POST 41. August 2, 2020. CORONAVIRUS. “Whenever a vaccine for the coronavirus becomes available, one thing is virtually certain: There won’t be enough to go around. That means there will be rationing.” (2)

to read POSTS 1-41 in chronological order, highlight and click on

“Someone will have to decide which of the world’s 7.8 billion people gets first crack at returning to a more normal life. Infectious disease experts and medical ethicists say this exceptionally complex decision must weigh not only who is most at risk from the virus and who is most likely to spread it, but also who is most important for maintaining the medical and financial health of a nation as well as its safety…

Arthur Caplan, a bioethicist at New York University, said the rush to bring vaccines to market likely will leave many questions unanswered at first about how well they work in different groups. He sees the first public doses as an extension of clinical trials. That will require careful tracking of recipients. “We keep acting as if the race to get FDA approval is the end of things,” he said. “I would say it’s just the start.”..

Traditionally, the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommends who should get vaccines, and it has been discussing since April how to divvy up a new coronavirus shot. It is unclear whether officials from the Trump administration’s Operation Warp Speed on vaccine development will want in on the decision as well. “It’s a black box,” said Paul Offit, a vaccine expert at Children’s Hospital of Philadelphia. He thinks Warp Speed will probably focus on distribution. The National Academy of Medicine, at the behest of the National Institutes of Health, has also created an expert panel to study the issue.

At the panel’s first meeting on Friday, Victor Dzau, the academy’s president, said he expected final recommendations by late September to early October. CDC Director Robert Redfield stressed that it was important for Americans to see vaccine allocation as “equitable, fair, and transparent.”

National Institutes of Health Director Francis Collins, who has faced some criticism for potentially adding to decision-making confusion, said this issue is so thorny, we can benefit from extra “deep thinkers.”

“This is going to be controversial,” he said. “Not everybody is going to like the answer.”

Caplan favors an independent commission that includes both scientists and representatives of affected communities, such as people with disabilities and children. Whoever makes the decisions, he said, “it’s got to be trustworthy.”..

Who goes first?

Priorities need to consider the multiple public health roles vaccines can play, said William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center. Typically, younger people mount the strongest immune response, said Schaffner, who represents the National Foundation for Infectious Diseases as a liaison to ACIP. They are currently catching COVID-19 at higher rates and spreading it to other, more vulnerable populations. Vaccinating them could weaken the chain of transmission.

Older people and those with chronic health problems are clearly getting sickest, but vaccines tend to be less effective in these groups. A third group are “the people in society that are responsible for its most essential functions,” Schaffner said: medical workers, police and firefighters, those who make, sell and distribute food.

Schaffner said it’s important not to create such narrow categories that vaccine sits unused in refrigerators. “Vaccine does not prevent disease,” he said. “Immunization prevents disease.”” (A)

“Last month, National Institutes of Health Director Francis Collins called the National Academy of Medicine asking for help: Would the esteemed group be interested in developing guidelines for who should get the first doses of a coronavirus vaccine?

“It will allow the public to know it’s transparent, it’s not political,” said Dr. Victor Dzau, the academy’s president who told Collins that his organization was up to the task. “The American public will want to know how are you making that decision? Why am I not getting it first?”

After months of missteps and criticism across the political spectrum on everything from testing to personal protective equipment, the Trump administration is aiming to prove it can roll out a coronavirus vaccine quickly and fairly to millions of Americans as soon as one is ready. That means tackling thorny challenges like deciding who is first in line for vaccination, securing millions of glass vials and syringes and convincing Americans to get inoculated.

The administration is making moves that experts applaud like tapping top health officials and industry experts to lead vaccine plans rather than politicians, but they are still concerned that the overall effort — dubbed Operation Warp Speed — remains shrouded in secrecy. And the administration’s response to the rest of the pandemic has not inspired confidence.

“It’s sort of being handled like a secret weapon, which is never good,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Transparency is always good.”

Once a vaccine is approved, every American won’t be able to get it at once. That sets up the unenviable task of deciding, amid a deadly pandemic, who is most vulnerable to the disease and who is most essential to inoculate quickly.

“People are a little uneasy about the government calling the shots here,” NIH’s Dr. Collins told a Senate panel earlier this month.

Experts will have to consider vulnerable populations like those in assisted-living facilities or prisons, people working in close quarters like meat packing plants and how to assess Americans with preexisting conditions.

