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This article was originally published Dec. 4, 2020 and has been updated by the author.

Since the beginning of the pandemic, little has generated more anticipation (or hesitancy) than the promise of a COVID-19 vaccine. Less than a year after the World Health Organization (WHO) declared COVID-19 a pandemic (March 11, 2020), that “promise” became a reality, when 2 major pharmaceutical and biotech companies, Pfizer (in partnership with BioNTech) and Moderna, Inc., announced unprecedented success following the primary efficacy analyses of their Phase 3 COVID-19 vaccine trials. By mid-December 2020, both  and  were issued Emergency Use Authorization (EUA) by the U.S. Food & Drug Administration (FDA). Not long after, Johnson & Johnson (J&J) also reported promising results from its Phase 3 vaccine trials and became . On Aug. 23, 2021, Pfizer's vaccine became the for prevention of disease in people 16 and older and the first mRNA vaccine to ever receive FDA approval.

Today, all 3 vaccines are  in the United States and several , and COVID-19 vaccines, including Sputnik V, Sinovac, Bharat-Biotech (Covaxin) and Oxford-AstraZeneca (Covishield) have also been authorized for emergency use outside of the U.S. Concurrently, there are 99 vaccines being tested in clinical trials, 33 of which have reached the final stages of testing (). 
 
Data from these studies are amongst the most pivotal advancements in the fight against COVID-19, to date. But amidst all the buzz, questions and misinformation continue to circulate, making it more vital than ever that the general public, and scientists alike, have a thorough understanding of what goes into and is coming out of these trials. One thing is certain: the success or failure of any vaccine depends as much on public acceptance as it does executive authorization/approval.

What is FDA Approval and How Does it Differ from Emergency Use Authorization (EUA)?

It’s important to recognize that EUAs are not the same as FDA approval, but rather a tool that allows the unapproved use of medical products to diagnose, treat or prevent serious or life-threatening disease in times of emergency, and when no other alternatives are available. The , which clearly requires “direct evidence of vaccine safety and efficacy in protecting humans from SARS-CoV-2 infection and/or clinical disease.”

FDA approval requires manufacturers to submit a , which includes extensive data and information that was previously submitted when the company applied for EUA, including preclinical and clinical data, details of the manufacturing process, vaccine testing results to ensure vaccine quality and inspections of the sites where the vaccine is made.

The difference between authorization and full FDA approval has less to do with the production of new or changing data than it does with ensuring that trial participants are followed for a long enough period of time to thoroughly evaluate the safety and efficacy of a particular product. In the case of the Pfizer-BioNTech vaccine, the median duration for safety-follow up was 2 months after receiving the 2nd dose of vaccine or placebo, and approximately 12,000 blinded and unblinded vaccine recipients have now been followed for 6 months or more.

Will EUA for the Pfizer-BioNTech COVID-19 vaccine still remain in place?

The EUA will remain in place and cover populations not included in the recent FDA approval. For example, adolescents 12-15 years of age may continue to receive the Pfizer vaccine and certain immunocompromised individuals may receive 3rd doses of vaccine under EUA.

What changes when a vaccine receives FDA approval?

Along with liscencing and approval comes a brand name and the ability to advertise the product. The brand name for the Pfizer-BioNTech COVID-19 vaccine, Comirnaty (pronounced Co-MER-na-tee), was created by the Brand Institute and, , represents a combination of the terms COVID-19, mRNA, community and immunity. 

Arguably, the most impactful outcomes of FDA approval will depend upon public opinion and responses. Some who have been hesitant to get vaccinated under EUA have stated that they were waiting for FDA approval to feel comfortable getting vaccinated. But time will tell whether the approval of Comirnaty increases trust within unvaccinated populations.        

How do Pfizer, Moderna and J&J vaccine platforms compare?

At the outset, the Pfizer and Moderna vaccines appear to be similar in structure and function. Both vaccines use mRNA platforms, a gene-based technology that has long been explored for its disease prevention and treatment potential but has generated little quantifiable success in the vaccine department, due primarily to engineering challenges...until now. Within a week’s time (Nov. 9-16, 2020), both companies reported their vaccine candidates to be more than 90% effective at preventing symptomatic COVID-19, and many are hoping these advancements in mRNA technology will .  
 
