The Journey Towards A Vaccine: Biological Realities And Ethical Concerns

Vaccine development can usually take up to a decade to complete all the requisite trials and repeat testing on animals and humans to ensure they are safe before going to market. With the Coronavirus pandemic being so devastating to public health and disruptive to global economies and industries worldwide, the need for haste has been a major motivating factor in the worldwide race for a vaccine. Currently over 200 drug companies, labs, and universities have commenced their experimental hunt for a vaccine but according to the WHO just over 25 candidate vaccines have reached the stage of clinical testing.[1] And of these candidates, only a few groups are at a stage where they can potentially get out a vaccine by the end of the year.

The Oxford University vaccine trial has the eyes and interest of many European countries and is currently embarking on Phase 3 of the process which are final and large scale trials taking place with volunteers sourced from Britain, Italy, Brazil and a few African countries (including South Africa). Oxford University has teamed up with companies Advent (an offshoot of the parent company IRBM) and Anglo-Swedish Drug-maker AstraZeneca to help source supplies and volunteers worldwide for the project. The Oxford lab is arguably leading the pack due to its earlier work on a similarly styled vaccine to prevent MERS which was first detected in Saudi Arabia in 2012. The lab had been conducting its first tests on Rhesus Monkeys during the initial phase of testing to a level of effective safety and success. There is no guarantee that the vaccine will work, or that it might only work on some people and not others - and have a limited duration of antibody protection once applied as is the case with other Coronavirus and flu vaccines, however it has already sourced the financial backing of Italy, Netherlands, France, and Germany for 400 million doses of the experimental vaccine on top of $1.2 billion in funding from similar deals with Britain and the United States.[2] Advent's lead scientist Stefania Di Marco stipulates that despite the haste to protect people from this dangerous pathogen, there are enormous challenges of forging a process to turn several drops of seed stock into three or four litres of vaccine on top of removing any impurities using a gel that isolates the vaccine from any contaminants.[3] Furthermore, there is the need to also organize the mass creation of glass vials and syringes to be able to distribute this vaccine to enormous numbers of people around the world. This is one of the jobs that 'Operation Warp Speed', a Taskforce set up by the Trump Administration to provide contracts to many manufacturing companies to help organize and hasten the distribution phase once an effective enough vaccine has been found. (The Operation Warp Speed initiative has pledged $10 billion and aims to develop and deliver 300 million doses of a safe and effective vaccine by January 2021.)

There are a variety of other vaccines being created worldwide, but the Oxford version utilizes a tweaked version of the virus found in Chimpanzees, which, upon being injected into a human body, is supposed to trigger an immune response. Di Marco explains that the Chimpanzee virus is loaded with a synthesized reproduction of the spike protein that the Coronavirus utilizes to harpoon itself onto human cells thereby fooling the body into thinking that it is being attacked by the real virus.[4] If the vaccine doesn't work, then months of work goes down the drain delaying the ultimate deployment timetable, so such work is always done 'on edge', especially with the health risks involved such as side effects from a failed deployment.

A major issue occurred in September 2020 putting AstraZeneca's Phase 3 trials on hold due to one of the participants suffering spinal cord damage. Although not confirmed by AstraZeneca to the frustration of world scientists following the vaccine's trajectory, it is likely the volunteer suffered from transverse myelitis which causes inflammation along the spinal cord, potentially causing muscle weakness, paralysis, pain and bladder problems. Although the participant recovered from hospitalization due to the severe inflammation thereby allowing the trials to resume in the United Kingdom, the British regulators at the NIH were very keen to conduct a thorough investigation. (This could take a month or two, and the US study would likely remain on hold until the FDA was ensured of the vaccine's safety.) If the vaccine was to lead to the worrisome phenomenon called 'molecular mimicry' and the occurrence of another case of transverse myelitis, the entire trial would likely be shut down altogether.[5] Currently 70% of testing participants have experienced fatigue, 68% experienced headaches, 60% experienced muscle aches, 56% chills and 18% reported a fever.[6] AstraZeneca's Phase 3 trials now underway in Brazil with 2,000 participants are expected to have results by the end of October, while the 2,000 participants trying the vaccine in South Africa are expected to have their results in November. If it is successful, AstraZeneca's chief executive aims to have over 2 billion doses ready by 2021.[7] On top of this, a licensing deal has already been negotiated in June with an institute in India to supply 300 million doses for low and medium income countries.