The National Academy of Medicine hopes to have its recommendations publicly available in August or September.

A second panel of vaccine advisers for the Centers for Disease Control and Prevention — the Advisory Committee on Immunization Practices (ACIP) — is also coming up with a set of guidelines. It’s still unclear whether the administration will select one set of recommendations over the other or take both into account when making its final decisions.

Last month, the ACIP convened electronically in a little-noticed meeting to discuss who counts as an essential worker, where teachers should fall in the priority list, vaccinations for pregnant women and whether race and ethnicity should factor into priority considerations.

“If we fail to address this issue of racial and ethnic groups as a high risk in prioritization, whatever comes out of our group will be looked at very suspiciously and with a lot of reservation,” Dr. José Romero, the panel’s chairman, said….

Once a vaccine is available, it could still take six months to a year to vaccinate enough of the population to slow the spread…

The CDC and Pentagon are working in tandem to deliver the vaccine across America, though they haven’t offered many details about how they plan to do so….

Convincing minority communities that have experienced higher rates of hospitalization and fatality to get vaccinated is a top concern. Experts said that will have to involve community outreach through organizations people already trust, such as faith-based organizations.

“There’s a lot of work that needs to be done in terms of making sure we that engage them earlier to gain their trust,” Dzau of the National Academy of Medicine said. “There are two ways that people can look at it. One is, are we the guinea pig? Or, two, we should get it first because we are more at risk.””  (B)

Why do we need more than one vaccine?

We’ll benefit from several vaccines, said Pulendran, because no single company could meet demand. In addition, the vaccines may differ, working better in some people than others.

“If we’ve got three acceptable vaccines, we’ll get the vaccine to more people,” said Ernst. “Maybe not everybody will get the best vaccine for somebody in their demographic. But assuming they’re equally safe and differ in efficacy only a modest amount, you’re better off being vaccinated than having no vaccine at all.”

Why first isn’t always best

Remember the Salk vs.Sabin polio vaccine debate? We started with Salk’s version, then shifted to Sabin’s. Now, with more information, we’re back to Salk’s.

Imagine that our first vaccine is only 50% effective. (The U.S. Food and Drug Administration, in an apparent effort to encourage vaccine companies, says that’s good enough for licensing, for now.) That will still leave some people, such as the elderly and those with high-risk medical conditions, perilously exposed.

If we’re lucky, vaccines will get better over time.

“It may not be the ultimate vaccine, but it’s the first iteration that can be improved upon,” said Pulendran.

“50% effective” sounds like more mask-wearing. Why can’t we do better?..

Who’s first in line?

If you’re an average healthy adult, you’ll likely be last in line. Health care workers and people at high medical risk would likely be first, Dr. Francis Collins, director of the National Institutes of Health, said Friday.

But there are other considerations. The military, students, underrepresented minorities, “essential workers” or people who volunteered for research may get priority too. If there’s an explosive local outbreak, vaccinating everyone nearby would limit the spread…

How will it be distributed?

Companies have said they’ll defer to the federal government. But experts, noting the disastrous distribution of PPE and tests, say we should look to the multi-channel distribution model of flu vaccines. They say it should be available from governments and doctors — but also directly from the companies, via CVS, Walgreens and other local pharmacies.

“It’s still inconceivable that we’ll be able to get vaccines to 330 million in three to six months,” Dr. Robert Wachter, chair of the Department of Medicine at UC San Francisco, tweeted this past week. During the 2009 swine flu epidemic, he noted, we vaccinated about one-quarter of all Americans — and that took six months.

Vaccinating 80 to 100 million of the nation’s most vulnerable people, including healthcare workers, “might be do-able by mid-’21,” he said.

Not everybody wants one.

Even people who believe in vaccines are showing reluctance to get the COVID-19 vaccine. They worry that politics are creating undue pressure, and corners will be cut in the rush to produce. Only about half of Americans say they would get a COVID-19 vaccine, according to a May poll from The Associated Press-NORC Center for Public Affairs Research. One-third weren’t sure and one-fifth would refuse, citing safety concerns.

If a vaccine is 50% effective, and 50% of the population gets vaccinated, then only 25% of the population is protected, said Ernst.

That’s far short of the 70% protection needed to stop this pandemic. The only solution is to make a better vaccine — and convince more people to take it.

