Legal Issues in COVID-19 Vaccine Development and Deployment

June 8, 2020 – November 25, 2020 R46399

Legal Issues in COVID-19 Vaccine Development November 25, 2020
and Deployment
Kevin J. Hickey
Private companies, universities, and governmental entities are working to develop a vaccine for
Legislative Attorney
coronavirus disease 2019 (COVID-19). Vaccines are biological products regulated under the

Public Health Service Act and the Federal Food, Drug, and Cosmetic Act (FD&C Act). New
Wen W. Shen
vaccines must generally be licensed by the U.S. Food & Drug Administration (FDA) before they
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can be marketed and used in the United States. To obtain licensure, the vaccine must be tested in

human subjects through clinical trials. The clinical trials inform the dosing schedule and labeling
that will be used for the approved vaccine. Sponsors use the data from clinical trials, along with
Erin H. Ward
other information, to prepare a biologics license application (BLA) to submit to FDA. FDA
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approves the BLA if it determines that the vaccine is safe, potent, and pure.

Because the development and review process can be lengthy, the FD&C Act provides several

avenues to accelerate this process for pharmaceutical products intended to treat or prevent serious
diseases or conditions. FDA may grant fast track product and breakthrough-therapy designation at the sponsor’s request for
products that are intended to fill an unmet need or improve existing therapies. Both designations entitle the sponsor to
increased communication with FDA and rolling review of the BLA. Products may also qualify for accelerated approval based
on intermediate or surrogate endpoints likely to predict a clinical benefit. FDA may also designate products for priority
review. Finally, in certain emergency situations, FDA may temporarily authorize the use of unapproved products or approved
products for unapproved uses through an emergency use authorization (EUA). For FDA to issue an EUA, the Secretary of
Health and Human Services (HHS) must determine that a qualifying emergency exists due to a biological, chemical, or
nuclear agent that can cause a serious or life-threatening disease. The Secretary must also determine that it is reasonable to
believe that the authorized product may treat or prevent the disease caused by the agent; the known and potential benefits
outweigh the known and potential risks; and there are no approved, adequate, and available alternatives. Products authorized
by an EUA may be marketed and used for the authorized use while the emergency persists unless FDA revokes the EUA.
FDA may also modify or waive good manufacturing practice and prescription requirements in an EUA.
FDA approval of a vaccine allows for its marketing, but does not guarantee that the vaccine will be widely available or
affordable. Because patents grant inventors a temporary monopoly on a patented invention, patents may influence access to
and the affordability of a COVID-19 vaccine. Federal agencies and funding support many of the COVID-19 vaccine
candidates in development, which may affect the allocation and scope of patent rights, depending on the form of federal
support and the terms of a vaccine developer’s contracts with the federal government. Under certain circumstances, the
federal government can also exercise several legal authorities if patent rights limit the affordability of or access to a COVID-
19 vaccine. For vaccines developed with federal support, the government may secure upfront guarantees on pricing or
distribution via funding or purchasing contracts with vaccine developers. For vaccines protected by patents subject to the
Bayh-Dole Act, the funding agency could invoke “march-in rights” to enable other producers to manufacture the vaccine. For
any U.S. patent, the federal government could use its “eminent domain” powers under 28 U.S.C. § 1498, which allows the
government to make and use patented inventions without license, if reasonable compensation is provided to the patent holder.
Even if widely available and affordable, a COVID-19 vaccine can only prevent outbreaks if enough members of a community
are vaccinated to achieve herd immunity. One legal tool for increasing vaccination rates is for the government to require it.
Courts have typically interpreted states’ general police power to promote public health and safety as encompassing the
authority to mandate vaccination. Congress’s authority to mandate vaccination, on the other hand, must emanate from its
enumerated powers in the Constitution. Two potential sources of such power, the Spending Clause and the Commerce
Clause, are subject to certain constraints that can limit the scope of a federal vaccination mandate.
Legal liability for injuries caused by a COVID-19 vaccine is likely to be subject to specialized rules under the Public
Readiness and Emergency Preparedness (PREP) Act. To encourage the expeditious development and deployment of medical
countermeasures, the Secretary of HHS declared COVID-19 a public health emergency and invoked the PREP Act for
COVID-19 countermeasures. Under HHS’s declaration, covered persons—including COVID-19 vaccine developers,
manufacturers, distributors, and health care professionals who administer a vaccine—are generally immune from legal
liability for losses relating to administration or use of an FDA-approved COVID-19 vaccine, except for willful misconduct
resulting in death or serious physical injury. However, individuals who are harmed by a COVID-19 vaccine may seek
compensation through the Countermeasures Injury Compensation Program, a regulatory process administered by HHS.
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Legal Issues in COVID-19 Vaccine Development

round the world, private companies, universities, and governmental entities are rapidly
working to develop a vaccine for coronavirus disease 2019 (COVID-19).1 In the United
A States, private industry and universities are developing and testing dozens of COVID-19
vaccine candidates,2 often in collaboration with federal agencies and/or supported by federal
funding. For example, the Biomedical Advanced Research and Development Authority
(BARDA), an agency within the U.S. Department of Health and Human Services (HHS), has
partnered with Janssen Pharmaceuticals (a Johnson & Johnson subsidiary), AstraZeneca, and
Sanofi to help develop and scale up manufacturing capacity for each company’s COVID-19
vaccine candidate.3 Together with the National Institute of Allergy and Infectious Diseases
(NIAID), BARDA is also collaborating with Moderna to support the development of its COVID-
19 vaccine candidate.4
In May 2020, the Trump Administration announced the creation of a program called Operation
Warp Speed, which seeks to use coordinated government support to accelerate the development,
manufacturing, and distribution of COVID-19 vaccines and other medical countermeasures.5
With respect to vaccines, the program initially selected fourteen promising candidates, which are
being narrowed down to “about seven.”6 Under Operation Warp Speed, the federal government is

1 See Draft Landscape of COVID-19 Candidate Vaccines, WORLD HEALTH ORG. (Aug. 25, 2020), https://www.who.int/
publications/m/item/draft-landscape-of-covid-19-candidate-vaccines (listing 173 COVID-19 vaccine candidates in
various stages of development worldwide); Jonathan Corum, Coronavirus Vaccine Tracker, N.Y. TIMES (Aug. 28,
2020), https://www.nytimes.com/interactive/2020/science/coronavirus-vaccine-tracker.html (tracking COVID-19
vaccines candidates in clinical trials); Jeff Craven, COVID-19 Vaccine Tracker, REG. AFF. PROFS. SOC’Y (Aug. 27,
2020), https://www.raps.org/news-and-articles/news-articles/2020/3/covid-19-vaccine-tracker (same); Aaron
Steckelberg, These Are the Top Coronavirus Vaccines to Watch, WASH. POST (Aug. 27, 2020) (tracking progress of
over 200 COVID-19 vaccine candidates in various stages of development).
2 See Tung Thanh Le et al., The COVID-19 Vaccine Development Landscape, NATURE REV. DRUG DISCOVERY (Apr. 9,
2020), https://www.nature.com/articles/d41573-020-00073-5 (breaking down COVID-19 vaccine candidates by
geographical location of lead developer).
3 BARDA is part of HHS’s Office of the Assistant Secretary for Preparedness and Response and was established to
support the development of medical countermeasures to deal with threats from chemical, biological, radiological, and
nuclear agents, pandemic influenza, and emerging infectious diseases through public-private partnerships. Biomedical
Advanced Research and Development Authority, U.S. DEP’T OF HEALTH & HUM. SERVS. (last updated July 22, 2020),
https://www.phe.gov/about/BARDA/Pages/default.aspx. See Press Release, U.S. Dep’t of Health & Hum. Servs.,
Trump Administration’s Operation Warp Speed Accelerates AstraZeneca COVID-19 Vaccine to be Available
Beginning in October (May 21, 2020), https://www.hhs.gov/about/news/2020/05/21/trump-administration-accelerates-
astrazeneca-covid-19-vaccine-to-be-available-beginning-in-october.html; Press Release, U.S. Dep’t of Health & Hum.
Servs., HHS Engages Sanofi’s Recombinant Technology for 2019 Novel Coronavirus Vaccine (Feb. 18, 2020),
https://www.hhs.gov/about/news/2020/02/18/hhs-engages-sanofis-recombinant-technology-for-2019-novel-
coronavirus-vaccine.html; Press Release, U.S. Dep’t of Health & Hum. Servs., HHS, Janssen Join Forces On
Coronavirus Vaccine (Feb. 11, 2020), https://www.hhs.gov/about/news/2020/02/11/hhs-janssen-join-forces-on-
coronavirus-vaccine.html.
4 See Press Release, U.S. Dep’t of Health & Hum. Servs., HHS Accelerates Clinical Trials, Prepares for Manufacturing
of COVID-19 Vaccines (Mar. 30, 2020), https://www.hhs.gov/about/news/2020/03/30/hhs-accelerates-clinical-trials-
prepares-manufacturing-covid-19-vaccines.html.
5 See Press Release, U.S. Dep’t of Health & Hum. Servs., Trump Administration Announces Framework and
Leadership for “Operation Warp Speed” (May 15, 2020), https://www.hhs.gov/about/news/2020/05/15/trump-
administration-announces-framework-and-leadership-for-operation-warp-speed.html.
6 See Press Release, U.S. Dep’t of Health & Hum. Servs., Fact Sheet: Explaining Operation Warp Speed (June 16,
2020), https://www.hhs.gov/about/news/2020/06/16/fact-sheet-explaining-operation-warp-speed.html. Previously, it
was reported that Operation Warp Speed selected five COVID-19 vaccine candidates as finalists. See Noah Weiland &
David E. Sanger, Trump Administration Selects Five Coronavirus Vaccine Candidates as Finalists, N.Y. TIMES (June
3, 2020), https://www.nytimes.com/2020/06/03/us/politics/coronavirus-vaccine-trump-moderna.html (identifying the
COVID-19 vaccines being developed by Moderna/NIAID, AstraZeneca/University of Oxford, Johnson & Johnson,
Merck, and Pfizer/BioNTech as the five finalists). BARDA’s COVID-19 countermeasures portfolio currently lists
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investing in scaling up manufacturing and distribution for selected COVID-19 vaccine candidates
“at risk” (that is, before safety and efficacy is demonstrated).7 Under the program, BARDA has
entered into agreements to accelerate the development and manufacturing—and to purchase
hundreds of millions of doses—for vaccine candidates being developed by AstraZeneca and the
University of Oxford,8 Sanofi and GlaxoSmithKline (GSK),9 Pfizer and BioNTech,10 Moderna
and NIAID,11 Novavax,12 and Johnson & Johnson.13 By November 2020, three of the
manufacturers participating in Operation Warp Speed—Pfizer/BioNTech, Moderna/NIAID, and
AstraZeneca/University of Oxford—announced encouraging safety and efficacy results from the
Phase 3 trials of their vaccines.14
This report overviews certain legal issues in COVID-19 vaccine development, testing, licensing,
production, and administration, focusing on four areas: (1) vaccine testing, authorization, and
licensure by the U.S. Food and Drug Administration (FDA); (2) patent and other intellectual
property (IP) rights that may protect a COVID-19 vaccine; (3) state and federal authority to
mandate vaccination; and (4) liability and compensation issues for individuals harmed by the
testing or administration of a vaccine. First, this report explains the existing legal requirements
for clinical trials and FDA authorization or licensure of new vaccines, including different options