In addition to the work being done by the Oxford Group and AstraZeneca, a Chinese biotech firm CanSino Biologics Inc in conjunction with China's Military Research Unit has also reported encouraging results in early-stage clinical trials and is also among the vaccine creation front-runners. Results published in The Lancet showed significant immune responses in the majority of recipients after a single immunization with no serious side-effects recorded. The vaccine is already being used by Chinese military personnel despite trial tests not yet being completed, and any results from this use will not count as completing Phase 3 trials which it will need to get full regulatory approval. (This limited use vaccine looks to be less effective for people older than 55 years, yet Phase 3 trials for the Chinese company had already commenced in Russia on August 15th through collaboration with Russian pharmaceutical company Petrovax.)

Another Chinese vaccine of interest is being developed by Sinopharm, China's State-run pharmaceutical company in conjunction with the Wuhan Institute of Biological Products. Also using an inactivated Coronavirus vaccine, tests have shown that it can trigger an immune response with no serious adverse effects.[8] Sinopharm launched its Phase 3 trials in mid-July in the United Arab Emirates with 15,000 volunteers aged 18 to 60, (and with no pre-existing conditions.) According to National Geographic, Sinopharm chose the UAE because of its diverse population made up of approximately 200 nationalities, and will also conduct Phase 3 trials in Bahrain and Peru.[9] Zheng Zhongwei, head of China's Coronavirus vaccine program stated that 'urgent use' of Sinopharm trial vaccines were also launched on July 22, 2020 with initial use for medical workers, diplomats and some state-owned enterprises.[10] Going against standard vaccine protocols that require the vaccine to be fully tested before unleashing it into the general public, Chinese authorities have also begun inoculations in the Fall to include food market employees, transport system operators, service industry workers, government employees, those traveling to medium or high risk countries for work, as well as members of the pharmaceutical industry itself.[11] The aim is to build an immunity barrier amongst special groups before the winter kicks in at the end of the year. The extended roll out raises issues of consent especially for employees of state owned companies and Chinese vaccine makers who might feel pressured to get inoculated. According to the New York Times, the companies have asked people taking the vaccines to sign a non-disclosure agreement barring them from talking about it to the media.[12] (Vaccine makers and local governments stress that participation in the emergency roll out is voluntary and can actually cost up to $148 to get inoculated.) Despite alarm by scientists worldwide due to the breaking of vaccine protocol and the risks of side effects, the country that becomes the first nation to crack the vaccine code will not only earn historic bragging rights but has the incredibly advantageous opportunity to distribute the first doses to its own citizens, enabling a more rapid return to economic and public health normality.[13]

Russia claims to be leading the front of the vaccine research pack announcing that it had officially approved their Coronavirus vaccine in August 2020.[14] (It is unsure why China delayed its announcement that it was using Sinopharm's and Sinovac's vaccines on regular citizens well before Russia made their claims as being the first. It is most likely due to being able to quietly stop the inoculation process should there have been any severe adverse side effects.) In fact, it had only just completed its second phase of testing when making the announcement.[15] Russia's Gamaleya Institute belatedly released scientific data on its vaccine testing in early September stating in the Lancet journal that it had appeared to be safe and to prompt an antibody response in all 40 people tested.[16] (Gamaleya has developed a viral vector vaccine that also uses a weakened version of the common cold-causing adenovirus to introduce the Coronavirus spike protein to the body. 2 injections are required 21 days apart to boost the immune response but the authors of the report on the Phase 2 study noted that they had only followed the participants for 42 days before publishing and most were only between the ages of 20 and 40.)

Due to political pressure from the Kremlin, the Gamaleya Institute has decided to vaccinate all health-workers and teachers in conjunction with their current entry into the Phase 3 trial stage. (Vladimir Putin claims that he has already used the vaccination on his daughter who only experienced mild fever side effects during both injections when making the global announcement.) This is also very high risk given the side effects that can occur with vaccine research that is incomplete, not to mention the public's confidence in such a vaccine, however it seems politically justifiable in Russia given the way it has ravaged the country with well over a million official cases.[17] The very notion that the vaccines are being speedily created also creates nervousness in society about the possibility of labs cutting corners in their race to get their product to market. For example, in 1955 the Cutter Labs accidentally inserted a live polio virus in their vaccine to over 200,000 children which infected 40,000, paralyzed hundreds and killed 10. The biggest issue, however, if the vaccine is only 30-50% effective, is the fact that if immunized people think they are safe after getting injected and stop socially distancing, this is likely to further spread the virus if it has not actually worked.