“We’re not going to get this disease under control by just vaccinating health care workers and kindergarten teachers,” said Ernst.

“We need to be thinking about how are we going to convince people to comply with vaccinations,” he said, “so that we’ve got a sufficient amount of the population covered to actually get COVID-19 under control.” (C)

“Federal health officials are already trying to decide who will get the first doses of any effective coronavirus vaccines, which could be on the market this winter but could require many additional months to become widely available to Americans.

The Centers for Disease Control and Prevention and an advisory committee of outside health experts in April began working on a ranking system for what may be an extended rollout in the United States. According to a preliminary plan, any approved vaccines would be offered to vital medical and national security officials first, and then to other essential workers and those considered at high risk — the elderly instead of children, people with underlying conditions instead of the relatively healthy.

Agency officials and the advisers are also considering what has become a contentious option: putting Black and Latino people, who have disproportionately fallen victim to Covid-19, ahead of others in the population.

In private meetings and a recent public session, the issue has provoked calls for racial justice. But some medical experts are not convinced there is a scientific basis for such an option, foresee court challenges or worry that prioritizing minority groups would erode public trust in vaccines at a time when immunization is seen as crucial to ending the pandemic.

“Giving it to one race initially and not another race, I’m not sure how that would be perceived by the public, how that would affect how vaccines are viewed as a trusted public health measure,” said Claire Hannan, executive director of the Association of Immunization Managers, a group represented on the committee.

While there is a standard protocol for introducing vaccines — the C.D.C. typically makes recommendations and state and local public health departments decide whether to follow them — the White House has pressed the agency at times to revise or hold off on proposals it found objectionable. President Trump, who has been pushing to reopen schools, fill workplaces and hold large public events, has been acutely focused on the political consequences of public health guidance…

To speed distribution, the most promising vaccines will start being made even before they have cleared the final stages of clinical trials and been authorized for public use by the Food and Drug Administration.

But there will be a gap between the first doses coming off the manufacturing lines and a stockpile large enough to vaccinate the U.S. population. “I would say months,” Dr. José R. Romero, the chairman of the Advisory Committee on Immunization Practices, predicted.

The committee, which reports to the C.D.C. director, has long played a key role in determining how to implement new vaccines. The group includes 15 voting members selected by the health secretary who come from immunology, infectious disease and other medical specialties, 30 nonvoting representatives from across the health field, and eight federal officials focused on vaccines. Still, it operates largely out of sight.

Dr. Romero is among four committee members who have been deliberating on the plans since this spring alongside doctors at the C.D.C., representatives from the health field, ethicists and other outside consultants. In June, they briefed the full committee on their work, offering a glimpse of the questions being considered.

As they come up with a multitiered schedule for the first 1.2 million vaccine doses and then the next 110 million, they have focused on who should be considered essential workers, what underlying conditions should be taken into account and what kinds of living environments — nursing homes, homeless shelters — put people at high risk. Among the questions: What should be done about pregnant women? Should teachers go toward the front of the line? Should prisoners be in a top tier?

But for the broader committee, questions of whether to prioritize race and ethnicity sparked the most debate.

Black and Latino people have become infected with the virus at three times the rate of whites, and have died nearly twice as frequently. Many of them have jobs that keep them from working at home, rely on public transportation or live in cramped homes that increase their risk of exposure. They are more likely to suffer from underlying health problems, including diabetes and obesity, that raise the risk of hospitalization and death. Not only do the groups have less access to health services, they have a documented history of receiving unequal care.” (H)

“But let’s suppose that health care workers and people with underlying medical conditions use up the first doses of the available vaccine. Should some be held in reserve for Black and Latino people? What about bus drivers and train conductors? Perhaps teachers or schoolchildren should get it so they can return to classrooms with peace of mind.

If shortages happen, most of the nation will have no chance to get the initial lots of a vaccine under the C.D.C.’s plan. And as the United States combats a soaring number of coronavirus cases, rising demand for drugs and maybe ventilators is expected. They, too, will need a fair system of distribution.

One solution that is starting to attract the attention of public health experts is a so-called weighted lottery, which gives everyone a chance at access, although some get a better shot than others.

Doctors and ethicists rank patients, deciding which groups should be given preference and how much. First-responders, for example, may be weighted more heavily than, say, very sick patients who are unlikely to recover.