seven COVID-19 vaccines that the agency is supporting, which are being developed by (1) Pfizer/BioNTech;
(2) Novavax; (3) AstraZeneca/University of Oxford; (4) Sanofi/GlaxoSmithKline; (5) Moderna/NIAID; (6)
Merck/IAVI; and (7) Johnson & Johnson. See COVID-19 Medical Countermeasures Portfolio, BARDA,
https://medicalcountermeasures.gov/app/barda/coronavirus/COVID19.aspx?filter=vaccine (last accessed Sept. 3, 2020).
7 See Jennifer Jacobs & Drew Armstrong, Trump’s ‘Operation Warp Speed’ Aims to Rush Coronavirus Vaccine,
BLOOMBERG (Apr. 29, 2020), https://www.bloomberg.com/news/articles/2020-04-29/trump-s-operation-warp-speed-
aims-to-rush-coronavirus-vaccine.
8 Press Release, U.S. Dep’t of Health & Hum. Servs., Trump Administration’s Operation Warp Speed Accelerates
AstraZeneca COVID-19 Vaccine to be Available Beginning in October (May 21, 2020), https://www.hhs.gov/about/
news/2020/05/21/trump-administration-accelerates-astrazeneca-covid-19-vaccine-to-be-available-beginning-in-
october.html.
9 Press Release, U.S. Dep’t of Health & Hum. Servs., HHS, DOD Partner With Sanofi and GSK on Commercial-Scale
Manufacturing Demonstration Project to Produce Millions of COVID-19 Investigational Vaccine Doses (July 31,
2020), https://www.hhs.gov/about/news/2020/07/31/hhs-dod-partner-sanofi-gsk-commercial-scale-manufacturing-
demonstration-project-produce-millions-covid-19-investigational-vaccine-doses.html.
10 Press Release, U.S. Dep’t of Health & Hum. Servs., U.S. Government Engages Pfizer to Produce Millions of Doses
of COVID-19 Vaccine (July 22, 2020), https://www.hhs.gov/about/news/2020/07/22/us-government-engages-pfizer-
produce-millions-doses-covid-19-vaccine.html
11 Press Release, U.S. Dep’t of Health & Hum. Servs., Trump Administration Collaborates with Moderna to Produce
100 Million Doses of COVID-19 Investigational Vaccine (Aug. 11, 2020), https://www.hhs.gov/about/news/
2020/08/11/trump-administration-collaborates-with-moderna-produce-100-million-doses-covid-19-investigational-
vaccine.html.
12 Press Release, Biomedical Advanced Rrch. and Dev. Auth., HHS, DOD Collaborate with Novavax to Produce
Millions of COVID-19 Investigational Vaccine Doses in Commercial-scale Manufacturing Demonstration Project (July
7, 2020), https://www.medicalcountermeasures.gov/newsroom/2020/novavaxhhsdod/.
13 Press Release, U.S. Dep’t of Health & Hum. Servs., HHS, DOD Collaborate With Johnson & Johnson to Produce
Millions of COVID-19 Investigational Vaccine Doses (Aug. 5, 2020), https://www.hhs.gov/about/news/2020/08/05/
hhs-dod-collaborate-with-johnson-and-johnson-to-produce-millions-of-covid-19-investigational-vaccine-doses.html.
14 Press Release, AstraZeneca, AZD1222 Vaccine Met Primary Efficacy Endpoint in Preventing COVID-19 (Nov. 23,
2020), https://www.astrazeneca.com/media-centre/press-releases/2020/azd1222hlr.html; Press Release, Moderna,
Moderna’s COVID-19 Vaccine Candidate Meets its Primary Efficacy Endpoint in the First Interim Analysis of the
Phase 3 COVE Study (Nov. 16, 2020), https://investors.modernatx.com/news-releases/news-release-details/modernas-
covid-19-vaccine-candidate-meets-its-primary-efficacy; Press Release, Pfizer, Pfizer and BioNTech Announce Vaccine
Candidate Against COVID-19 Achieved Success in First Interim Analysis from Phase 3 Study (Nov. 9, 2020),
https://www.pfizer.com/news/press-release/press-release-detail/pfizer-and-biontech-announce-vaccine-candidate-
against.
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to accelerate those processes. Second, it analyzes who might own the patent rights in a potential
COVID-19 vaccine, and the federal government’s legal options should patent rights restrict the
vaccine’s affordability or availability. Third, it overviews the scope of the federal and state
governments’ authority to mandate vaccination. Fourth, it reviews the protections from legal
liability available to vaccine developers, manufacturers, administrators, and health care
professionals under the Public Readiness and Emergency Preparedness (PREP) Act.
FDA Law Considerations: Bringing a New Vaccine
to Market
Vaccines are intended to prevent diseases and generally work by introducing pathogens to the
human body (usually by injection) to trigger an immune response to the disease (i.e., producing
antibodies to the pathogen).15 Vaccines are biological products approved and regulated by FDA’s
Center for Biologics Evaluation and Research (CBER) under Section 351 of the Public Health
Service Act (PHSA).16 A biologic such as a vaccine generally cannot be introduced into
commerce unless FDA approves it.17 To be approved, FDA must determine that the vaccine is
safe, potent, and pure based on data from laboratory studies and clinical trials.18 This section
discusses the legal framework for developing, testing, and licensing (i.e., approving) new
vaccines under the PHSA and the Federal Food, Drug, and Cosmetic Act (FD&C Act), as well as
existing legal avenues that could expedite the process of bringing a new vaccine to market.
Clinical Trials of Investigational New Drugs
Sponsors use clinical trials to generate the data needed to obtain FDA approval to market their
products. Because clinical trials expose human subjects to unapproved pharmaceutical products,
they risk causing unanticipated serious adverse side effects in the participants. To manage these
risks, the FD&C Act and FDA regulations impose procedural requirements, such as advance and
ongoing scientific and ethical review, on clinical trials to help protect the participants by
minimizing risks, requiring informed consent, and ensuring that the studies collect the necessary
data to determine whether to approve the product.
Using Clinical Trials to Collect Substantial Evidence
Sponsors must submit “substantial evidence” to FDA that their products are safe and effective (or
safe, potent, and pure) to obtain FDA approval.19 Section 505(d) of the FD&C Act defines
substantial evidence to mean adequately and well-controlled investigations on the basis of which
qualified scientific experts could fairly and responsibly conclude that the product has the

