What Does A Successful COVID-19 Vaccination Campaign Look Like?

With Israel vaccinating over 50% of its population, I have been thinking for some time about the parameters of a successful vaccination program in the US. 

Assumptions

• Mutations (i.e. variants with demonstrably biological differing properties) will continue to occur. Already the B.1.351 (South African) strain has exhibited "immune escape" from convalescent plasma, i.e. antibodies for the older strain were much less effective at fighting the virus.
• Vaccine nationalism, i.e. the country of origin will get priority for their own production, is inevitable and will continue to be a factor going forward. This is not to say it will always break down this way, as Israel attests, but it seems a general pattern until manufacturing can keep up.
  
• Manufacturing delays and shortfalls will persist for longer than anyone is comfortable with, in addition to pratfalls by the EU itself that prevented early vaccination rollouts. (Another post on that later.) AstraZeneca, Pfizer, Moderna, Johnson & Johnson, and Novavax have all had manufacturing problems at one point or another. (Novavax particularly had manufacturing issues that caused them to postpone their Phase III trial.)
• I assume that by now the problems of vaccine spoilage and overly specific prioritization criteria have been laid bare, and people recognize that flexibility is important. Every arm with a shot in it is an arm closer to victory.
  

 What Needs To Be Done?

• Manufacturing agility and volume is key. mRNA can turn around fastest of all the technologies, from what I can tell, and in fact both Moderna and Pfizer are already looking at boosters for the new variants. Vectored vaccines appear to have a complex manufacturing process that makes scaling difficult. Protein subunit and inactivated vaccines are also slower to turn around (it appears) than mRNA. The worst-case scenario is that the developed west will have to build out a lot of mRNA manufacturing capacity to inoculate whole populations in a couple months.
• Transportability and refrigeration. Vectored virus vaccines (Johnson & Johnson's Janssen, AstraZeneca) seem to have better storage requirements than the mRNA vaccines (Moderna and Pfizer). Novavax can be stored at refrigerator temperatures (2-8C).
  
• The two prior factors will determine undeveloped world vaccinations. Distribution to Africa and other undeveloped countries with sketchy or nonexistent cold chains will preclude mRNA in those places. This means vectored virus/protein subunit/inactivated will be how those populations get vaccinated. Unfortunately, this opens the door to a longer pandemic with hot spots that can possibly cause serious mutations.
• Price and manufacturing capacity will limit vaccination in eastern Europe and other mid-tier nations. One of the big problems the EU had acquiring vaccines was getting all 27 member states to sign up at a price acceptable to its poorer members, while fending off defections from the larger countries. Consequently, if Germany is lagging the UK and US, it is still well ahead of Bulgaria or Hungary.
  
• Lockdowns cannot last forever. Once most affected populations are vaccinated, start reopening. Continue monitoring infections, with an emphasis on sequencing to track novel variants.

This may end up a years-long effort, especially with large-scale reservoirs of disease overseas spawning mutations. But there has to be an exit plan; the pandemic cannot be allowed to remain a pandemic out of sheer bureaucratic inertia.