The goal is to prevent haphazard or inequitable distribution of a treatment or vaccine when there isn’t enough to go around. Such a system has already been used in allocations of remdesivir, the first drug shown to be effective against the coronavirus.

“This is all very new,” said Dr. Douglas White, an ethicist and vice chairman of the department of critical medicine at the University of Pittsburgh, which began using a weighted lottery last month to distribute remdesivir.

Patients have accepted the results, even when they lost in the lottery and ended up being denied the drug, he added.

“I speculate that is because we are very transparent about the reason and the ethical framework that applies to everyone who comes into hospital, whether that is the hospital president or someone who is homeless,” he said.

To allocate the drug, Pittsburgh doctors decided that the lottery would give preference to health care workers and emergency medical workers. The doctors also weighted the odds to favor people from economically disadvantaged areas, who tend to be mostly Black and Hispanic.

People with other illnesses and limited life spans, like end-stage cancer patients, had the odds weighted against them, giving them a smaller chance to win in the lottery. The system did not consider age, race, ethnicity, quality of life, ability to pay or whether a patient has a disability.

The lottery began in early June, Dr. White said: “We had 64 patients. We had to make the supply of remdesivir last at least two weeks. We only had enough to treat one in four patients.”

They had a brief respite from the lottery when cases began falling and supplies of remdesivir seemed adequate. But on Sunday, with cases rising again and enough remdesivir for only about half the patients who could be helped by taking it, the hospital system was forced to go back to a lottery….

Still, in principle, lottery data about a vaccine can be as useful as randomized clinical trial data, Dr. Pathak said.

“We would like to get people to think ahead about how vaccines are allocated,” he said. “There is no way we can vaccinate everybody, so we have to think about what’s fair and what’s just.”” (D)

“TA: Given that equitable distribution of vaccines is, at least in part, a question of ethics, how can computer models help us arrive at a solution?

Swann: It’s an interesting intersection, isn’t it? We can think of problems in terms of our objectives, which in this case might include efficiency (speed), effectiveness (avert deaths), and equity across the population. In public health, equity can be defined in different ways, including geographically (urban and rural) or by population (pro-rata). It can also be defined in terms of outcomes. For example, right now we know that communities of color, including African Americans, Hispanics, and Native Americans, are experiencing much higher rates of COVID-19 mortality than whites, and we know that people who are older or have high-risk medical conditions are also experiencing greater mortality than others.

Computer models can do many things to help with equitable distribution of vaccines. One really important role is to project the impact of different vaccination scenarios or strategies. For example, if there are limited vaccines, what is the impact of vaccinating essential workers, or ones who might interact with a vulnerable group (e.g., nursing home workers)? If there is a group at lower direct risk (e.g., children) who have significant contact with people at risk (parents or grandparents), what would be the impact of vaccinating them? If a vaccine requires two doses, or if immunity wanes after a time period, what strategies can avert the most hospitalizations and deaths? Which strategies would be most effective at reducing the disparities in COVID-19 outcomes associated with communities of color? These are just a few examples of many different decisions where humans could be aided by input from computer models.” (I)

“Nationwide distribution of any coronavirus vaccine will be a “joint venture” between the Centers for Disease Control and Prevention, which typically oversees vaccine allocation, and the Department of Defense, a senior administration official said today.

The Department of Defense “is handling all the logistics of getting the vaccines to the right place, at the right time, in the right condition,” the official said in a call with reporters, adding that CDC will remain in charge of tracking any side effects that emerge post-vaccination and “some of the communications through the state relationships [and] the state public health organizations.”

The plan breaks with the longstanding precedent that CDC distributes vaccines during major outbreaks — such as bad flu seasons — through a centralized ordering system for state and local health officials.

“We believe we’ve actually combined the best of both,” the official said. A second senior administration official stressed the agencies would be working as “one team” to distribute hundreds of millions of doses if any of the vaccines in development are approved in the coming months.

Private companies are also likely to join the effort. The first official said the government is bringing in people to integrate CDC IT capabilities with “some new applications that we’re going to need that the CDC never had.”

The background: The Pentagon will be guiding not just distribution logistics but also manufacturing and “kitting,” the process of safely packaging a vaccine with its necessary equipment such as syringes and needles.

