What we know about AstraZeneca's head-scratching vaccine results

Carl Zimmer and Rebecca Robbins, The New York Times

Posted at Nov 25 2020 10:51 AM | Updated as of Nov 25 2020 12:38 PM

Vials with a sticker reading, "COVID-19 / Coronavirus vaccine / Injection only" and a medical syringe are seen in front of a displayed AstraZeneca logo in this illustration taken Oct. 31, 2020. Dado Ruvic, Reuters/File

This month has seen a torrent of news about experimental vaccines to prevent COVID-19, with the latest development from AstraZeneca and the University of Oxford. On Monday they announced that a preliminary analysis showed their vaccine was effective — especially when the first dose was mistakenly cut in half.

The announcement came on the heels of stunning reports from Moderna, as well as Pfizer and BioNTech. But AstraZeneca’s news was murkier, leaving many experts wanting to see more data before passing final judgment on how effective the vaccine may turn out to be.

What is the AstraZeneca vaccine?

Researchers at the University of Oxford built the vaccine using a kind of virus, called an adenovirus, that typically causes colds in chimpanzees. They genetically altered the virus so that it carried a gene for a coronavirus protein, which would theoretically train a person’s immune system to recognize the real coronavirus.

Adenovirus-based vaccines are also being tested by Johnson & Johnson, as well as by labs in China, Italy and elsewhere. An adenovirus-based vaccine called Sputnik V is already being distributed in Russia on an emergency basis, although researchers have yet to release detailed results from their late-stage trial.

Scientists have been testing adenovirus-based vaccines for decades, but it wasn’t until July of this year that the first one was licensed, when Johnson & Johnson got approval from European regulators for an Ebola vaccine.

What have the AstraZeneca trials found?

In the spring, AstraZeneca and Oxford started running clinical trials, first in Britain and then in other countries including the United States. The first round of trials showed that the vaccine prompted volunteers to produce antibodies against the coronavirus — a good sign.

On Monday, AstraZeneca and Oxford released details about the first 131 volunteers to get COVID-19 in late-stage trials in the United Kingdom and Brazil. All of the volunteers got two doses about a month apart, but in some cases the first dose was only at half strength.

Surprisingly, the vaccine combination in which the first dose was only at half strength was 90% effective at preventing COVID-19 in the trial. In contrast, the combination of two, full-dose shots led to just 62% efficacy.

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Why would that be?

No one knows. The researchers speculated that the lower first dose did a better job of mimicking the experience of an infection, promoting a stronger immune response. But other factors, like the size and makeup of the groups that got different doses, may also be at play.

Why did the researchers test two different doses?

It was a lucky mistake. Researchers in Britain had been meaning to give volunteers the initial dose at full strength, but they made a miscalculation and accidentally gave it at half strength, Reuters reported. After discovering the error, the researchers gave each affected participant the full strength booster shot as planned about a month later.

Fewer than 2,800 volunteers got the half-strength initial dose, out of the more than 23,000 participants whose results were reported Monday. That’s a pretty small number of participants on which to base the spectacular efficacy results — far fewer than in Pfizer’s and Moderna’s trials.

Is the AstraZeneca vaccine safe?

For years, Oxford researchers have been testing their chimpanzee adenovirus vaccine, ChAdOx1, on a number of other diseases including Ebola and Zika. Although none of those studies have reached the final, Phase 3 trials, they have allowed researchers to examine the safety of the vaccine platform. The researchers have not found any serious side effects.

When the researchers adapted ChAdOx1 for COVID-19, their early clinical trials also did not turn up any adverse reactions. In Phase 3 trials, however, the testing had to be paused twice when volunteers experienced neurological problems. The Food and Drug Administration did not directly tie the vaccine to the problems, but when the agency allowed the trial to resume in the United States, it advised the company to be vigilant for any signs of similar problems.

In their announcement on Monday, AstraZeneca and Oxford said that no serious safety issues were confirmed related to the vaccine.

How much does the vaccine cost?

AstraZeneca’s vaccine has a number of advantages over other leading vaccine candidates: It’s easier to mass produce and store, and it’s also cheaper, at $3 to $4 per dose. That reflects the prices paid by governments like the United States that have placed orders for tens or even hundreds of millions of doses of the vaccine. U.S. health officials have promised that COVID-19 vaccines will be available free of charge to any American who wants one.

Does this mean it will soon be available in the United States?

There’s still a long way to go.

It is not yet clear whether the results announced Monday are enough for AstraZeneca to take the first formal step of the regulatory process: submitting an application to the FDA to get emergency authorization to distribute its vaccine. AstraZeneca plans to start testing the half-strength initial dose in its continuing United States trial and to ask the agency for guidance on how to proceed. The agency is likely to advise the company to collect more data on its promising dosing plan before submitting a formal application to authorization, several vaccine experts said.

Collecting more data might mean waiting for more results from participants in Britain who got the half dose. It might also mean waiting for the first results from the American study, which aren’t expected until next year.

How does the AstraZeneca vaccine stack up to the other candidates?

Outside experts have plenty of unanswered questions.

“The only thing that you can really say right now is that the vaccine seems to work,” Florian Krammer, a virologist at the Icahn School of Medicine at Mount Sinai in New York City. “It’s just hard to say how well it works compared to others.”

Experts have had a hard time parsing the results because of the way they were announced. Like the results from Pfizer and Moderna, the data on AstraZeneca’s vaccine was summarized in a news release.

Although the announcement gave efficacy rates, it left out details that would have helped outside researchers independently assess the data: It did not say how many cases of COVID-19 were found in the group that got the half-strength initial dose, or in the group that got the regular-strength initial dose, or in the group that got a placebo. It also did not say how many severe cases were found in the placebo group.

The results were pooled from across the two studies in Britain and Brazil, which have slightly different designs. To complicate matters further, details weren’t available on exactly how those trials were designed, because AstraZeneca and Oxford haven’t publicly released the protocol documents that serve as a road map for how those trials are evaluating the vaccine. (AstraZeneca has, however, released the protocol for its continuing trial in the United States.) That means we don’t know, for example, how many COVID-19 cases will need to turn up in order to prompt the end of the British and Brazilian studies.

Some of these questions may be answered when the results are published in a peer-reviewed journal, which is expected soon.