15 Vaccines: The Basics, CTRS. FOR DISEASE CONTROL & PREVENTION, https://www.cdc.gov/vaccines/vpd/vpd-vac-
basics.html (last updated Mar. 14, 2012); Understanding How Vaccines Work, CTRS. FOR DISEASE CONTROL &
PREVENTION, https://www.cdc.gov/vaccines/hcp/conversations/understanding-vacc-work.html (last updated Aug. 17,
2018).
16 42 U.S.C. § 262; Vaccine Product Approval Process, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/vaccines-
blood-biologics/development-approval-process-cber/vaccine-product-approval-process (last updated Jan. 30, 2018)
[hereinafter FDA Vaccine Approval Process].
17 42 U.S.C. § 262(a)(1).
18 Id. § 262(a)(2); 21 C.F.R. § 601.2.
19 21 U.S.C. § 355(d).
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purported effect.20 FDA assesses both the quality and quantity of the data provided when
determining whether a product meets this standard.21
Quality refers to the strength of the evidence and the amount of certainty it provides as to the
product’s safety and effectiveness—that is, whether the investigation is “adequate” and “well-
controlled.”22 The quality of the evidence depends on how the clinical trial is designed and how
the study is conducted.23 Under FDA regulations, the design must allow for a valid comparison of
the product to a control, such as a placebo, an existing therapy, or no treatment.24 FDA also
evaluates whether the study’s method for selecting participants and assigning them to groups is
adequate to ensure that meaningful data are collected.25 The methodology must also include a
well-defined and reliable means of assessing the participants’ responses and explain the analytical
and statistical methods used to assess the results.26 Finally, sponsors must provide a clear
statement of the investigation’s objectives and take adequate measures to minimize bias in the
study.27 FDA may, however, waive any of these criteria for a specific investigation if the sponsor
can show the criteria are not reasonably applicable to the study and an alternative approach yields
substantial evidence of effectiveness.28 FDA guidance further clarifies how sponsors should select
their clinical trial design, endpoints, and statistical methods.29
As for quantity, FDA generally requires that sponsors complete two “adequate and well-
controlled clinical investigations” to meet the substantial evidence standard.30 FDA notes in its
guidance that completing two studies, particularly if they are designed and conducted differently,
reduces the likelihood of a design flaw, bias, or other issue or anomaly that could result in
erroneous conclusions.31 However, under the Food and Drug Modernization Act of 1997,32 FDA
may allow sponsors to rely on one large, multicenter, adequate, and well-controlled clinical
investigation supported by another form of additional data,33 such as data regarding the
effectiveness of other drugs in the same pharmacological class.34 In deciding whether to allow a
sponsor to rely on a single study, FDA states that it considers, among other factors, the
seriousness of the disease, whether there is an unmet medical need, and whether additional trials
would be ethical and practicable.35

20 Id.
21 U.S. FOOD & DRUG ADMIN., DEMONSTRATING SUBSTANTIAL EVIDENCE OF EFFECTIVENESS FOR HUMAN DRUG AND
BIOLOGICAL PRODUCTS: DRAFT GUIDANCE FOR INDUSTRY 3 (Dec. 2019), https://www.fda.gov/media/133660/download
[hereinafter DEMONSTRATING SUBSTANTIAL EVIDENCE].
22 Id. at 5.
23 21 C.F.R. § 314.126.
24 Id. § 314.126(b)(2).
25 Id. § 314.126(b)(3) & (4).
26 Id. § 314.126(b)(6) & (7).
27 Id. § 314.126(b)(1) & (5).
28 Id. § 314.126(c).
29 DEMONSTRATING SUBSTANTIAL EVIDENCE, supra note 21, at 5.
30 Id. at 8.
31 Id. at 9–10.
32 Pub. L. No. 105-115, § 115, 111 Stat. 2313 (1997).
33 21 U.S.C. § 355(d).
34 DEMONSTRATING SUBSTANTIAL EVIDENCE, supra note 21, at 12.
35 Id. at 10.
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Given the flexibility afforded sponsors in designing and conducting their clinical trials, FDA uses
written guidance and individual meetings to help sponsors ensure that their investigations will
generate the substantial evidence needed for approval.36 Sponsors that obtain fast track product or
breakthrough therapy designation for their products are entitled to additional assistance from and
communication with FDA staff to craft efficient and effective clinical trial designs.37
Submitting an Investigational New Drug Application to FDA
New drugs and biological products that are being tested in clinical trials are referred to as
investigational new drugs.38 Section 505(i) of the FD&C Act, Section 351(a)(3) of the PHSA, and
their implementing regulations allow investigational new drugs to be used for research before
they are approved.39 To conduct clinical trials of investigational new drugs, the company
developing the product (i.e., sponsor) must generally receive FDA approval for the investigation
and comply with regulatory requirements for human subjects research.40
Sponsors obtain FDA approval to test an investigational new drug on human subjects through an
investigational new drug application (IND).41 The IND gives FDA an opportunity to ensure the
study will protect the safety and rights of its human subjects and gather scientific data that
adequately show the product’s safety and effectiveness.42 The sponsor may begin its clinical trials
30 days after submitting an IND unless FDA notifies the sponsor that it is either (1) authorizing
the IND and the study can begin immediately or (2) imposing a clinical hold due to concerns
about the study.43 If FDA imposes a clinical hold, the study cannot begin (or resume, for ongoing
investigations) pending further notification.44
FDA regulations prescribe the information sponsors must include in an IND.45 The IND must
contain information about the product, such as the substance and formulation; existing data on
use in animals or humans if available; and anticipated risks and side effects.46 The IND must also
contain a general investigational plan, which explains why the sponsor is undertaking the study
and includes, among other things, the indications being studied, the sponsor’s approach to
evaluating the product, the kinds of clinical trials being conducted, the anticipated number of
participants, and any anticipated risks.47 Along with the general investigational plan, the IND
must include specific protocols for each clinical trial phase.48 The sponsor must also generally
certify that an institutional review board (IRB) will provide initial and continuing review of each

36 See, e.g., 21 C.F.R. § 312.47; DEMONSTRATING SUBSTANTIAL EVIDENCE, supra note 21.
37 See “Shortening the Development and Review Processes.”
38 21 C.F.R. § 312.3.
39 21 U.S.C. § 355(i); 42 U.S.C. § 262(a)(3); 21 C.F.R. § 312.2(a).
40 See generally 21 C.F.R. pts. 50, 56, & 312.
41 21 C.F.R. § 312.20; Investigational New Drug (IND) Application, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/
drugs/types-applications/investigational-new-drug-ind-application (last updated May 12, 2020).
42 21 C.F.R. § 312.22.
43 Id. §§ 312.40 & 312.42.
44 Id. § 312.42(a) & (e).
45 Id. § 312.23.
46 Id.
47 Id.
48 Id.
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study, including the proposed protocols and any subsequent changes to the study.49 FDA may,
however, waive any IRB requirements, including the requirement of IRB review itself.50
Institutional Review Board Review and Approval
An IRB is a group convened by an institution to review and approve biomedical research
involving humans.51 IRBs evaluate the initial clinical study design and protocols, along with any
changes implemented during the investigation, in an effort to ensure the rights and well-being of
the human subjects are protected.52 To that end, IRBs assess whether risks to the participants are
minimized and reasonable in relation to the anticipated benefits, both to the participants directly
and from the knowledge expected to be gained from the study.53 IRBs also aim to ensure that the
researchers will obtain adequate informed consent from all participants (unless an exemption
applies) and that selection of the participants will be equitable.54 IRBs may also require (as
appropriate) that the research plan provide for monitoring of the collected data to protect the
participants’ safety and privacy.55 To the extent the study may include participants from
populations that may be vulnerable to coercion or undue influence (e.g., children, prisoners),
IRBs must ensure that sufficient safeguards are in place to protect these populations in participant
selection and during the clinical trials.56
IRBs review clinical trial plans and protocols from various standpoints, including ensuring the
study complies with legal, ethical, and professional standards; is scientifically sound; and is free
from illicit discrimination. Accordingly, to ensure adequate and independent review, IRBs must
have at least five members from multiple backgrounds, including at least one member with a
scientific background and at least one with a nonscientific background.57 At least one member
must be independent from the institution running the clinical trials, and the IRB members cannot
have any financial or other conflicting interests in the project.58 IRB review must comply with
any other requirements relating to IRBs and human subject research found in Parts 50 and 56 of
Chapter 21 of the Code of Federal Regulation.
Clinical Trial Phases
Clinical trials for a new pharmaceutical product generally proceed in three phases, transitioning
from smaller trials focused on initial safety early on to larger trials assessing safety and
effectiveness to inform approval and labeling.59 The size, duration, and specific purpose of each
clinical trial phase varies from product to product depending on such factors as the type of
product (e.g., a vaccine, treatment, or preventative medication), how the product works, and the

