A good read about The AstraZeneca saga.
The World Needs the Not-for-Profit AstraZeneca Vaccine, Minus the AstraZeneca Drama
A series of unforced errors by the British pharma company has turned hope into hesitancy.
By Stephanie Baker and Suzi Ring
April 7, 2021, 11:01 PM CDT
Mene Pangalos, head of biopharmaceuticals research for AstraZeneca Plc, went to bed on Monday, March 22, feeling good for the first time in a while. After working around the clock through the weekend, heâd just announced better-than-expected interim results from the companyâs large U.S. vaccine trial: The shot was safe and 79% effective at preventing cases of symptomatic Covid-19. Positive news, at last, after months of questions about everything including safety and supply shortfalls.
But at around 5 the next morning, Pangalos was jolted out of bed in the U.K. by a call from AstraZeneca Chief Executive Officer Pascal Soriot, ringing from Australia to ask what on earth was happening. The U.S. National Institute of Allergy and Infectious Diseases (Niaid) had just issued a late-night statement announcing that the safety board overseeing the trial was concerned AstraZeneca âmay have included outdated informationâ in its results, which âmay have provided an incomplete view of the efficacy data.â Niaid, which is part of the National Institutes of Health, urged the company to release up-to-date figures as soon as possible.
While they were asleep in Europe, Pangalos and his team had received a harsh email from the Data and Safety Monitoring Board, the independent committee of experts appointed by the NIH to oversee the trial. The DSMB accused the company of releasing âpotentially misleadingâ figures, saying the data were âthe most favorable for the study as opposed to the most recent and most complete.â The experts added that âdecisions like this are what erode public trust in the scientific process.â Astra executives were stunned. No one had reached out to them to discuss the concerns first, and Niaidâs decision to publicize the independent committeeâs critique of the interim results was unprecedented.
The contents of the DSMBâs letter quickly leaked to the Washington Postand the New York Times. Within hours, Anthony Fauci, director of Niaid, was on Good Morning America, talking about the flap. âIt really is unfortunate that this happened,â he said. âThis is really what you call an unforced error, because the fact is this is very likely a very good vaccine, and this kind of thing does nothing but really cast some doubt.â
Astra had received approval the Friday before from the safety board to conduct its interim analysis, based on 141 verified Covid cases dating to Feb. 17. The board had advised the Astra team to be mindful of the unverified cases that had come in since then, to be sure they wouldnât produce a significantly different efficacy figure, according to people familiar with the discussions. The team had looked at the cases, but, believing that their potential effect on the efficacy number was negligible, they hadnât mentioned in their statement that the final percentage might change.
Now, with the DSMBâs letter public knowledge, the trial team raced to review the additional 49 cases, a process that normally takes weeks. Two days later, AstraZeneca announced the updated results. The differences were statistically insignificant: Overall efficacy dropped 3 percentage points, to 76%, though it actually rose 5 percentage points in seniors, to 85%. The vaccine was 100% effective at preventing hospitalization and severe disease. This time, AstraZeneca was careful to note that there were still 14 more possible or probable Covid cases to be assessed, which could cause the numbers to fluctuate. The companyâs executives were deeply upset by the events of the week. âItâs just hugely frustrating,â one says. âHonestly, it breaks our hearts.â
The week after the updated results came out, Fauci downplayed the drama. âI didnât question their data at all,â he said when asked about the incident by Bloomberg Businessweek at a White House briefing on March 31. âThis is a good vaccine that is going to have a very important role in the global response to this outbreak.â
The story of the vaccine that AstraZeneca developed with the University of Oxford is marked by noble intentions, communication blunders, messy trials, manufacturing nightmares, and political and economic rivalry. Most seriously, the shot is facing a spate of reports that a small number of people who received it, most of them younger than 60, developed a rare form of cerebral blood clotting. The World Health Organization and British and European regulators said that theyâd found a possible link between the vaccine and the clots but that the benefits of getting the shot outweigh the risks. The EU regulator has recommended that clotting be listed as a rare side effect, while the U.K. is advising that the vaccine not be used on people under 30. Some governments have already halted the shotâs use in younger people. Despite all the issues, many European Union leaders have been clamoring for doses, complaining that AstraZeneca has failed to meet its supply promises and even threatening to block vaccines made or bottled in the EU from being exported.
In the span of a year, Astra has gone from favored child to problem child in the family of coronavirus vaccines. âThereâs this little cloud thatâs followed it around everywhere it goes, which I think is slightly unfair,â says John Bell, the Canadian-born Oxford professor of medicine overseeing relations between the university and AstraZeneca. âIf people keep beating this vaccine up, nobodyâs going to have the confidence to use the darn thing, and then weâve got a massive problemâbecause itâs deployable, itâs cheap, you can use it globally, and itâs clearly highly effective.â
As Bell suggests, Astraâs vaccine is more easily transported and stored than the mRNA-based vaccines from Modernaand Pfizer-BioNTech. The U.K. company has promised to deliver as many as 3 billion shots in 2021, selling them on a not-for-profit basis, at a few dollars a dose. Only the single-shot vaccine from Johnson & Johnson, which has also agreed to sell doses for no profit, is expected to make a comparable contribution to ending the pandemic, but itâs far behind Astraâs on production. By contrast the Pfizer-BioNTech vaccine is expected to bring in $15 billion in revenue this year, while Moderna Inc. is forecasting $18 billion for its shot. More than 135 million Astra doses have thus far been distributed around the world, and the shot has become the workhorse of Covax, the WHO-backed program that provides vaccines to low- and middle-income countries.