In mid-September, Russia's sovereign wealth fund signed a deal to supply India with 100 million doses of the Sputnik V vaccine in what is looking like a competitive move to outpace the Western vaccines who are highly concerned about the risks being taken with the hasty deployment. (Brazil, Mexico and Kazakhstan have also agreed to purchase Sputnik V.) Yet at the same time this 'global race to market' is forcing the Trump Administration to apply significant pressure on American vaccine makers to get one out as early as possible, especially to be able to make an announcement before the November 3 election.[18] (China's Sinopharm also announced in mid-September that it would provide emergency doses of one of its two trial vaccines to the United Arab Emirates - a traditionally American ally. As a result, China are the only country in the world to supply vaccines to the Middle East as the global race heats up to expand their geopolitical and diplomatic influence despite not being fully tested. Jordan and Bahrain are both using Sinopharm's trials and Egypt also signed up after the delay with AstraZeneca's vaccine program.) Arthur Caplan, head of the division of medical ethics at New York's University's Grossman School of Medicine believes this rushed deployment is a terrible idea, and is very worried about the medical impacts of these geopolitical dynamics at play.[19] (America, China and Russia have all currently refused to sign up to the WHO's Covax initiative which has over 150 countries aiming to equitably distribute vaccines globally.)

Another form of vaccine known as RNA which is based on deploying a tiny snip of genetic code called messenger RNA to trigger the immune system also looks promising despite never having been approved for release on the world market before. It is being attempted by five entities from the UK, China, Germany and the United States including a laboratory at the Imperial College of London, the People's Liberation Army Academy of Military Sciences in China and three pharmaceutical companies including CureVac, Pfizer, and Moderna.[20] The RNA vaccines are attractive because they are faster and cheaper to manufacture and deploy en-masse some companies arguing it can go for as little as $5 a dose. The RNA groups have been able to bolt out of the gate because the genetic sequence of the Coronavirus that was shared online back in January can be rapidly designed on computers. A high stakes, high risk approach, this vaccine strategy is tipped to be one of the greatest scientific vaccine experiments ever attempted, particularly given that its testing of varied technologies differs markedly from traditional vaccine strategies which utilize inactivated or killed virus elements or bits of the virus as attempted when creating seasonal flu vaccines.

The Imperial School of London lab has recently received $50 million in funding from Britain's Health Secretary to commence human trials with 9 volunteers and upon receiving promising initial results have currently moved to provide the dose for 300 further volunteers over the summer. (The research team took only two weeks to identify the bit of genetic material they wanted to deploy to attempt to trigger an immune response.) The Imperial College hopes to launch a 6,000 person trial by October 2020.

The USA trial attempted by the Massachusetts biotechnology company Moderna will also enter its crucial third phase involving 30,000 volunteers in the United States where half get the RNA vaccine and half a placebo.[21] The company went from forming a genetic sequence by computer to a shot in the arm in a record 66 days. Initial testing results published in the New England Journal of Medicine show that the vaccine worked to trigger an immune response with only mild effects such as chills, muscle pain, headaches, fever, fatigue and pain at the injection site.[22] (The Phase 1 study involved tests on 45 volunteers.) Of the two injections, delivered 28 days apart, it was the second injection that caused the most side effects. Participants were given either 100 ml dose injections or 250 ml, and it was the latter that caused the most severe reactions. One study participant of the higher dose suffered a severe fever and upon going home to sleep for several hours, woke up but felt light-headed and nauseous. Upon standing up, he vomited and feinted. The report states that his girlfriend caught him when he feinted, and he remained mildly fatigued for up to six days afterwards.[23]

The Moderna RNA vaccine ultimately aims to turn the body's cells into miniature vaccine factories reproducing them in the body, but given this approach has not been tested on masses of people before, it is uncertain how the process of distributing and applying this vaccine will go. Despite the need for more testing, (using less of a dose then that which adversely affected the patient stipulated above), and if all goes to plan, then it aims to release between 500 million and 1 billion doses each year from 2021. (Results from the third clinical trial are likely to be completed in October 2021, although early results will be known by November, 2020.) In addition, the German pharmaceutical company Pfizer is creating four RNA vaccines and plans to adopt a 30,000 person clinical trial in Argentina, Germany and Brazil pending regulatory approval with the hope of formulating 1.3 billion doses by the end of 2021 as part of the worldwide scientific effort to overcome the Coronavirus pandemic. (Pfizer's vaccine takes two doses, 28 days apart and their partner BioNTech have reported good immune response results and tolerable side effects from the vaccines it has been trialing.)