“The DoD is handling all of those logistics — that is where their comparative advantage is,” said the first senior official. “And the CDC, some of their IT systems, relationships with the states following post-vaccination will belong to them.”…

State and local government groups have already raised concerns about Pentagon involvement and using new methods in coronavirus vaccine distribution. The CDC “already leads and maintains a highly effective system of vaccine ordering and distribution,” groups including the Association of State and Territorial Health Officials wrote in June. “With time of the essence we strongly recommend against designing new and untested systems of vaccine distribution.”

The state and local officials also questioned whether military involvement in vaccine administration would undermine already shaky public confidence in vaccines.”  (G)

“Executives from four companies in the race to produce a coronavirus vaccine — AstraZeneca, Johnson & Johnson, Moderna Therapeutics and Pfizer — told lawmakers on Tuesday that they are optimistic their products could be ready by the end of 2020 or the beginning of 2021. All four companies are testing vaccines in human clinical trials.

Three of the firms — AstraZeneca, Johnson & Johnson and Moderna — are getting federal funds for their vaccine development efforts. AstraZeneca and Johnson & Johnson pledged to the lawmakers that they would produce hundreds of millions of doses of their vaccines at no profit to themselves. Moderna, however, which has been granted $483 million from the government to develop its product, made no such promise.

“We will not sell it at cost,” said Dr. Stephen Hoge, the president of Moderna.

Many Democratic lawmakers have argued that federal funding for vaccine development should include provisions to guarantee affordability and guard against profiteering.

At the Congressional hearing on Tuesday, some House members raised concerns about Pfizer’s decision to reject federal funds, suggesting it could lead to price-gouging and a lack of transparency… (E)

“On June 26, a small South San Francisco company called Vaxart made a surprise announcement: A coronavirus vaccine it was working on had been selected by the U.S. government to be part of Operation Warp Speed, the flagship federal initiative to quickly develop drugs to combat Covid-19.

Vaxart’s shares soared. Company insiders, who weeks earlier had received stock options worth a few million dollars, saw the value of those awards increase sixfold. And a hedge fund that partly controlled the company walked away with more than $200 million in instant profits.” (F)

“The Serum Institute, which is exclusively controlled by a small and fabulously rich Indian family and started out years ago as a horse farm, is doing what a few other companies in the race for a vaccine are doing: mass-producing hundreds of millions of doses of a vaccine candidate that is still in trials and might not even work.

But if it does, Adar Poonawalla, Serum’s chief executive and the only child of the company’s founder, will become one of the most tugged-at men in the world. He will have on hand what everyone wants, possibly in greater quantities before anyone else.

His company, which has teamed up with the Oxford scientists developing the vaccine, was one of the first to boldly announce, in April, that it was going to mass-produce a vaccine before clinical trials even ended. Now, Mr. Poonawalla’s fastest vaccine assembly lines are being readied to crank out 500 doses each minute, and his phone rings endlessly.

National health ministers, prime ministers and other heads of state (he wouldn’t say who) and friends he hasn’t heard from in years have been calling him, he said, begging for the first batches.

“I’ve had to explain to them that, ‘Look I can’t just give it to you like this,’” he said.

With the coronavirus pandemic turning the world upside down and all hopes pinned on a vaccine, the Serum Institute finds itself in the middle of an extremely competitive and murky endeavor. To get the vaccine out as soon as possible, vaccine developers say they need Serum’s mammoth assembly lines — each year, it churns out 1.5 billion doses of other vaccines, mostly for poor countries, more than any other company…

But right now it’s not entirely clear how much of the coronavirus vaccine that Serum will mass-produce will be kept by India or who will fund its production, leaving the Poonawallas to navigate a torrent of cross-pressures, political, financial, external and domestic.

India has been walloped by the coronavirus, and with 1.3 billion people, it needs vaccine doses as much as anywhere. It’s also led by a highly nationalistic prime minister, Narendra Modi, whose government has already blocked exports of drugs that were believed to help treat Covid-19, the disease caused by the coronavirus.

Adar Poonawalla, 39, says that he will split the hundreds of millions of vaccine doses he produces 50-50 between India and the rest of the world, with a focus on poorer countries, and that Mr. Modi’s government has not objected to this.” (J)

“First we have to look at the global level. The private sector is really driving the vaccine development process, rather than government or academic labs. Major efforts are underway to figure out how private industrial developers can make vaccines available at an affordable price to all countries, particularly low and middle-income countries. It’s a bit like the ventilator supply situation we’ve all faced, but on steroids. Initially there will be scarce supply of the vaccine, governments will be scrambling to procure it, and, unless these efforts work, the winners will be fairly predictable: countries that have the resources.

