurance executive, stressed the need for prominent health officials to communicate clearly about the benefits of the one-shot vaccine, according to three people who heard his remarks and spoke on the condition of anonymity to discuss a private conversation.

The Johnson & Johnson vaccine proved safe and effective in a clinical trial, completely preventing hospitalization and death, including in South Africa against a more transmissible variant. When moderate cases were included, however, it was 66 percent protective, compared to efficacy of more than 90 percent reported for a vaccine jointly developed by U.S. pharmaceutical giant Pfizer and German biotech firm BioNTech and one from U.S. biotech company Moderna. Trials were conducted at different points during the pandemic, and in different countries with different transmission rates, which makes head-to-head comparisons impossible.

The apparent differences, Baker said, could nonetheless create uncomfortable questions for state and local leaders promoting the new vaccine to people who might ask, as one person paraphrased his comments, “Why didn’t you give us the good stuff?”

A spokeswoman for Baker declined to make him available for an interview. But the apprehension he articulated is shared by governors, as well as state and local health officials, throughout the country, even as they celebrate the third vaccine and acknowledge that the United States faces an embarrassment of riches compared with many countries.

“J&J is going to be a challenge for all of us,” Washington Gov. Jay Inslee (D) said in an interview.

In North Dakota, which has achieved one of the fastest rates of inoculation, Gov. Doug Burgum (R) said the new product intensified concerns not just about “vaccine hesitancy, but the potential for brand hesitancy as well.” The problem has been on display in Germany, where some residents are shunning shots developed by AstraZeneca in favor of those made by Pfizer-BioNTech, because of the different levels of protection reported in clinical trials, according to officials there.

The challenge in the United States is especially acute in the context of the racial and economic disparities exacerbated by the pandemic, according to state and local officials. If a vaccine thought to be less effective — though still well above the threshold of 50 percent set forth last summer by federal regulators — is used overwhelmingly in communities of color, it could erode trust. The Biden administration signaled Sunday it was concerned about that possibility, as senior administration officials stressed that the new vaccine would be shared equally throughout the country.

Fulfilling that promise is critical, advocates said.

“If we end up with a hierarchy that says all rich White people get Pfizer, and all poor Black people get J&J, that would be a problem,” said Helene D. Gayle, president and chief executive of the Chicago Community Trust, one of the largest community foundations in the country.

To complicate matters further, these dilemmas are inseparable from characteristics of the new vaccine that make it a logistical gift. The easier storage and scheduling requirements position the Johnson & Johnson product to penetrate hard-to-reach populations, such as those without housing, as well as transient groups, including people moving through the criminal justice system.

Because people of color are overrepresented in both populations, however, the racial undertones of a targeted approach to distribution could become pronounced.

“There is a risk of that,” acknowledged Mouhanad Hammami, director of the Wayne County Health Department, which serves Detroit as well as suburbs that include some of the richest Zip codes in Michigan.

The risk, too, is that residents may try to be selective about which vaccine they’re getting. “We hold our clinics based on the vaccine made available to us, so we have a Pfizer clinic or a Moderna clinic,” he said. “And probably people will come — or choose not to come — based on the product being offered.”

That is unwise, specialists said. “The vaccine that’s available to you, get that vaccine,” Anthony S. Fauci, the nation’s leading infectious-disease expert, said during a briefing on the eve of Johnson & Johnson’s authorization.

But Inslee said his constituents naturally want options, and with more supply in the near future, that may be possible. In the meantime, his pitch for Johnson & Johnson is simply this: “It’s going to save your life, which we think is a pretty high value. It has a downside of slightly lower efficacy to prevent you from getting a headache — but you only have to have one shot instead of two.”

Burgum said the one-shot vaccine may be especially appealing to younger or less vulnerable people, stressing that no one should be “assigned something they feel is less effective,” even if the numbers don’t support that conclusion. During a meeting of a Centers for Disease Control and Prevention advisory group on Sunday, a college president in Iowa said the easier-to-use vaccine should be rushed to 18- to 29-year-olds, a highly mobile population that includes “some of our biggest spreaders.”

At 42, Florida Gov. Ron DeSantis said he would prefer to take the Johnson & Johnson vaccine. “I’m just going to get one shot and be done,” the Republican said last week.

At first, few people will have the option of passing on the Johnson & Johnson vaccine because there’s so little of it. Nearly 4 million doses are expected to be shipped this week to states and other jurisdictions, as well as to pharmacies and federally administered sites. Company executives have promised 20 million doses by the end of March, and federal officials say production is supposed to pick up considerably in April.

The federal government is not specifying how states should allocate the new vaccine, although senior administration officials said federal oversight would guard against concentrating its use in certain communities. Officials in multiple states said Sunday they were still deciding where to direct their first allotments.

In testimony before a House subcommittee last week, Richard Nettles, vice president of U.S. medical affairs for Johnson & Johnson’s Janssen division, said the vaccine was “tested at the height of the pandemic globally, and included a significant number of participants from South Africa” and other places where threatening variants of the virus have emerged. The vaccine was found to be more than 80 percent effective at preventing severe illness in South Africa — a performance that stands out because the other two vaccines authorized in the United States have not been tested against variants.

But state and local health officials have yet to communicate these attributes to the public, because they’ve been reluctant to get ahead of the Food and Drug Administration.

A similar dynamic has been at play in the White House, where officials have been crafting communication about the new vaccine but are conscious of the need to tailor it to the recommendations of federal regulators and other experts. President Biden, in a statement Saturday night, praised the authorization of a third vaccine as “exciting news for all Americans.” In a White House video posted Sunday on social media, Fauci was more direct, affirming, “I would definitely take the Johnson & Johnson vaccine.”

“Most of the messaging has been press releases,” acknowledged Helen “Keipp” Talbot, an infectious-disease specialist at Vanderbilt University and a member of the CDC advisory panel that makes recommendation about how vaccines should be used. “It’s incredibly important that we start providing information about the vaccine in a clear and transparent way.”

There is disagreement about how to do that, however, especially about how much detail the public needs. Gayle, a former CDC official, said, “We should able to craft messages that make it clear you’re not getting an inferior product if you’re getting the J&J vaccine. You’re getting vaccinated.”

She also stressed the communal benefits of vaccination, saying it matters less what product “you get individually” than the fact that the “population you’re circulating in is protected.”

Paul Biddinger, medical director for emergency preparedness at Mass General Brigham and chairman of the vaccine advisory group in Massachusetts, also emphasized the remarkable performance of all three authorized vaccines. But he cautioned against papering over possible differences, saying he was interested in whether a second shot of the Johnson & Johnson vaccine might “look as good as Pfizer and Moderna.” The company is studying that, and expects to have results later this year.

“Equity means assuring those who have suffered most from this pandemic … are clearly able to access the most effective therapies with the data we have at the time,” Biddinger said.

He also said it was wrong to assume that “communities of color or hard-hit communities are more in need of a single-shot regimen.” Community health centers and other vaccinators catering to hard-hit populations, he said, “have proved they can handle the logistics of cold storage and the execution of two-shot regimens.”

The East Boston Neighborhood Health Center is already ramping up to 6,000 vaccinations a week across four sites, said Manny Lopes, the center’s president and chief executive. Mostly, people just want to be vaccinated, he said. Some ask about the difference between Pfizer-BioNTech and Moderna, and staff members are anticipating similar questions about Johnson & Johnson, he said.

In his view, Baker was right to raise concerns about how to present the data supporting the new vaccine, especially if it ends up being directed at certain populations.

“We feel confident that we’ll be able to answer based on science,” Lopes said. “It’s very, very effective, and we will share that information with our community.”

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