Dr. Penny Heaton, chief executive officer of the Bill and Melinda Gates Foundation recently wrote in an editorial of the New England Journal of Medicine that 'accelerating the development of Covid-19 vaccine candidates beyond Phase 1 depends on continued parallel tracking of activities and fulsome resources...which has led to 6-years work being completed in just 6 months.'[24] She questions however, whether the vaccine multi-verse can achieve this again for the next 6 months. Many other experts also express their doubts about the feasibility of getting a vaccine to market within 12-18 months, a process which in normal cases takes between 8 and 15 years.[25] (The fastest vaccine in history has been created in 4 years for Mumps.)

The Malaghan Institute in New Zealand is one of a number of players involved with New Zealand's response to Covid-19 and working on a vaccine with professors from Victoria and Otago Universities, (albeit not utilizing new vaccine technology). Professor Graham Le Gros of the Malaghan Institute states that "although it is not a complex virus, it's the testing timeframe that is the most challenging, especially when people aren't accepting that it can take 5 years."[26] The problem with rushing to the end line is the risk of having a program killed off because not all the side effects were properly assessed, especially in an age where the public tolerance of such side effects are limited.[27] (Both Moderna and Pfizer have released their vaccine trial rule books to the public to raise confidence in the transparency and trust of the developmental process given the public confusion resulting from public health messaging by President Trump given his need to appeal to voters.)

Clinical trials are difficult to speed up because of the time it takes for antibodies to develop within the body. Some patients can clearly be subjected to 'challenge trials' which helps speed up the process by purposefully exposing them to the virus. This however is ethically controversial, as such challenge trials are generally only attempted with curable diseases, (such as typhoid fever), which Covid-19 clearly is not. The volunteers risking their lives for these current phases in clinical testing are indeed showing incredible bravery, and it is important for the public to be educated on all the side effects such vaccines can produce. (This is why many of the trials are taking place in viral hotspots such as the USA, Brazil and South Africa to accelerate the timeframe and likelihood of the participants catching the virus.)

As the journey towards creating an effective vaccine continues, as well as the logistical challenges of manufacturing hundreds of millions of doses not to mention competing over limited resources to make the glass vials needed to distribute them, there is also the challenge of how such a mass deployment of the vaccine will unfold? In the United States for example, the Federal Government will have to allocate doses perhaps via a patchwork of State and local health providers that have yet to set up a system for the mass deployment of a vaccine. The CDC, which would normally undertake such a deployment has been alarmingly absent from discussions. This is a worrying sign based on the failures of the political leadership in the country thus far throughout the course of the pandemic which could continue to disrupt the process. On top of this, 20% of Americans have already stated they will refuse to get a Covid-19 vaccine, with another 31% unsure whether they want to, which even if the vaccine was fully biologically effective, would place some serious limitations on herd immunity.[28]

As a side note, a Covid-19 vaccine is unlikely to achieve what Scientists call 'sterilizing immunity' which would prevent the disease from affecting you altogether. The reason being that most vaccines are shots given straight to the muscle to help forge a recognition by the body that this particular foreign disease is entering and thus commences an immune response that creates antibodies that circulate throughout the blood. However, given that Covid-19 is a respiratory virus that usually enters through the mucous membranes in the nose or throat, there are unlikely to be enough antibodies present there to prevent entry of the disease. Instead it will ultimately help those vaccinated from receiving a severe version of the disease, helping to protect deeper tissues such as the lungs and other organs.

Given it is likely that the vaccine will emanate a flu shot requiring multiple doses over a period of time, rather than like what would occur with the one-off polio shot, this will also cause significant issues with how a mass deployment will unfold. For example, upon offering a certain number of doses to State and local health departments who would presumably pass this on to General practitioners, schools, hospitals, pharmacies and employers, it may be possible to eventually achieve getting it to those most needed over a period of months if it was just one shot required, but way more tricky logistically if two or more shots are required. (Vaccines that require two doses use the first one to prime the immune system, while the second dose allows the body to amount a stronger immune response.) Further complications arise if the Covid-19 vaccine being used requires storage in temperatures below -80 degrees centigrade to remain effective. (There are approximately 7,000 US hospitals that stock an ultra-cold freezer, which if utilized to vaccinate the 142 million Americans needed to achieve a viable level of herd immunity will each require 40,000 annual visits, or nearly 800 each week.)