49 Id.
50 Id. § 56.105(c).
51 Id. § 56.102(g).
52 Id.
53 Id. § 56.111(a)(1)–(2).
54 Id. § 56.111(a)(3)–(5).
55 Id. § 56.111(a)(6)–(7).
56 Id. § 56.111(b) & (c).
57 Id. § 56.107(a)–(c).
58 Id. § 56.107(d)–(e).
59 Id. § 312.21.
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relevant underlying patient population. However, as defined by FDA regulations, a clinical
investigation generally proceeds as follows:
 Phase 1 Trials. Phase 1 trials are the first time the product is introduced in
human subjects.60 These carefully controlled trials typically involve 20 to 80
patients or volunteer subjects, though the exact numbers may vary depending on
the product.61 Phase 1 trials generally assess how the product acts in the body and
evaluate initial safety (i.e., side effects).62 They may also be used to determine the
dosing levels to use in phase 2 (e.g., the maximum safe dose or what dose is
required to have an effect).63 Depending on the product, phase 1 trials may also
provide some initial indication as to whether the product may be effective.64 In
the case of vaccines specifically, phase 1 trials also assess their ability to provoke
an immune response in the body (i.e., immunogenicity).65
 Phase 2 Trials. Phase 2 trials continue to assess safety but also evaluate the
product’s effectiveness and common short-term side effects or other risks
associated with the product.66 Phase 2 trials are also used to determine the
optimal dose of the product.67 For vaccines, phase 2 assesses how much of the
vaccine to administer and on what dosing schedule (e.g., whether a boost is
needed to maximize its effectiveness or whether the vaccine must be
administered on a regular schedule to maintain immunity).68 As with phase 1
studies, phase 2 studies are carefully controlled.69 However, phase 2 involves a
larger (though still relatively limited) number of volunteer subjects—generally no
more than a few hundred participants.70
 Phase 3 Trials. Phase 3 trials involve an expanded number of participants—from
several hundred to thousands—and are used to assess the product’s safety and
effectiveness across a wide range of patient categories through controlled and
uncontrolled studies.71 These trials are intended to present a clearer picture of
expected risks and benefits under real-world conditions.72 The information
obtained from phase 3 trials also forms the basis for the product’s labeling.73
Sponsors must generally complete all three phases to obtain FDA approval unless they obtain
accelerated approval,74 in which case FDA requires postapproval trials to confirm the expected

60 Id. § 312.21(a).
61 Id.
62 Id.
63 Id.
64 Id.
65 FDA Vaccine Approval Process, supra note 16.
66 21 C.F.R. § 312.21(b).
67 See, e.g., Kert Viele & Jason T. Connor, Dose Finding Trials: Optimizing Phase 2 Data in the Drug Development
Process, 314 J. AM. MED. ASS’N 2294, 2294 (2015), https://jamanetwork.com/journals/jama/fullarticle/2473474.
68 FDA Vaccine Approval Process, supra note 16.
69 21 C.F.R. § 312.21(b).
70 Id.
71 Id. § 312.21(c).
72 Id.
73 Id.
74 Accelerated Approval, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/patients/fast-track-breakthrough-therapy-
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clinical benefit.75 FDA may also require, at its discretion, additional clinical trials after approval
(i.e., phase 4 trials) for any approved product to continue assessing the product’s safety and
effectiveness once on the market.76
Considerations for Congress
The current legal framework seeks to balance various competing interests, which may be
amplified in the current crisis. The FD&C Act and implementing regulations provide standards
and factors to consider but otherwise give FDA and IRBs discretion to evaluate investigational
plans and clinical trial protocols for investigational new drugs. FDA may also waive requirements
relating to IRB review and clinical trial design. To the extent Congress may seek to direct how
FDA and IRBs exercise that discretion with respect to any potential COVID-19 vaccine, Congress
could consider implementing legislation that provides more specific direction on how to approach
clinical trials either specifically for the current COVID-19 pandemic or in epidemic, pandemic, or
other emergency situations more generally. For example, courts have determined that Congress
can cabin FDA’s discretion by imposing mandatory (e.g., “shall”) rather than permissive (e.g.,
“may”) language in a statute.77
In light of the multiple companies involved in developing potential COVID-19 vaccines,
Congress could also consider facilitating the coordination of any clinical trials or appointing a
neutral scientific body to consider the ethical and scientific considerations and generate
guidelines or a master protocol. The World Health Organization (WHO) employed this approach
to facilitate development of an Ebola vaccine following the 2014 to 2016 Ebola epidemic.78
Congress could also direct or fund increased global collaboration between regulators to promote
information sharing, which could potentially result in more streamlined clinical investigations
with fewer participants being exposed to investigational vaccines.79 Congress could also consider
providing additional funding or other resources to facilitate the clinical trials themselves or any
research directed toward understanding the SARS-CoV-2 virus or COVID-19 disease to allow for
improved risk minimization in future clinical trials.
FDA Approval and Options for Bringing a New Vaccine to Market
Faster
If the clinical trials are successful, the sponsor may seek FDA approval to market its new vaccine.
FDA approves new vaccines through biologics license applications (BLAs) reviewed by CBER.80

accelerated-approval-priority-review/accelerated-approval (last updated Jan. 4, 2018).
75 DEMONSTRATING SUBSTANTIAL EVIDENCE, supra note 21, at 2.
76 21 C.F.R. § 312.85.
77 See, e.g., Cook v. FDA, 733 F.3d 1, 8 (D.C. Cir. 2013).
78 WORLD HEALTH ORG., WHO R&D BLUEPRINT – AD-HOC WORKSHOP ON EBOLA VACCINES: DELIBERATIONS ON
DESIGN OPTIONS FOR CLINICAL TRIALS TO ASSESS THE SAFETY AND EFFICACY OF INVESTIGATIONAL EBOLA VACCINES
(Jan. 23, 2019), https://www.who.int/docs/default-source/blue-print/ebola-vaccine-meeting-
report.pdf?sfvrsn=9dd492f4_2.
79 See, e.g., Summary of FDA & EMA Global Regulators Meeting on Data Requirements Supporting First-in-Human
Clinical Trials with SARS-CoV-2 Vaccines, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/news-events/fda-
meetings-conferences-and-workshops/summary-fda-ema-global-regulators-meeting-data-requirements-supporting-first-
human-clinical-trials (last updated Mar. 18, 2020).
80 21 U.S.C. § 262(a); FDA Vaccine Approval Process, supra note 16. For additional information about the biologics
licensing process, see CRS Report R45666, Drug Pricing and Intellectual Property Law: A Legal Overview for the
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BLAs contain data from the laboratory and clinical studies and information about how and where
the biologic will be manufactured.81 As courts have recognized, FDA exercises its scientific
judgment when deciding whether to license vaccines based on such studies.82 Biologics that are
approved through a BLA receive 12 years of regulatory exclusivity, during which time FDA
cannot approve any biosimilars (i.e., abbreviated applications for the same biologic that depend
on the clinical data in the BLA to demonstrate safety, potency, and purity).83
The process of developing and testing a new vaccine to the point where it meets the safety, purity,
and potency standard can be a lengthy process. The FD&C Act provides several options that may
allow a sponsor to bring a new vaccine to market faster.84 Generally, these options use one of two
approaches. First, FDA can direct more of its resources to the product to accelerate the
development and/or review processes (e.g., fast track product designation, breakthrough therapy
designation, and priority review). Second, FDA can modify how it evaluates the risks and benefits
of the vaccine before allowing its use, either by relying on different types of evidence (e.g., the
accelerated approval process) or lowering the evidentiary standard in emergency situations (e.g.,
an EUA). (For ease of reference, this section uses the general term “biologic” because vaccines
are biological products, but the pathways discussed below are also available for traditional small
molecule drugs.)
Shortening the Development and Review Processes
Several avenues are available for expediting the development and review processes for biologics
used to treat or prevent serious or life-threatening conditions and diseases. In its guidance, FDA
generally considers a condition or disease serious if it substantially affects day-to-day functioning
and is irreversible, persistent, or recurrent.85 A condition or disease may be found to be serious as
a matter of clinical judgment based on its effect on survival, day-to-day functioning, or the
likelihood that it will progress to a more serious condition if left untreated.86 As a matter of
course, FDA considers any life-threatening condition or disease to be serious.87 The drug must
also be intended to treat the serious condition or disease by having an effect on the disease itself
or a serious aspect of the disease, such as a symptom or other manifestation.88 Among the
examples FDA provides in its guidance is a product intended to prevent the serious condition.89
Given that COVID-19 is life threatening, a vaccine intended to prevent COVID-19 seems likely
to qualify as a drug used to treat or prevent a serious or life-threatening condition or disease—
making it eligible for the following designations to accelerate the approval process.