AstraZeneca and Oxford have had their share of bad luck, but they also made a series of missteps that derailed their front-runner status. âItâs shocking that they made so many errors,â says Ezekiel Emanuel, a medical ethics and health policy professor at the University of Pennsylvania who advised President Bidenâs Covid transition team. For all the blunders, the world desperately needs Astraâs shot to end the pandemic. This is how itâs gone wrong.
âWe must be able to trust the vaccines. ... These are findings we cannot ignoreâ
Last spring, scientists at Oxford were advancing quickly through lab and animal testing of their vaccine candidate, which they were planning to deliver in a single dose. They were under pressure to team up with a big pharmaceutical company, given that manufacturing at scale would require months of intensive planning and vast logistical capacity. Early talks with U.S.-based Merck & Co.ground to a halt after U.K. officials, wary that American nationalism could leave them without access to doses, said they wanted to keep development and manufacturing in British hands. GlaxoSmithKline Plc, a major U.K. vaccine developer, passed on the opportunity to join forces. That left the only other British player of any size, AstraZeneca.
Astra was on a roll under Soriot, whoâd fended off a $117 billion hostile bidfrom Pfizer Inc. in 2014 and developed a reputation as a miracle worker in getting new drugs, especially treatments for cancer, to market. When Bell spoke with Soriot last April, he said Oxford had two conditions: the vaccine had to be sold on a not-for-profit basis at least for the first year, and Astra had to help ensure the developing world got doses. Bell says Soriot didnât hesitate to agree, replying, âIâm completely with you.â Astra would get a massive public relations coup and, down the road, lots more business if booster or annual shots proved necessary.
Other than a nasal spray for flu, though, Astra had almost no experience in vaccines. âTheyâre in this game for the first time, so theyâre making their way,â Bell says. âThey donât have five authoritative big guns in the vaccine world to stand up and say, âHey guys, pay attention to this. This is really good stuff.âââ
Some potential for dysfunction was baked into the process from the start. By the end of April, when it reached the final partnership agreement with Astra, Oxford had already begun human trials, whose protocols would become quite complex. It had large Phase III trials set to start in the U.K. and Brazil, along with a smaller Phase I-II in South Africa. For the U.S. Phase III trial, Astra took charge, designing a straightforward two-arm protocol.
With the backing of the U.K. government, the partnership moved swiftly on manufacturing, building on the universityâs early work with Oxford Biomedica, a small nearby biotech company, to get domestic production off the ground. In mid-May, the British government announced it had preordered 100 million doses, and Operation Warp Speed, former President Donald Trumpâs vaccine program, pledged as much as $1.2 billion to accelerate the shotâs development and secure 300 million doses for the U.S. Oxford soon started its Phase III trial in the U.K. Everything seemed to be coming along.
Out of the public eye, though, the scientists at Oxford realized theyâd miscalculated the concentration of the vaccine, which had led some Phase III trial participants to receive a half-dose. Around the same time, the team decided to move from a one-shot to a two-shot regimen after seeing signs it would produce better protection, settling on a dosing interval of about four weeks. The U.K. regulator authorized them to continue with the half-dose group and follow up with a full dose, but the miscalculation and the decision to add a second shot meant the team would need to make more vaccine. That in turn delayed the second jab for a large number of volunteers.
Continuing with the half-dose group seemed justifiable to many of those in the loop, given that the pandemic was accelerating, a vaccine was urgently needed, and itâs normal to try different dosage regimens, if not usually on the fly. But some U.S. officials heard about the changes to the protocol and thought, âWhat are these guys doing?â according to a former senior Trump administration figure. The moves undermined American confidence in the British developersâjust as the NIH was working with AstraZeneca on setting up the U.S. Phase III trial.
Astraâs team had been hoping to start the U.S. trial in July, which ended up being about the time Moderna and Pfizer began their Phase IIIs. But U.S. officials wanted to make sure manufacturing of the vaccine could be scaled up and tested before an expensive trial began, and that took longer than expected, according to three former senior officials. Also, the Food and Drug Administration and some Warp Speed officials were asking for detailed immune-response data in over 65s, people familiar with the situation say; Oxford had been slow to recruit older adults to its large U.K. trial. With the delays, AstraZeneca wasnât able to begin dosing volunteers in the U.S. until the end of August.