Finally there is the issue of prioritization of the vaccines. Naturally healthcare workers on the frontline would be first, as well as other essential workers key to the successful workings of society, but who gets the call up after that? Does it go to the high risk members of the community such as the elderly or immuno-compromised, (even though the side effects of such a vaccine may be hazardous to these people), or to races such as Blacks and Latinos that have been most adversely affected by the virus? The fact that the CDC have not been a key part of these discussions, nor any insight from Trump's 'Operation Warp Speed' Taskforce means there is likely to be a major issue with deployment down the line, unless these processes are formalized. Ultimately, it seems there will be an outcome where some people are desperate to get the vaccine and others will be hesitant. Given the culture war that has erupted over the wearing of masks, it is highly uncertain as to how the process will play out. A botched roll-out could be devastating on multiple levels, not just for this current pandemic, but for the public trust in all vaccines altogether which could lead to other outbreaks in vaccine preventable diseases, let alone future novel pandemics we will need to face. (A best case scenario could see up to 4 billion people vaccinated by the end of 2021 which is still less than the 5.5 billion acquired to attain 70% herd immunity globally. The current goal is to have 20% (almost 2 billion) of the world vaccinated by the end of 2021.)

Making haste with the vaccine process clearly has its public health risks and ethical issues but the benefits arguably outweigh those initial risks, especially given statistics recently emerging from the International AIDS Society predicting over a million extra deaths from diseases such as AIDS, Tuberculosis, and Malaria due to the complications that the Coronavirus imposes on funding their prevention and treatment programs not to mention the challenges getting non Covid-19 patients into the hospital system.[29] With less testing for HIV being completed, it is estimated that it will take the fight to control the virus back by 12 years. (HIV was initially seen as a temporary disease, but as with Covid-19, it didn't take long for society to realize that we would have to learn to live with the virus long-term and thus change our sexual behaviour significantly to help mitigate its ongoing spread.)

Furthermore, the Stop TB partnership mathematical modeling estimates that four months of global lockdown could result in more than 1.8 million extra cases of Tuberculosis globally leading to 340,000 extra deaths on top of the 1.5 million that die each year from the disease. (Tuberculosis is spread through the release of droplets in the air to infect others, similar to Coronavirus and disease transmission of TB equates to one person infecting between 10-15 people in a year.)

Malaria deaths could also double in 2020 reaching over 750,000 deaths given the restrictions on delivering millions of insecticide-treated bed nets across 30 countries. There are also likely to be increases in infections such as measles, rubella, diphtheria and polio due to delays and suspension of immunization programs. Routine immunizations in at least 68 countries have been impacted - equating to approximately 80 million babies under the age of 1 not receiving their vaccines according to the WHO.[30] Furthermore, financial resources, facilities and staff redeployed towards the Coronavirus vaccine programs diverts from research going into other troublesome diseases such as zika virus and improvements on a malaria vaccine. (The current malaria vaccine is only 40% effective.)

On a positive and hopeful note however, the combined global effort and total focus being displayed on the Covid-19 vaccine has which has undoubtedly sped up the process, and raised the possibility of mitigating ourselves from severe cases of the virus, thereby make living alongside it more palatable. However given how far it has already spread, it is definitely going to be with us even after a vaccine has been created, that is, until an unpredictable time frame when Covid-19 dies out altogether.

This article is taken from an extract from Nathan's book: 'Papatuanuku's Breath' recently published by Lulu Global Media. See https://www.lulu.com/en/us/shop/nathan-gray/papatuanukus-breath/paperback/product-vqwrzd.html

[1] Washington Post, June 20, 2020, Chico Harlan and Stefano Pitrelli. 'From Oxford to an Italian lab, one race for Coronavirus vaccine is gaining backers.'

[2] The world will ultimately require more than one vaccine in any case because if successful, one company will never be able to supply the enormous demand for it arising from around the planet.

[3] Washington Post, June 20, 2020, Chico Harlan and Stefano Pitrelli. 'From Oxford to an Italian lab, one race for Coronavirus vaccine is gaining backers.'

[4] Ibid.