116th Congress, coordinated by Kevin J. Hickey, at 17–27.
81 21 C.F.R. § 601.2.
82 Rempfer v. Sharfstein, 583 F.3d 860, 868 (D.C. Cir. 2009).
83 21 U.S.C. § 262(k)(7)(A).
84 See generally 21 U.S.C. § 356.
85 U.S. FOOD & DRUG ADMIN., GUIDANCE FOR INDUSTRY: EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS – DRUGS AND
BIOLOGICS 2–3 (2014), https://www.fda.gov/media/86377/download [hereinafter EXPEDITED PROGRAMS FOR SERIOUS
CONDITIONS: FDA GUIDANCE].
86 21 C.F.R. § 312.300(b)(1).
87 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 3.
88 Id.
89 Id.
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Fast Track Product Designation
Section 506 of the FD&C Act allows FDA to designate certain biologics as fast track products,
which receive FDA assistance in expediting development and review.90 A biologic may be
designated as a fast track product if FDA determines that the biologic will treat or prevent a
serious or life-threatening disease or condition and fill an unmet medical need.91 An unmet
medical need exists when available therapies do not adequately address treating or diagnosing a
condition or disease.92 FDA recognizes in its guidance that an unmet medical need necessarily
exists if there is no available therapy.93 Sponsors may provide FDA with nonclinical or clinical
data to demonstrate that the drug has the potential to fill that unmet medical need.94 Given that
there are no approved vaccines for COVID-19, any vaccine that showed potential to prevent
COVID-19 in laboratory or clinical trials would seem likely to qualify for fast track designation.
On May 12, 2020, FDA designated Moderna’s COVID-19 vaccine as a fast track product after it
completed its Phase 1 trials.95
At its discretion, the biologic’s sponsor requests fast track designation for its product.96 It may
request fast track designation when it submits an IND or any time thereafter.97 FDA has 60 days
to determine if the biologic qualifies for the designation.98 Once FDA designates a biologic as a
fast track product, FDA must facilitate its development and expedite review of the biologic.99 In
practice, this process generally means that the biologic’s sponsor has greater access to FDA
through written and in-person communications during the development and testing process to
improve efficiency and ensure that appropriate data are collected.100 FDA may also review the
BLA for a fast track product on a rolling basis as sections are complete (rather than waiting for a
completed application) if initial clinical testing shows the biologic may be effective.101
Breakthrough Therapy Designation
Section 506 of the FD&C Act also allows FDA to designate certain biologics as breakthrough
therapies, which similarly heightens FDA involvement in the development and review process.102
Breakthrough therapy designation is based on preliminary clinical evidence showing the biologic
may be a substantial improvement over available therapies for one or more clinically significant

90 21 U.S.C. § 356(b).
91 Id.
92 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 4.
93 Id. at 5.
94 Id. at 9.
95 Press Release, Moderna, Moderna Receives FDA Fast Track Designation for mRNA Vaccine (mRNA-1273) Against
Novel Coronavirus (May 12, 2020), https://investors.modernatx.com/news-releases/news-release-details/moderna-
receives-fda-fast-track-designation-mrna-vaccine-mrna.
96 21 U.S.C. § 356(b)(2).
97 Id.
98 Id. § 356(b)(3).
99 Id.
100 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 9; Fast Track, U.S. FOOD &
DRUG ADMIN. (Jan. 4, 2018), https://www.fda.gov/patients/fast-track-breakthrough-therapy-accelerated-approval-
priority-review/fast-track.
101 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 10; Fast Track, U.S. Food &
Drug Admin., supra note 100.
102 21 U.S.C. § 356(a).
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endpoints.103 Endpoints measure the outcome of a clinical trial.104 Under FDA guidance, a
clinically significant endpoint generally measures an effect on irreversible morbidity or mortality
or on symptoms representing serious consequences of the disease or condition.105 Unlike fast
track product designation, which can be based on laboratory data, breakthrough therapy
designation requires evidence from clinical trials.106 FDA exercises its judgment in determining
whether the data show a substantial improvement over existing therapies, taking into
consideration both the magnitude of the biologic’s effects on the endpoint and the importance of
the effect measured by that endpoint to treating the disease or condition.107 When there are no
existing therapies, such as with a COVID-19 vaccine, FDA compares the biologic to a placebo or
well-documented historical control.108 A COVID-19 vaccine may be eligible for breakthrough
therapy designation if the sponsor can demonstrate potential effectiveness in early clinical trials.
At its discretion, the sponsor requests breakthrough therapy designation and may do so with
submission of an IND or at any time thereafter.109 FDA must determine whether the biologic
qualifies as a breakthrough therapy within 60 days of receipt.110 As with fast track product
designation, the FD&C Act directs FDA to expedite the development and review of applications
for breakthrough therapies.111 Per FDA guidance, expedited development and review of
breakthrough therapies entails (1) intensive assistance from FDA on efficient development and
clinical trial design; (2) organizational commitment from FDA, including senior management and
experienced staff; (3) rolling review of the BLA; and (4) other actions to expedite review, such as
priority review discussed below.112 Extensive FDA assistance during the development process and
the involvement of senior managers distinguishes breakthrough therapy designation from fast
track product designation.
Accelerated Approval
Section 506 of the FD&C Act also allows FDA to approve certain biologics based on surrogate or
intermediate endpoints, referred to as accelerated approval.113 In general, sponsors select
endpoints that directly measure the clinical outcome (i.e., the benefits expected from the
biologic), such as whether the patient feels better or lives longer.114 Surrogate and intermediate
endpoints do not measure the clinical benefit directly but instead measure an effect that is

103 Id. § 356(a)(1).
104 Surrogate Endpoint Resources for Drug and Biologic Development, U.S. FOOD & DRUG ADMIN.,
https://www.fda.gov/drugs/development-resources/surrogate-endpoint-resources-drug-and-biologic-development (la
updated July 24, 2018).
105 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 12.
106 Id. at 11–12; compare 21 U.S.C. § 356(a)(1), with id. § 356(b)(1).
107 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 12.
108 Id.
109 21 U.S.C. § 356(a)(2).
110 Id. § 356(a)(3)(A).
111 Id. § 356(a)(3)(B).
112 EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 13–15.
113 21 U.S.C. § 356(c); see also Accelerated Approval, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/patients/fast-
track-breakthrough-therapy-accelerated-approval-priority-review/accelerated-approval (updated Jan. 4, 2018).
114 See Surrogate Endpoint Resources for Drug and Biologic Development, U.S. FOOD & DRUG ADMIN.,
https://www.fda.gov/drugs/development-resources/surrogate-endpoint-resources-drug-and-biologic-development (last
updated July 24, 2018).
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expected to predict a clinical benefit.115 For example, a drug to treat strokes would have an
intended clinical outcome of reducing the incidence or severity of strokes.116 But rather than
measuring the incidence of strokes directly, an investigator might measure the drug’s effect on
blood pressure as a surrogate endpoint due to the strong correlation between strokes and blood
pressure.117
To qualify for accelerated approval, (1) the biologic must treat a serious or life-threatening
condition or disease and (2) FDA must determine that the biologic has an effect on a surrogate or
intermediate endpoint that is reasonably likely to predict a clinical benefit. When deciding
whether to approve a biologic on this basis, FDA must consider how severe, rare, or prevalent the
condition is and the availability of alternative treatments. A vaccine for COVID-19 could qualify
for accelerated approval if investigators identified a surrogate or intermediate endpoint that could
reasonably predict the vaccine would be effective against the virus.
Priority Review
Once a BLA is submitted, FDA can designate the BLA for standard review or priority review.118
FDA aims to act on priority review applications within 6 months, compared to 10 months or more
for standard review applications.119 FDA makes this determination for every application, though a
sponsor can expressly request priority review.120 FDA may designate a BLA for priority review if
it represents a “significant improvement” over existing treatments in terms of safety or
effectiveness in treating, diagnosing, or preventing the disease or condition.121 In the absence of
any approved vaccine for COVID-19, FDA would likely designate for priority review any BLA
for such a vaccine.
Emergency Use Authorizations Before Approval
In certain emergency situations, Section 564 of the FD&C Act allows FDA to authorize the use of
a drug or biologic (e.g., a vaccine) before it is approved (i.e., an Emergency Use Authorization or
EUA).122 FDA may issue an EUA only if the HHS Secretary has declared that circumstances exist
justifying emergency authorized use of the medical product.123 Of relevance to the COVID-19
pandemic, on February 4, 2020, the Secretary determined that there is a public health emergency
that has a significant potential to affect national security or the health and security of U.S. citizens
living abroad, and that involves a biological, chemical, radiological, or nuclear agent (BCRN
agent)—namely, the virus that causes COVID-19.124 Based on this determination, the Secretary