The J&J vaccine differs from Pfizer and Moderna in that it uses a viral vector platform, which relies on a harmless, recombinant adenovirus, to help deliver its targeted genetic message to host cells. This type of vaccine is not entirely new to the company, as J&J uses the same viral vector platform in the initial dose of their Ebola vaccine, which became the in December 2019. At the end of January 2021, J&J reported its COVID-19 vaccine to be 72% effective at preventing moderate to severe disease in the U.S. and 66% effective amongst all trial participants. 

How do mRNA vaccines work?

mRNA vaccines are synthetic in design. The Pfizer and Moderna vaccines both consist of  encoding a prefusion stabilized form of SARS-CoV-2 spike (S) protein, surrounded by a lipid nanoparticle coat, which protects the mRNA from enzymatic degradation before it reaches the protein-making machinery (ribosomes) of host cells. 
 
S protein is the portion of SARS-CoV-2 that binds to human ACE2 receptors. It is characteristic of SARS-CoV-2, required for infection and has been identified as a viable antibody target. Vaccination delivers a genetic message that signals host cells to produce copies of this antigen. Ribosomes translate the mRNA and initiate host production of spike protein copies. Then antigen-presenting cells display the antigen on their surfaces, triggering the immune system to produce antibodies and T-cells in response to the foreign protein.

How do viral-vectored vaccines work?

Viral-vectored vaccines are based on another type of  that’s more stable and less expensive to manufacture than mRNA vaccines. These vaccines use modified forms of viruses, other than the target pathogen, to carry genetic messages to host cells. The J&J vaccine uses a recombinant adenovirus called human adenovirus type 26 (Ad26). It is a double-stranded DNA virus that has been genetically modified to be replication deficient and therefore incapable of causing infection. 

Like Moderna and Pfizer, J&J targets the SARS-CoV-2 spike protein. DNA encoding the S gene is added to Ad26. Vaccination introduces the resultant, specialized viral vectors to host cells. Once engulfed, the adenovirus pushes its DNA into the nucleus of the host cell, but because its own DNA has been modified to be non-replicating, the gene encoding S protein is the only thing that gets copied and transcribed into mRNA. That mRNA then leaves the nucleus to be subsequently translated by ribosomes and initiate host cell production of S protein. Antigen-presenting cells then display the antigen on their surfaces, and the immune system begins producing antibodies and T-cells against the foreign protein. 

Is it possible for someone to contract COVID-19 from these vaccines?

No. Because these vaccines use the genetic code of a single virus protein to generate an immune response, they cannot cause SARS-CoV-2 infection in vaccine recipients. Furthermore, the adenovirus used for the J&J vaccine is genetically engineered to be unable to replicate or cause infection inside of host cells.

How were the studies conducted and what do the data show?

When a vaccine trial hits Phase 3, the product is being actively tested in large populations of humans. Both  and  Phase 3 trials were randomized, observer blinded, 1:1 placebo-controlled studies. Enrolled participants were randomly administered a predetermined dosage of vaccine (30 µg for Pfizer and 100 µg for Moderna) or a placebo saline injection, and those in charge of measuring, recording and assessing the trial did not know who was assigned to each group. 
 
The mRNA vaccines both rely on a 2-dose regimen that must be administered 3-4 weeks apart. Pfizer injections were given 21 days apart, while Moderna injections were given 28 days apart. The primary endpoint of these studies was laboratory confirmed, symptomatic COVID-19, and researchers began evaluating cases 7 days post-injection with the second dose of Pfizer’s vaccine (or placebo) and 14 days post-injection with the second dose of Moderna’s vaccine (or placebo). At that point, if a patient developed symptoms of disease and tested positive for COVID-19, trial records were consulted in order to determine if that participant had been given the vaccine or placebo. 
 
J&J’s Phase 3 vaccine trial was also randomized, double blinded and placebo controlled. Enrolled participants were randomly administered a single dose of vaccine, at a dose level of 5x10^¹⁰ virus particles, or given a placebo injection. Efficacy was evaluated 14 and 28 days post-injection. 

Data from the ,  and  Phase 3 trials have been published. 