[5] CNN, September 15, 2020, Arthur Allen and Liz Szabo. 'NIH very concerned about serious side effect in AstraZeneca Coronavirus vaccine trial.' The USA has backed 6 developmental vaccines to hedge its investment bets should the AstraZeneca/Oxford study fall through. One of them is by Johnson & Johnson which is in final stage trials with 60,000 participants of the first single shot vaccine that is potentially due by the end of 2020. If successful, it aims to manufacture a billion doses next year.

[6] Newsroom, July 24, 2020, Farah Hancock. 'Be prepared for Covid-19 vaccine side-effects.'

[7] Newsroom, August 10th, 2020, Farah Hancock. 'Frontrunners in the vaccine race.'

[8] National Geographic, August 21, 2020, Amy McKeever. 'Dozens of Covid-19 vaccines are in development. Here are the ones to follow.' These are the first published data results utilizing an inactivated virus.

[9] Ibid.

[10] Washington Post, August 24, 2020, Eva Dou. 'China says it began public use of Covid-19 vaccine a month ago, bypassing clinical trials.'

[11] New York Times, September 26, 2020, Sui-Lee Wei. 'China Gives Unproven Covid-19 Vaccines to Thousands, With Risks Unknown.' In 1976, a vaccination program to 40 million people against swine flu in the United States led to the campaign being later linked to cases of a neurological disorder called Guillain-Barre syndrome exposing the risks of mass roll outs before all potential side-effects are assessed.

[12] Ibid.

[13] Interestingly, complaints have been lodged by the USA, UK and Canada regarding cyber hacks over their Coronavirus vaccine research by Russian, China and Iranian entities.

[14] CNN, July 28, 2020, Matthew Chance. 'Russia prepares for world's first approval of Covid-19 vaccine by mid-August, but questions remain.'

[15] National Geographic, August 11, 2020, Nsikan Akpan. 'Fauci 'seriously doubts' the Russian vaccine is ready for widespread use.' Phase 3 trials, (which take the longest time to conjure results from), have supposedly started in the United Arab Emirates, Philippines, Saudi Arabia, Russia and possibly Brazil although the Associated Press could find no documentation in the Russian Health Ministry records citing that these trials had been approved.

[16] Stuff, September 5, 2020, Daria Litvinova and Maria Cheng. 'Russia publishes virus vaccine results, weeks after approval.'

[17] The Atlantic, July 24, 2020, Sarah Zhang. 'A Vaccine Reality Check.'

[18] Washington Post, September 18, 2020, Eva Dou and Isabelle Khurshudyan. 'China and Russia are ahead in the global Coronavirus vaccine race, bending long-standing rules as they go.'

[19] Ibid.

[20] Washington Post, July 5, 2020, William Booth and Carolyn Johnson. 'Elegant but Unproven, RNA leap to the front of the Coronavirus vaccine race. Will they work?'

[21] As a side note, the University of Oxford Phase 3 vaccine study utilizing 5000 volunteers in Brazil has decided to use a quadrivalent Meningitis ACWY vaccine as the control instead of a placebo. The reason being that the Meningitis vaccine is expensive and not widely distributed in Brazil thus giving the volunteers an extra benefit for participating.

[22] CNN, July 14th, 2020, Jacqueland Howard and Jihn Bonifield. 'Moderna vaccine shows promising safety and immune response results published in phase 1 study, but more research is needed.'

[23] Newsroom, July 24, 2020, Farah Hancock. 'Be prepared for Covid-19 vaccine side-effects.'

[24] CNN, July 14th, 2020, Jacqueland Howard and Jihn Bonifield. 'Moderna vaccine shows promising safety and immune response results published in phase 1 study, but more research is needed.'

[25] Council on Foreign Relations, June 30, 2020, Claire Felter, 'What is the world doing to create a Covid-19 vaccine?'

[26] Newsroom, July 24, 2020, Farah Hancock. 'Be prepared for Covid-19 vaccine side-effects.'

[27] Washington Post, 14 September, 2020, Carolyn Johnson. 'Vaccine companies reveal their study designs, even as Trump sows confusion.'

[28] The Atlantic, July 24, 2020, Sarah Zhang. 'A Vaccine Reality Check.'

[29] CNN, July 6, 2020, Meera Senthilingham. 'Efforts to beat the Coronavirus pandemic could cause over 1 million extra deaths from other disease, experts warn.'

[30] Ibid.

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