115 Id.
116 Id.
117 Id.
118 Prescription Drug User Fee Act of 1992, Pub. L. No. 102-571, 106 Stat. 4491 (1992); Priority Review, U.S. FOOD &
DRUG ADMIN., https://www.fda.gov/patients/fast-track-breakthrough-therapy-accelerated-approval-priority-
review/priority-review. (last updated Jan. 4, 2018) [hereinafter Priority Review].
119 Priority Review, supra note 118; EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at
24–25.
120 Priority Review, supra note 118.
121 Id.; EXPEDITED PROGRAMS FOR SERIOUS CONDITIONS: FDA GUIDANCE, supra note 85, at 24–25.
122 21 U.S.C. § 360bbb-3; see also Emergency Use Authorization, U.S. FOOD & DRUG ADMIN., https://www.fda.gov/
emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-framework/emergency-use-
authorization#2019-ncov (last updated May 22, 2020) [hereinafter Emergency Use Authorization].
123 See 21 U.S.C. § 360bbb-3(b).
124 Alex M. Azar II, Sec’y of the Dep’t of Health & Human Servs., Determination of a Public Health Emergency and
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has authorized the emergency use of several diagnostic tests.125 On March 2, 2020, the Secretary
determined that circumstances exist to allow for the emergency use of certain respirators not
approved by the agency,126 and FDA issued an EUA allowing for the emergency use of such
respirators.127
After the Secretary determines a public health emergency exists (one of four bases for declaring
an emergency or threat), FDA may issue an EUA for a specific product if the Secretary concludes
that
1. the BCRN agent can cause a serious or life-threatening disease or condition;
2. it is reasonable to believe, based on the totality of the scientific evidence available, that
a. the product may be effective in diagnosing, treating, or preventing the disease or
condition caused by the BCRN agent; and
b. the known and potential benefits of the product outweigh the known and potential
risks; and
3. there is no adequate, approved, and available alternative to the product.128
In evaluating a product for an EUA, FDA uses a lower evidentiary standard, determining whether
the product “may be effective” in diagnosing, treating, or preventing a disease rather than
evaluating its “effectiveness” in doing so.129 As discussed above, COVID-19 is a serious or life-
threatening disease, confirmed by the fact that FDA has already issued EUAs in connection with
COVID-19 for diagnostic tests and certain personal protective equipment.130 There is also no
alternative to a COVID-19 vaccine at this time.131 Any decision by FDA to issue an EUA for a
COVID-19 vaccine would accordingly depend on whether the totality of the evidence available to
FDA shows that it is reasonable to believe that (1) the vaccine may be effective in preventing
COVID-19 and (2) those benefits outweigh any known or potential risks from the vaccine. FDA
would have to conduct this evaluation for each vaccine that is developed and submitted for an
EUA.
The FD&C Act requires FDA to impose certain conditions on EUAs as necessary and appropriate
to protect the public health.132 The conditions vary depending on whether the product is
unapproved or approved but for a different use.133 In general, the conditions provide for

Declaration that Circumstances Exist Justifying Authorizations Pursuant to Section 564(b) of the Federal Food, Drug,
and Cosmetic Act, 21 U.S.C. § 360bbb-3 (Feb. 4, 2020), https://www.fda.gov/media/135010/download.
125 See Emergency Use Authorization, supra note 122.
126 Alex M. Azar II, Sec’y of the Dep’t of Health & Human Servs., Declaration that Circumstances Exist Justifying
Authorizations Pursuant to Section 564(b) of the Federal Food, Drug, and Cosmetic Act, 21 U.S.C. § 360bbb-3 (Mar. 2,
2020), https://www.fda.gov/media/135787/download.
127 Letter from Denise M. Hinton, Chief Scientist, U.S. Food & Drug Admin., to Dr. Redfield, Dir., Ctrs. for Disease
Control & Prevention (Mar. 28, 2020), https://www.fda.gov/media/135763/download.
128 21 U.S.C. § 360bbb-3(c).
129 U.S. FOOD & DRUG ADMIN., EMERGENCY USE AUTHORIZATION OF MEDICAL PRODUCTS AND RELATED AUTHORITIES:
GUIDANCE FOR INDUSTRY AND OTHER STAKEHOLDERS 12 (Jan. 2017), https://www.fda.gov/media/97321/download.
130 Emergency Use Authorization, supra note 122.
131 Press Release, Nat’l Insts. of Health, NIH Clinical Trial of Investigational Vaccine for COVID-19 Begins (Mar. 16,
2020), https://www.nih.gov/news-events/news-releases/nih-clinical-trial-investigational-vaccine-covid-19-begins;
WHO Draft Landscape of COVID-19 Candidate Vaccines, supra note 1.
132 21 U.S.C. § 360bbb-3(e).
133 Id. § 360bbb-3(e)(1) & (2).
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monitoring, reporting, and recordkeeping as well as ensuring that the health care professionals
administering the product and the individuals being treated with the product are informed about
the benefits and risks of using the product.134 FDA may also waive good manufacturing practices
and certain prescription requirements when issuing an EUA and may impose conditions related to
advertising the product.135
Considerations for Congress
The current legal regime for approving new pharmaceutical products such as vaccines generally
aims to strike a balance between bringing products to market sooner and ensuring that products
on the market are safe and effective. For serious or life-threatening diseases and conditions or in
emergency situations, the law gives FDA a certain amount of discretion to shift that balance. FDA
generally expedites the process one of two ways: shifting its resources or shifting its standard in
evaluating the risks and benefits.
In considering avenues to facilitate the development of a COVID-19 vaccine, Congress has
similar options. Congress could consider providing additional resources to FDA to exercise its
existing authorities. Congress is already employing this approach: The Coronavirus Preparedness
and Response Supplemental Appropriations Act, 2020, enacted on March 6, appropriated $61
million to FDA “to prevent, prepare for, and respond to coronavirus, domestically or
internationally, including the development of necessary medical countermeasures and vaccines,
advanced manufacturing for medical products, the monitoring of medical product supply chains,
and related administrative activities.”136 Alternatively, Congress could direct FDA to strike a
different balance when evaluating the risks versus the benefits specifically in the context of
potential COVID-19 vaccines. In assessing that balance, Congress and FDA would face weighing
the benefits from disseminating a vaccine to the public sooner (e.g., limiting the spread of the
virus or reducing the economic consequences) against the risk that the vaccine may have been
authorized prematurely and prove ineffective or unsafe, potentially leading to worse public health
outcomes. Any alteration to this balance that requires FDA to exceed or contradict its existing
authority would require an act of Congress to amend the agency’s statutory authority.
Should FDA authorize or approve a COVID-19 vaccine, other considerations may come to bear.
For example, registered manufacturers may not be able to produce an adequate supply of the
vaccine. FDA is currently addressing hand sanitizer shortages by exercising its enforcement
discretion with respect to production by over-the-counter drug manufacturers and
compounders.137 Congress may consider other avenues for increasing supply of the vaccine. In

134 Id.
135 Id. § 360bbb-3(e)(3) & (4).
136 Pub. L. No. 116-123, 134 Stat. 146 (2020) (emphasis added).
137 Press Release, U.S. Food & Drug Admin., Coronavirus (COVID-19) Update: FDA Provides Guidance on
Production of Alcohol-Based Hand Sanitizer to Help Boost Supply, Protect Public Health (Mar. 20, 2020),
https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-provides-guidance-
production-alcohol-based-hand-sanitizer-help-boost; U.S. FOOD & DRUG ADMIN., TEMPORARY POLICY FOR
PREPARATION OF CERTAIN ALCOHOL-BASED HAND SANITIZER PRODUCTS DURING THE PUBLIC HEALTH EMERGENCY
(COVID-19): GUIDANCE FOR INDUSTRY, https://www.fda.gov/media/136289/download (updated June 1, 2020); U.S.
FOOD & DRUG ADMIN., POLICY FOR TEMPORARY COMPOUNDING OF CERTAIN ALCOHOL-BASED HAND SANITIZER
PRODUCTS DURING THE PUBLIC HEALTH EMERGENCY: IMMEDIATELY IN EFFECT GUIDANCE FOR INDUSTRY
https://www.fda.gov/media/136118/download (updated June 1, 2020).
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addition, existence of a vaccine would raise questions of mandatory vaccination to address the
public health crisis, which is addressed in a CRS Legal Sidebar.138
Patent Rights in COVID-19 Vaccines: Incentives,
Access, and Affordability
FDA authorization or licensure of a COVID-19 vaccine would permit the manufacturer to market
the vaccine, but does not guarantee that the vaccine will be widely available or affordable. A
significant factor that may influence COVID-19 vaccine affordability and accessibility is the
existence and allocation of IP rights in a vaccine, such as patent rights. While IP rights, such as
patent rights, may provide critical incentives for manufacturers to invest in the development of
COVID-19 vaccines,139 they may also significantly affect the accessibility and affordability of a
COVID-19 vaccine.140 If some element of a successful COVID-19 vaccine was patented, for
example, the patent holder would have the exclusive right to make and use that COVID-19
vaccine within the United States.141
Some Members of Congress have raised concerns about whether a COVID-19 vaccine and other
medical countermeasures, if shown to be safe and effective, will be affordable and accessible to
the public—especially if federal funds contribute to their development.142 Several of the
congressional responses to the COVID-19 pandemic contain provisions that relate to this issue.
Under the Coronavirus Aid, Relief, and Economic Security (CARES) Act, most private health
insurance plans must cover a COVID-19 vaccine and other COVID-19 preventative services
without cost sharing (e.g., deductibles or co-pays).143 Although individuals without health