Pfizer (Comirnaty)

• 43,538 enrolled participants.
• 150 clinical trial sites in 6 countries and 39 U.S. states.
• 42% of global and 30% of U.S. participants came from racially and ethnically diverse backgrounds. Pfizer provided a further .
• 41% of global and 45% of U.S. participants aged 56-85. 
• 95% efficacy was reported after the  (Nov. 18, 2020). The efficacy in adults 65+ years of age was determined to be over 94%, and 9/10 severe cases of COVID-19 were observed in the placebo group.  
• What that means: The final analysis was based on 170 confirmed cases of symptomatic COVID-19. 162 of those were observed in the placebo group. That means only 8 people became naturally infected with SARS-CoV-2 and developed symptoms after receiving the Pfizer vaccine.
• FDA approval was based on follow-up data from this ongoing trial. The median duration for safety-follow up was 2 months after receiving the 2nd dose of vaccine or placebo, and approximately 12,000 blinded and unblinded vaccine recipients have now been followed for 6 months or more.
• Follow-up analysis included approximately 22,000 vaccinated and 22,000 placebo recipients. Overall, the vaccine .
• What that means: The follow-up analysis was based on 77 cases of COVID-19 that occurred in the vaccinated group and 833 cases of COVID-19 that occurred in the placebo group.

Moderna

• Approx. 30,000 enrolled U.S. participants (aged 18+).
• 37% of participants from communities of color, including more than 6,000 identifying as Hispanic or Latinx and more than 3,000 identifying as Black or African American.
• 42% of participants from medically high-risk groups (including individuals 65 years of age and older, as well as those with pre-existing/underlying chronic diseases, such as diabetes, severe obesity and cardiac disease).
• 94.1% overall efficacy and 100% efficacy against severe disease were reported after the (Nov. 30, 2020).
• What that means: The final analysis was based on 196 confirmed cases of symptomatic COVID-19. 185 of those were observed in the placebo group. That means only 11 people became naturally infected with SARS-CoV-2 and developed symptoms after receiving the Moderna vaccine. Furthermore, 30/30 severe cases were observed in the placebo group, meaning there were zero cases of severe COVID-19 disease in those who were vaccinated.

J&J

• 43,783 enrolled participants (aged 18+).
• Trial sites in 8 countries and 3 continents.
• 44% U.S. participants, of which 74% are white; 15% are Hispanic and/or Latinx; 13% are Black/African American; 6% are Asian and 1% are Native American.
• 34% of participants over age 60 and 41% of participants with comorbidities associated with increased medical risk.
• 66.9% efficacy against moderate to severe disease and 85% efficacy against severe/critical COVID-19 (with disease onset 28 days or more post vaccination) was reported amongst all volunteers (even those infected with circulating SARS-CoV-2 variants).  
• What that means: The analysis was based on 468 cases of confirmed, symptomatic COVID-19. 116 cases occurred in the vaccine group and 348 occurred in the placebo group. 
• Because the study was conducted after some SARS-CoV-2 variants (such as Alpha and Beta) were identified as potential threats to vaccine function, J&J was able to design its trial to test the efficacy against these specific variants. Following the (Jan. 21, 2021), the vaccine was reported to be 72% effective at preventing moderate to severe disease in the U.S., 66% effective in Latin America and 57% effective in South Africa, 28 days or more post vaccination.

 

Which vaccine is the most effective?

Direct comparison of the efficacy values of these studies does not account for differences in trial design or the presence of circulating variants. For example, J&J evaluated how effectively their vaccine prevented combined endpoints of moderate and severe COVID-19, while Pfizer and Moderna evaluated how effectively their vaccines prevented a primary endpoint of symptomatic COVID-19.
 
However, all 3 vaccines have been shown to not only stimulate antibody production, but also to induce T-cell activity against SARS-CoV-2 and prevent COVID-19. Interestingly, virus specific T-cells, lymphocytes that recognize and eliminate infected cells,  even in cases of SARS-CoV-2 infection that do not appear to generate detectable antibodies. Furthermore, the growing number of COVID-19 vaccines that have been successfully administered provides additional evidence of their safety and efficacy.

Who evaluates the data from these studies?

An independent Data and Safety Monitoring Board is in charge of evaluating the safety and efficacy of vaccine trials. These committees are composed of people who do not own the company or trials under review, which is important to help ensure that those who stand to profit from the vaccine are not involved in the evaluation of trial data. 

What are the side effects of COVID-19 Vaccines?

The most commonly reported vaccine side effects include the following:

• Injection site reactions (pain, redness, swelling).
• Fatigue.
• Headache.
• Muscle and joint pain.

