How AstraZeneca's vaccine got mired in politics and mistrust to become Europe's least favorite shot

• Europeans are turning down the AstraZeneca vaccine, threatening the EU's path out of the pandemic.

• The problem flared last week but has been months in the making.

• Both AstraZeneca and EU leaders made mistakes that sapped public confidence.

• Experts and regulators say the shot is safe, and EU leaders are moving to repair the damage.

• Visit the Business section of Insider for more stories.

"There is currently an acceptance problem with the AstraZeneca vaccine," German Chancellor Angela Merkel said last week. She was putting it lightly.

Merkel's interview with the Frankfurter Allgemeine Zeitung came as governments across Europe realized that mistrust among their people for this particular shot imperiled the continent's entire vaccination drive.

Official European Union data showed that as of Wednesday only 28% of the 7.3 million doses of the jab had been put into people's arms, a massive underutilization of a precious resource.

Vaccinations centers stood almost empty, and national leaders scrambled to instill trust in the vaccine as some Europeans were doing their utmost to instead get injected with the alternatives.

AstraZeneca's shot should have had the upper hand. It is the cheapest and easiest to store of all the vaccines approved in the EU so far and can be produced in vast quantities. The company has committed to producing it at cost price for low- and middle-income countries in perpetuity. The World Health Organization has called it a "vaccine for the world."

AstraZeneca has not sought authorization for the shot in the US, leaving Europe as its main proving ground. Uptake in the UK, where it was developed by Oxford University scientists, has been strong. But elsewhere it has faltered.

AstraZeneca did not respond to multiple opportunities to comment for this article.

Merkel's acknowledgment was the culmination of a string of failures months in the making - by politicians but also by AstraZeneca itself - which led to many perceiving the shot to be a lesser option.

In Belgium, the shot's affordability was turned against it, with many disparagingly labeling it the "Aldi vaccine" after the budget grocery chain.

"It was a series of little things from one to another, and then it went like a rolling stone," Heidi Larson, an anthropology professor who is the director of the Vaccine Confidence Project, told Insider in an interview.

The errors were born of poor communication, which began months ago when AstraZeneca announced its trial results and continued when European leaders fought publicly with the company over its delivery plans.

A messy race to procurement

"Some of the initial frustration had to do with not getting vaccines when other countries seem to be getting them," Larson told Insider.

The EU took a cautious approach to vaccine acquisition that ultimately came back to bite it. Its strategy was first to hold out for the vaccine manufacturers to lower their prices, provide stronger data, and promise enough doses to vaccinate the whole bloc, according to Politico.

But it was undercut by nations such as the UK and Israel, which spent more freely and made commitments sooner. AstraZeneca signed its deal with the UK in May, while the EU finalized its deal in August.

The UK approved the AstraZeneca shot relatively quickly and was rolling it out by January.

At the same time, the EU's European Medicines Agency had yet to approve it, while AstraZeneca told the EU that issues with the supply chain meant the company would cut its first-quarter deliveries for Europe by 60%.

The contrast with the UK was stark and set off a damaging public fight between the EU and the company it was banking on to vaccinate its populace.

EU leaders accused the Cambridge, England-based company of prioritizing the UK markets and hit back by threatening to stop vaccines at the border between Ireland and Northern Ireland, reopening the most sensitive issue from the Brexit divorce.

"I imagine the political bickering around distribution of the Oxford-AstraZeneca candidate has probably not played out very well with the general public," Michael Head, a senior research fellow in global health at the University of Southampton, told Insider.

Confusing results set the stage for skepticism

Meanwhile, questions had been circling over how well the AstraZeneca vaccine worked from the moment its trial results were released.

The vaccine emerged with what the vaccine-confidence expert Larson called "a stumbling start" with its trial results in November.

By then, its competitors Pfizer and Moderna were widely received as a triumph after having already released late-stage trial data showing their vaccines had about 90% efficacy.

AstraZeneca's results also showed a highly effective vaccine - but prompted questions and confusion thanks to a messy process.

In a press release, AstraZeneca announced the vaccine's efficacy was 70%. Unexpectedly, it said this figure was an average of two very different results observed in trials.

The company explained that for some trial participants, the efficacy was about 60%. These people had received two full doses of the vaccine.

Meanwhile, a subset of trial participants under the age of 55 were given half the planned dose of vaccine followed by a full dose later. The vaccine efficacy in that case was a lot higher: 90%.

Initially, there was no explanation. Later the scientists acknowledged making a mistake in the dosing, instilling more doubts.

"The Oxford-AstraZeneca phase-three trials were not the most definitive of all the studies of all the vaccines," Paul Hunter, a professor of medicine at the University of East Anglia, told Insider in an interview, "which I think is a big shame."

"These things can happen" in clinical trials, Larson said, "but it sends a signal that things were not that transparent."

The EMA approved the use of the AstraZeneca vaccine in January, almost a month after the UK. After reviewing the data, the EMA said the vaccine was only 60% effective, lower than AstraZeneca's initial analysis.

'Quasi-ineffective'

As the approval process continued, the confusion was magnified.

The UK and several other countries had approved the vaccine in all people over 18 and were already giving it out.

But nearly half of the EU member states, including Germany, France, Italy, and Belgium, decided there wasn't enough data to approve it for older populations.

As the peak of the EU-AstraZeneca fight over delivery amounts, French President Emmanuel Macron commented that the vaccine seemed "quasi-ineffective" in older people, a comment that earned him widespread condemnation and which he later walked back.

But the impression was crystallizing that the vaccine was to be avoided. Adding to the confusion was a story in the prestigious German newspaper Handelsblatt claiming that the German government believed the shot was only 8% effective in people over 65.

The next day, German Health Minister Jens Spahn's office said the 8% figure had no basis in fact and appeared to be an embarrassing error.

But another blow had been struck - and the approvals for older patients were still withheld.

Real-world data and a European U-turn

While all this was happening, the European public was watching.

A few reports of strong flu-like side effects after administration of the vaccine to health workers started coming out of Europe, further pushing mistrust in the vaccine.

The AstraZeneca vaccine received another blow when, on February 7, a trial in South Africa was halted because the vaccine was found not to provide full protection against mild disease. A variant of the virus first identified in that country - and a cause for concern around the world - was on the rise.

But on February 10, a WHO panel of experts recommended the use of the vaccine, even in places where variants were circulating.

Since then, early real-world data coming out of Scotland has started to vindicate the vaccine. The data suggests that while the AstraZeneca vaccine may not always protect against milder forms of the disease, it significantly reduced recipients' risk of hospitalization.

Importantly, it also suggested the AstraZeneca vaccine performed more or less as well in Scotland as the one developed by Pfizer and BioNTech.

"The AstraZeneca vaccine may not be as good as Pfizer at stopping asymptomatic infection, but it seems to be every bit as good at the moment at stopping severe infection," Hunter, the professor of medicine, told Insider.

"You know, I don't give a damn if I get mild COVID-19 - I just don't want to go into hospital.

"If people are delaying using it, then people will undoubtedly be dying who would have not have died if they hadn't been so fussy."

In light of this new data, European leaders are reversing course.

On Monday, France's health minister, Olivier Véran, confirmed that France would give the AstraZeneca shot after all to those ages 65 to 74.

Germany and Belgium are also rethinking their policy and may distribute it more widely.

EU leader are also strongly pushing messages to encourage vaccine uptake.

For Larson, regaining people's trust is paramount. "The truth is that if the trust is there, people will put up with some risk," Larson told Insider. "But clearly, there's not a lot of trust going around in some areas."

Dr. Catherine Schuster-Bruce contributed reporting for this article.

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