On the next level, some wealthy countries will likely end up with substantial amounts of vaccine. Over time, if all goes well, these countries will have to decide how much product they’re going to keep and how much, if any, they’re willing to share with other countries where the vaccine may be in very short supply. These are complex questions of ethics, and they’re wrapped up in geopolitics, and also national politics.

There’s a term called vaccine nationalism—where countries understand their obligations to be primarily, if not exclusively, to their own residents. Although there is an expectation that countries with the resources and production capacity will meet their own health needs first, should they ignore the needs of people living in other countries with severe economic constraints? From an ethics perspective, a balance must be struck.” (K)

“As soon as the first COVID-19 vaccines get approved, a staggering global need will confront limited supplies. Many health experts say it’s clear who should get the first shots: health care workers around the world, then people at a higher risk of severe disease, then those in areas where the disease is spreading rapidly, and finally, the rest of us. Such a strategy “saves the most lives and slows transmission the fastest,” says Christopher Elias, who heads the Bill & Melinda Gates Foundation’s Global Development Division. “It would be ludicrous if low-risk people in rich countries get the vaccine when health care workers in South Africa don’t,” adds Ellen ‘t Hoen, a Dutch lawyer and public health activist.

Yet money and national interest may win out. The United States and Europe are placing advance orders for hundreds of millions of doses of successful vaccines, potentially leaving little for poorer parts of the world. “I’m very concerned,” says John Nkengasong, director of the Africa Centres for Disease Control and Prevention.

To avoid such a scenario, the World Health Organization and other international organizations have set up a system to accelerate and equitably distribute vaccines, the COVID-19 Vaccines Global Access (COVAX) Facility, which seeks to entice rich countries to sign on by reducing their own risk that they’re betting on the wrong vaccine candidates. But the idea has been put together on the fly, and it’s unclear how many rich countries will join.” (L)

“As scientists and pharmaceutical companies work at breakneck speed to develop a vaccine for the novel coronavirus, public health officials and senior U.S. lawmakers are sounding alarms about the Trump administration’s lack of planning for its nationwide distribution.

The federal government traditionally plays a principal role in funding and overseeing the manufacturing and distribution of new vaccines, which often draw on scarce ingredients and need to be made, stored and transported carefully.

There won’t be enough vaccine for all 330 million Americans right away, so the government also has a role in deciding who gets it first, and in educating a vaccine-wary here public about its potential life saving merits.

Right now, it is unclear who in Washington is in charge of oversight, much less any critical details, some state health officials and members of Congress told Reuters…

Health officials and lawmakers say they worry that without thorough planning and coordination with states, the vaccine distribution could be saddled with the same sort of disruptions that led to chronic shortages of coronavirus diagnostic tests and other medical supplies…

Some state public health officials, meanwhile, say their entreaties to the Trump administration have been unanswered.

“We have not heard anything from the federal government since April 23,” Danielle Koenig, health promotion supervisor for the Washington State Department of Health, said in an email.

That is when her agency received preliminary guidance on vaccine planning from the CDC.

Immunization experts along with state and local public health officials sent a letter here to Operation Warp Speed on June 23 pleading for fresh guidance.

States need to know promptly if the federal government will pay for the vaccines, as it did during the H1N1 outbreak in 2009, the letter says. Will alcohol swabs, syringes and personal protective equipment be included? What about record-keeping and refrigeration to store the vaccine and who will deliver it?

So far, there’s been no official response, said Claire Hannan, executive director of the Association of Immunization Managers, one of four organizations that signed the letter.

“We urgently await federal, state and local collaborative discussions to identify challenges and plan solutions. A vaccination campaign of this magnitude is unprecedented and it’s going to take more than an army,” Hannan said on Tuesday, referring to Trump’s repeated statements that the U.S. military stands ready to deliver vaccines.

Trump insists everything is in place.

“We’re all set to march when it comes to the vaccine,” Trump said at a White House briefing on Thursday. “… And the delivery system is all set. Logistically we have a general that’s all he does is deliver things whether it is soldiers or other items.

“We are way ahead on vaccines, way ahead on therapeutics and when we have it we are all set with our platforms to deliver them very, very quickly,” Trump said. (M)

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