In some cases, nausea and fever have occurred. And  have been reported following administration of Moderna (0.0025% or 2.5 cases per 1 M doses), Pfizer (0.0047% or 4.7 cases per 1 M doses) and J&J (2 cases total, as of Feb. 26, 2021). In most cases, these reactions have occurred in individuals with a history of severe allergic reaction. It’s important to understand that the side effects mentioned above are signs that the immune system is working and not that the vaccine is unsafe for use.

Additionally, data have indicated that there is a small, but significant risk of myocarditis and pericarditis among males under 40 years of age compared to females and older males who receive mRNA vaccines. This risk appears to be highest in males 12-17 years old. Information about potential long-term health implications is not yet known, but symptoms are normally mild and resolve quickly. No serious, long-term side effects have yet been reported, but this will continue to be closely monitored as vaccine doses are administered.

What are the key differences between the 3 vaccines?

Viral-vectored vaccines are more stable.

mRNA vaccine development has been historically stunted by engineering challenges because unprotected RNA is environmentally unstable. Enzymes that degrade RNA, called RNases, are found in almost every type of prokaryotic and eukaroyotic cell. In fact, RNases are naturally secreted in human tears, saliva and mucus as a defense against microbial invasion. Fortunately, enveloping mRNA with a lipid nanoparticle coating ensures the genetic messages reach their target cells unscathed.

Viral-vectored vaccines are more stable than mRNA vaccines for multiple reasons. First, DNA is, by nature, more environmentally stable than RNA; and second, the adenovirus shell helps protect the genetic message that is carried inside. As a result, the J&J vaccine can be transported and stored at normal refrigerator temperatures.

mRNA vaccines require ultra-cold storage.

The fragility of RNA makes storage of this type of vaccine significantly more challenging. Basic laboratory protocol calls for unprotected RNA to be stored at -80°C to remain viable. Pfizer’s vaccine candidate requires similar subzero storage temps (-70°C). Unfortunately, many hospitals and treatment centers () are unequipped and can’t afford to accommodate those requirements. In order to address these concerns, Pfizer has designed its own packaging, which uses dry ice to keep the vaccine cold enough to be stored for a few weeks without the need for specialized freezers.
 
Moderna, on the other hand, has announced that its vaccine candidate and up to 30 days at normal refrigerator conditions (2-8°C). The difference likely has to do with the way the vaccine is encased. According to an , which quoted a Moderna spokesperson, the increased durability of the Moderna vaccine is due to its “lipid nanoparticle properties and structure.” Time will tell how each company manages manufacturing, distribution and storage demands.

Viral-vectored vaccines are less expensive to manufacture.

Viral-vectored vaccines are less expensive to manufacture than mRNA vaccines, a factor that when coupled with J&J’s current single-dose regimen, may be a game changer when it comes to increasing the global supply of COVID-19 vaccines.

mRNA vaccines can be more rapidly produced.

mRNA vaccines are especially efficient to produce, a factor that has undoubtedly given this platform an advantage during the pandemic. The reason mRNA vaccines can be so quickly engineered is that they're almost entirely synthetic. All researchers really need is the genetic sequence of the desired protein (and a delivery platform). No live virus, culture, eggs or bioreactors required. 

Within 2 months of learning the sequence of the SARS-CoV-2 spike protein, Moderna was able to engineer enough vaccine to begin its first human trials, but this speedy production was not rushed. It is important to understand that COVID-19 vaccines are dependent upon, and made possible by, nearly 17 years of research, which began when SARS-CoV was first identified in 2003, as well as decades of research and development surrounding mRNA technology.  

What other candidates are showing promise?

There are  in the pipeline, a number of which are showing promise and/or have already received authorization outside of the U.S. Below is a brief introduction to 2 of them. 

Sputnik V

Sputnik V is another adenovirus-based vaccine, developed by a Russian company, known as the Gamaleya Research Institute of Epidemiology and Microbiology. It is unique in that its 2-dose regimen relies on 2 different adenovirus vectors to carry S protein DNA to host cells. Much like J&J, the first dose uses recombinant Ad26, but the second dose uses a recombinant version of Ad5. 
 