138 CRS Legal Sidebar LSB10300, An Overview of State and Federal Authority to Impose Vaccination Requirements,
by Wen S. Shen.
139 See, e.g., Adam Mossoff, Gutting Patent Protections Won’t Cure COVID-19 , HUDSON INST. (May 23, 2020),
https://www.hudson.org/research/16069-gutting-patent-protections-won-t-cure-covid-19 (“Without [IP] protections,
there’d be little incentive for private companies and investors to dedicate hundreds of billions of dollars to the scientists
at the cutting edge of biomedical research.”); see generally Henry G. Grabowski et al., The Roles of Patents and
Research and Development Incentives in Biopharmaceutical Innovation, 34 HEALTH AFF. 302, 302 (2015) (“Patents
and other forms of intellectual property protection are generally thought to play essential roles in encouraging
innovation in biopharmaceuticals.”).
140 See, e.g., Médecins Sans Frontières/Doctors Without Borders, MSF Calls for No Patents or Profiteering on COVID-
19 Drugs, Tests, and Vaccines in Pandemic, MSF ACCESS CAMPAIGN (Mar. 27, 2020), https://msfaccess.org/msf-calls-
no-patents-or-profiteering-covid-19-drugs-tests-and-vaccines-pandemic (urging suspension of patent rights in COVID-
19 countermeasures to ensure affordability and access); Jennifer Hillman, Drugs and Vaccines Are Coming—But to
Whom?, FOREIGN AFF. (May 19, 2020), https://www.foreignaffairs.com/articles/world/2020-05-19/drugs-and-vaccines-
are-coming-whom (expressing concern that “intellectual property rights could prevent vaccines or drugs from reaching
the poor and vulnerable”); but see Daniel Hemel & Lisa Larrimore Ouellette, Pharmaceutical Profits and Public
Health Are Not Incompatible, N.Y. TIMES (Apr. 8, 2020) (arguing that encouraging COVID-19 countermeasure
development need not come at the cost of reducing patient access).
141 See 35 U.S.C. § 271(a).
142 See Ariel Cohen, Senators Worry About COVID-19 Vaccine Affordability, Distribution, INSIDE HEALTH POLICY
(May 14, 2020), https://insidehealthpolicy.com/daily-news/senators-worry-about-covid-19-vaccine-affordability-
distribution; Letter from Reps. James E. Clyburn & Carolyn Maloney to Sec. Alex M. Azar II (June 2, 2020),
https://oversight.house.gov/sites/democrats.oversight.house.gov/files/2020-06-
02.Clyburn%20CBM%20to%20HHS%20re%20Vaccine%20and%20Treatment%20Contracts.pdf; Letter from Rep.
Jan Schakowsky et al. to President Donald J. Trump (Feb. 20, 2020), https://freepdfhosting.com/20bf1d75af.pdf.
143 Pub. L. No. 116-136, § 3203 (2020). Most specifically, this requirement applies to COVID-19 vaccines
recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention and to group health plans and health insurance issuers offering group or individual health insurance as
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insurance generally fall outside of this mandate, the Trump Administration has promised that the
federal government will provide a COVID-19 vaccine for free to “any American who is
vulnerable, who cannot afford the vaccine[],”144 which would presumably include many such
individuals. Although these provisions may lessen concerns about the cost of a COVID-19
vaccine for patients, they do not directly address other pricing issues, such as the potential cost to
health care providers, health insurance companies, or the federal government.145
The Coronavirus Preparedness and Response Supplemental Appropriations Act (CPRSA)
contains two general provisions related to the affordability of COVID-19 countermeasures. First,
products purchased by the federal government using funds appropriated by CPRSA, including
vaccines, therapeutics, and diagnostics for COVID-19, “shall be purchased in accordance with
Federal Acquisition Regulation guidance on fair and reasonable pricing.”146 Second, CPRSA
states that the Secretary of HHS “may take such measures authorized under current law to ensure
that vaccines, therapeutics, and diagnostics developed from funds provided in [CPRSA] will be
affordable in the commercial market.”147 These provisions were repeated in the appropriations for
COVID-19 vaccines and other medical countermeasures in the CARES Act.148
This section reviews IP rights provisions under current law that the federal government could use
to try to ensure that COVID-19 countermeasures such as a vaccine are accessible and affordable.
After explaining the basics of the U.S. patent system as applied to a potential COVID-19 vaccine,
it analyzes the scope of two existing legal authorities—Bayh-Dole “march-in rights” and
governmental use under 28 U.S.C. § 1498—that the federal government could invoke should U.S.
patent rights inhibit the development, distribution, access, or affordability of a COVID-19
vaccine. Finally, it discusses potential legislative options should Congress conclude that these
existing authorities are insufficient.

defined by PHSA Section 2791. See id. § 3203(b)(1), (3). For an analysis of the current federal insurance coverage
requirements for COVID-19 testing, treatments, and vaccinations, see CRS Report R46359, COVID-19 and Private
Health Insurance Coverage: Frequently Asked Questions, by Vanessa C. Forsberg.
144 See Lev Facher, Trump Administration Pledges Future COVID-19 Vaccines Will Be Free for ‘Vulnerable’
Americans, STAT (June 16, 2020), https://www.statnews.com/2020/06/16/free-covid-19-vaccines-vulnerable-
americans/.
145 It is likely that the federal government will be a primary purchaser and distributor of a COVID-19 vaccine. The
federal government currently purchases over half of the pediatric vaccines administered in the United States (primarily
for children who are uninsured or eligible for Medicaid). See Christoph Diasio, Pediatric Vaccination: Who Bears The
Burden?, HEALTH AFF. (Feb. 6, 2016), https://www.healthaffairs.org/do/10.1377/hblog20160209.053058/full/; see
generally Vaccines for Children Program (VFC), CTRS. FOR DISEASE CONTROL & PREVENTION (Feb. 18, 2016),
https://www.cdc.gov/vaccines/programs/vfc/index.html; COMM. ON THE EVALUATION OF VACCINE PURCHASE FIN. IN THE
U.S., FINANCING VACCINES IN THE 21ST CENTURY: ASSURING ACCESS AND AVAILABILITY 4 (2003),
https://www.ncbi.nlm.nih.gov/books/NBK221813/pdf/Bookshelf_NBK221813.pdf.
During the 2009 to 2010 H1N1 influenza pandemic, the H1N1 vaccine and ancillary supplies (e.g., needles, syringes,
etc.) were purchased by the federal government and distributed to health care providers, who could charge only for the
administration of the vaccine. See Questions and Answers on 2009 H1N1 Vaccine Financing, CTRS. FOR DISEASE
CONTROL & PREVENTION (Nov. 30, 2009), https://www.cdc.gov/H1N1flu/vaccination/statelocal/vaccine_financing.htm.
146 Pub. L. No. 116-123, tit. III, 134 Stat. 146, 149 (2020).
147 Id.
148 See Pub. L. No. 116-136, tit. VIII (2020).
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Patent Basics
Under the Patent Act,149 any person who “invents or discovers any new and useful process,
machine, manufacture, or composition of matter” may apply for a patent on the invention with the
U.S. Patent and Trademark Office (PTO).150 PTO patent examiners evaluate the application to
ensure it meets all the applicable legal requirements to merit the grant of a patent.151 If the patent
examiner concludes that the claimed invention is new, nonobvious, useful, directed at patentable
subject matter, and adequately disclosed and claimed,152 PTO will issue the patent.153 If granted,
patents typically expire 20 years after the initial patent application is filed.154
Patents are available for almost every field of technology, including biotechnology, chemistry,
computer hardware, electrical engineering, mechanical engineering, and manufacturing
processes.155 In the pharmaceutical context, if an inventor is the first to synthesize a particular
chemical that is useful in treating disease, she may seek a patent claiming the chemical itself.156
That said, patents on a pharmaceutical’s active ingredient are only a subset of patents relating to
pharmaceuticals and other medical treatments.157 Particular drug formulations, methods of using
the pharmaceutical to treat a particular disease, methods and technologies to administer a
pharmaceutical, and methods and technologies to manufacture a pharmaceutical are all patentable
if they meet the Patent Act’s requirements.158
Under the Supreme Court’s long-standing interpretation of the Patent Act, “products of nature”
(such as isolated human DNA sequences) are not patentable.159 However, genetically engineered
organisms are patentable because they are not naturally occurring.160 Thus, while the antigen of a
vaccine may sometimes be patentable—as in the case of genetically modified viral vector—the
antigen of a vaccine using a naturally occurring form of a virus may not be patentable as such.
However, a vaccine developer would still be able to seek patents on methods of manufacturing
the vaccine, other vaccine components (such as adjuvants), and particular vaccine formulations,
among other things.161