Only a week later, the health news service Stat reported that the U.S. trial had been paused after a volunteer in the U.K. experienced an unspecified illness. It soon emerged that vaccination had been suspended in all the partnershipâs global trials as the situation was investigated. It isnât uncommon for clinical trials to be halted as a precaution, especially in the large-scale final phaseâitâs a sign that safety is being taken seriously. But this wasnât a normal trial; it was one of the most closely watched scientific projects in history.
The first reported pause to a coronavirus vaccine trial set off a media storm. Under huge pressure to divulge further details, the developers refused, citing participant confidentialityâstandard practice with such events and one that usually goes unnoticed. A throwaway comment by Matt Hancock, the U.K. health secretary, then revealed that Oxfordâs Phase III trial had been paused over a safety concern once before.
During a subsequent private investor call, Soriot revealed some of the details journalists and scientists had been demanding. The participant was a woman whoâd begun suffering from neurological symptoms consistent with transverse myelitis, an inflammation of the spinal cord that can be caused by a viral infection. Soriot said it was unclear whether this specific condition had been diagnosed and whether the vaccine was to blame. Again, the information leaked, and again, a storm ensued.
Soriotâs selective disclosure renewed the demands for details, which the company once more refused to divulge. The woman who suffered from the adverse reaction was complaining that her health was being dissected in the media around the world, according to people familiar with the situation. Releasing additional information about her condition before a full investigation was conducted could also have compromised the integrity of the trial and potentially encouraged other participants to report similar issues where none were occurring.
Regulators in Brazil and the U.K. cleared Oxford to resume its trial roughly a week after the pause began, but the U.S. kept the study there on hold for almost seven weeks as Pfizer and Moderna zipped ahead with theirs. American officials were asking Astra for detailed information on every neurological event in any participant whoâd ever received the vaccine, according to people familiar with the request. Three former senior U.S. officials say they grew frustrated at how long Astra was taking to provide them the data they requested. The FDA had no desire to slow things down given the urgency of the pandemic, one former official says. Other companies were able to respond quickly to FDA requests, and several U.S. officials began to assume AstraZeneca and Oxford were having problems communicating.
Some working on the U.K. governmentâs vaccine effort were baffled by the holdup. On Oct. 12, Stat reported that Johnson & Johnson had paused its trial because of an unexplained illness. Like AstraZeneca, the American company didnât announce the pause beforehand and declined to release details, citing patient privacy; it later revealed in a report to the FDA that a 25-year-old male volunteer had suffered blood clotting in his brain, resulting in cerebral hemorrhage. After concluding that the event was unrelated to the vaccine, J&J resumed its U.S. trial, saying it would start back up less than two weeks after the pause began.
By then some American officials had soured on the AstraZeneca vaccine, safe in the assumption they had Pfizer and Moderna in the bag, with Johnson & Johnson not far behind. âAstraZeneca looked like the gang that couldnât shoot straight,â says the former senior Trump administration figure. âIt was almost an attitude of: If they make it, they make it; if they donât, they donât. But weâre not going to go out of our way to make AstraZeneca successful. Thatâs for sure. They had fumbled the ball so many times.â
By November, Pfizer and Moderna had produced a set of clear results for their vaccines in U.S. trials, showing efficacy of about 95%âbetter than anyone had dared hope for. When Oxford reported interim results from its Phase III U.K. and Brazil trials on Nov. 23, they were also good, but they looked messy by comparison.
Whereas Pfizer had enrolled more than 40,000 participants, and Moderna had more than 30,000, Oxford reported interim efficacy data on fewer than 12,000. Oxford also didnât produce a single efficacy figure, instead coming out with two that seemed counterintuitiveâan issue that traced to the now-public fact that one group had been given a half-dose for their first shot. The vaccine was 62% effective in one cohort who got two full doses spaced about a month apart. Surprisingly, in the smaller group of about 2,700 people whoâd received the half-dose for their first shot, the number rose to 90%
Initially, Oxford and AstraZeneca offered conflicting stories about what had happened with the dosing. Sarah Gilbert, the Oxford scientist who led the vaccineâs development, explained it away as a function of experimentation. âWe donât want to stick to a very low dose and discover we have an immune response that is too low,â she told Bloomberg News. âOn the other hand, we would like a vaccination regimen thatâs well-tolerated.â The next day, Pangalos told Reuters the Oxford scientists had actually âunderpredicted the dose by half.â He cast the lower doseâs relative success as âserendipity.â
The muddled trial, coupled with Oxford and Astraâs inability to coherently explain what had happened, overshadowed the strong efficacy number for the smaller group in many peopleâs minds. As one former senior U.K. official says, it âwasnât their finest hour.â
Although relations between AstraZeneca and Oxford didnât appear strained through all this, a common refrain emerged. When AstraZeneca executives talked about the U.K. trial, they would say, âWell, itâs Oxfordâs trial. We had nothing to do with it.â When Oxford scientists were asked about delays to the U.S. trial, they would say, âWell, thatâs AstraZenecaâs trial. Weâre not involved.â Bell says the relationship is good. âWeâre still in there swinging with AstraZeneca, trying to help. Weâve been fused at the hip from the beginning.â