A  showed 91.4% efficacy 28 days after the first dose and 95% efficacy 21 days after the second dose was published on Nov. 23, 2020. At that time, 22,000 participants had received the first dose of vaccine and 19,000 had received the second of the 2-dose regimen. The vaccine was initially criticized for being rolled out prior to the release of final trial data. But in Feb. 2021, Phase 3 trial results  with no unusual side effects, and the vaccine is currently being administered in multiple countries including Russia, Argentina, Belarus, Hungary, Serbia and the United Arab Emirates.

AstraZeneca 

The University of Oxford partnered with AstraZeneca, a British-Swedish multinational pharmaceutical company, to produce another adenovirus-based vaccine using a replication deficient, modified form of chimpanzee adenovirus ChAdOx1 to deliver S protein DNA to host cells.
 
On Nov. 22, 2020, , announced that at the interim analysis of its clinical trial the vaccine had an average efficacy of 70%. However, the company simultaneously revealed that there was  between the testing sites of the trial (United Kingdom and Brazil). In the U.K., 2 different vaccine doses were tested, while the Brazilian site used only one. Unfortunately, this inconsistency caused a range in efficacy from 62%-90%.
 
Further investigation of  pointed to an efficacy of 82.4% in patients who received 2 standard doses of the vaccine, and despite some uncertainty, the European Medicines Agency (EMA) and India authorized the vaccine for conditional emergency use. Unfortunately, concerns about reports of blot clots caused many European countries, including Denmark, Norway, Iceland, Ireland, France, Germany and Italy to suspend use of the vaccine in March 2021. AstraZeneca has since  of its vaccine, in which they reported a careful review of available safety data from over 17 million people vaccinated in the European Union (EU) and U.K., with 15 events of deep vein thrombosis (DVT) and 22 events of pulmonary embolism (as of March 8, 2021). The company also stated “This is much lower than would be expected to occur naturally in a general population of this size and is similar across other licensed COVID-19 vaccines.”  adverse reactions, the committee has concluded that the vaccine is of thromboembolic events or blood clots.

What questions still need to be addressed?

Biology and Immunology

There are a number of questions surrounding COVID-19 vaccines that remain unanswered. Some of these have to do with the biology of the virus and/or host immune system, including how long the vaccine will remain protective and will boosters be needed? Scientists are actively researching the immunopathology of SARS-CoV-2, and although  against early variants, the virus is continuing to evolve. While vaccines remain highly effective at preventing the worst outcomes of SARS-CoV-2 caused by the highly transmissible Delta variant, including severe disease, hospitalization and death, vaccinated sera show reduced neutralization activity against Delta. And we still do not know how long vaccines will remain protective.

The , at least 28 days after administration of the second dose of Pfizer or Moderna COVID-19 vaccines, for people who are moderately to severely immunocompromised. And the on Aug. 18, based on data indicating that protection against SARS-CoV-2 infection begins to decrease over time following the initial doses of vaccination, that establishes a plan to offer booster shots for all Americans, beginning the week of September 20 and starting 8 months after an individual’s second dose of vaccine.

Pregnancy and Children

The Phase 3 trials detailed above were conducted on non-pregnant participants, 18 years of age and older. Thorough investigation of the safety and efficacy of these vaccines in pediatric and pregnant populations is ongoing. The Pfizer vaccine is now authorized for use in people 12-15 years of age and approved for use in people 16 and older. are underway, but the vaccine is still only authorized for people 18 and up. The FDA has requested that both companies to include at least 3,000 patients aged 5-11 as a precautionary measure to detect rare side effects that could be associated with vaccination in children.

Vaccine Hesitancy

Another subset of questions has to do with public confidence and vaccine hesitancy. As case numbers continue to ebb and flow across the country, and many are experiencing local surges of SARS-CoV-2, weariness seems to be spreading as quickly as the virus itself. For some, the news of an effective way to prevent further spread of this disease could not come soon enough. For others, particularly those from underrepresented and underserved communities, it is a harbinger of a new kind of uncertainty and unease. Can we trust a vaccine that was developed so quickly? How do we address and prevent the recurrence of historical abuses and vaccine mishandling? 
 
In order to , vaccine researchers and production companies must be open and transparent with their trial data, and scientists must address sources of vaccine hesitancy and  directly. We must be honest about what we do not yet know and work to share the knowledge we do have in a way that empowers everyone to make informed decisions, which promote the health and well-being of ourselves and our communities.