149 See Patent Act of 1952, Pub. L. No. 82-593, 66 Stat. 792 (1952) (codified as amended at 35 U.S.C. §§ 1–390).
150 35 U.S.C. §§ 101, 111.
151 Id. § 131.
152 Id. §§ 101, 102–103, 112. For a summary of the requirements for patentability, see generally CRS Report R46525,
Patent Law: A Handbook for Congress, by Kevin T. Richards, at 8–16.
153 35 U.S.C. § 151, 153.
154 Id. § 154(a)(2).
155 See id. § 101; Patent Technology Centers Management, U.S. PATENT & TRADEMARK OFF., https://www.uspto.gov/
patent/contact-patents/patent-technology-centers-management (last visited May 29, 2020) (listing technological
divisions for PTO examiners). For a full discussion of the scope of patentable subject matter, see generally CRS Report
R45918, Patent-Eligible Subject Matter Reform in the 116th Congress, by Kevin J. Hickey.
156 See 35 U.S.C. § 101 (allowing patents on “any new and useful . . . composition of matter”).
157 See Amy Kapczynski et al., Polymorphs and Prodrugs and Salts (Oh My!): An Empirical Analysis of “Secondary”
Pharmaceutical Patents, 7 PLOS ONE 1, 4–6 (2012).
158 See Hickey et al., supra note 80, at 12–13.
159 See Ass’n for Molecular Pathology v. Myriad Genetics, Inc., 569 U.S. 576, 589–90 (2013). For a full discussion of
the judicially developed law of patent-eligible subject matter, including the product-of-nature exception, see generally
CRS Report R45918, Patent-Eligible Subject Matter Reform in the 116th Congress, by Kevin J. Hickey.
160 Diamond v. Chakrabarty, 447 U.S. 303, 309–10 (1980).
161 See Hickey et al., supra note 80, at 12–13.
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To encourage innovation, a valid patent holder has the exclusive right to make, use, sell, and
import (collectively, “practice”) the patented invention in the United States.162 Patents are thus
said to confer a “temporary monopoly” on the patent holder: anyone else who wishes to practice
the invention needs to obtain permission from the patent holder to do so (and, typically, pays for
that permission).163 In some situations, patent rights can confer substantial market power on
patent holders, enabling them to charge higher-than-competitive prices for the patented product,
as a monopolist would.164 Some empirical studies have found patent rights are among the most
important factors driving high prices for pharmaceutical products.165 At least to some extent,
higher prices are part of the patent system’s design, in that they enable inventors to recoup the
costs of research and development necessary to produce the invention in the first place.166 IP law
thus seeks to balance the importance of providing incentives to innovate against the costs that IP
rights impose on the public in the form of higher prices and reduced competition.167
Patent Rights in Inventions Made with Federal Assistance
Patent rights initially vest in the individual inventor or inventors, as a general rule.168 Commonly,
however, employees agree by contract to assign their patent rights to inventions made during the
course of their employment to their employer, who may seek a patent on an employee’s behalf.169

162 35 U.S.C. § 271(a). These actions are the core of direct patent infringement. There are also a variety of ways to
indirectly infringe a patent, such as actively inducing another person to infringe a patent or selling a component
especially made or especially adapted for an infringing use. See id. § 271(b)-(c), (f)-(g).
163 See, e.g., Festo Corp. v. Shoketsu Kinzoku Kogyo Kabushiki Co., 535 U.S. 722, 730 (2002) (characterizing patents
as a “temporary monopoly”). It should be noted that this usage of “monopoly” is somewhat imprecise, because the
exclusive rights provided by IP law do not necessarily confer monopolistic market power in the economic sense; for
example, there may be noninfringing substitutes for a patented good in the relevant market. See WILLIAM M. LANDES &
RICHARD A. POSNER, THE ECONOMIC STRUCTURE OF INTELLECTUAL PROPERTY LAW 22 (2003) (“[IP] protection creates a
monopoly, in the literal sense in which a person has a monopoly in the house he owns but [only] occasionally in a
meaningful economic sense as well because there may be no good substitutes for a particular intellectual work.”).
164 See FTC v. Actavis, Inc., 570 U.S. 136, 147 (2013) (“[Patent rights] may permit the patent owner to charge a higher-
than-competitive price for the patented product.”).
165 See, e.g., Aaron S. Kesselheim et al., The High Cost of Prescription Drugs in the United States: Origins and
Prospects for Reform, 316 JAMA: J. AM. MED. ASS’N 858, 861 (2016) (“The most important factor that allows
manufacturers to set high drug prices for brand-name drugs is market exclusivity, which arises from 2 forms of legal
protection against competition [i.e., patent rights and FDA regulatory exclusivities.]”); Generic Competition and Drug
Prices, FOOD & DRUG ADMIN. (Nov. 28, 2017), https://www.fda.gov/aboutfda/centersoffices/
officeofmedicalproductsandtobacco/cder/ucm129385.htm (finding association between generic competition and lower
drug prices).
166 See, e.g., Kewanee Oil Co. v. Bicron Corp., 416 U.S. 470, 480 (1974) (“The patent laws promote [the progress of
the useful arts] by offering a right of exclusion for a limited period as an incentive to inventors to risk the often
enormous costs in terms of time, research, and development.”); Emily Michiko Morris, The Myth of Generic
Pharmaceutical Competition under the Hatch-Waxman Act, 22 FORDHAM INTELL. PROP. MEDIA & ENT. L.J. 245, 252
(2012) (“[P]harmaceuticals are also widely recognized as one of the industries most dependent on patent protection to
recoup its enormous research, development, regulatory, and post-marketing costs . . . .”).
167 See Sony Corp. of Am. v. Universal City Studios, Inc., 464 U.S. 417, 429 (1984) (“[D]efining the scope of [patents
and copyrights] involves a difficult balance between the interests of authors and inventors in the control and
exploitation of their writings and discoveries on the one hand, and society’s competing interest in the free flow of ideas,
information, and commerce on the other hand . . . .”); Mark A. Lemley, Property, Intellectual Property, and Free
Riding, 83 TEX. L. REV. 1031, 1031 (2005) (“[Traditionally,] the proper goal of intellectual property law is to give as
little protection as possible consistent with encouraging innovation.”).
168 Bd. of Trustees of Leland Stanford Junior Univ. v. Roche Molecular Sys., Inc., 563 U.S. 776, 785 (2011) (“Our
precedents confirm the general rule that rights in an invention belong to the inventor.”); see 35 U.S.C. §§ 100(f), 101.
169 See Roche, 563 U.S. at 793 (noting “common practice” of assignment of patent rights in inventions from employees
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A number of the COVID-19 vaccine candidates currently in development are supported by
federal funding or other assistance, which can affect the allocation and scope of any resulting
patent rights. When private parties rely on federal assistance to develop an invention, any
resulting patent rights will typically be owned by either the U.S. government or the federal
contractor, depending on the nature of federal involvement.
For inventions made by federal employees during their official duties, the federal government
will typically obtain title to the patent.170 The federal government’s general policy for federally
owned inventions, under the Stevenson-Wydler Technology Innovation Act171 and the Federal
Technology Transfer Act of 1986,172 is to encourage their commercialization by licensing the
federally owned patent rights to private parties—a process called “technology transfer.”173 Under
technology transfer agreements, federal agencies grant private parties the exclusive or
nonexclusive right to practice the invention,174 while the U.S. government retains (1) a
“nontransferable, irrevocable, paid-up license . . . to practice the invention . . . by or on behalf of”
the United States (the “government-use license”);175 and (2) the power “to terminate the license in
whole or in part” based on grounds similar to the conditions for Bayh-Dole “march-in rights.”
As discussed in greater detail below,176 the Bayh-Dole Act of 1980 (Bayh-Dole),177 as amended,
applies to inventions that a federal contractor conceives or first reduces to practice during the
performance of a funding agreement with a federal agency.178 Under Bayh-Dole, the federal
contractor may elect to retain the patent rights for a federally funded invention.179 In exchange,
however, the contractor provides the federal agency with a government-use license,180 and the
United States retains the authority to grant compulsory licenses to third parties in certain
circumstances (“march-in rights”).181 Although Bayh-Dole, by its terms, only applies to federal
contractors that are nonprofit organizations or small businesses, long-standing executive practice
(codified by regulation) has applied Bayh-Dole to all federal contractors, regardless of size.182
Finally, federal laboratories and private parties may enter into cooperative research and
development agreements (CRADAs) in which both parties agree to provide services, facilities,

to their employer); 35 U.S.C. §§ 118, 152, 261.
170 See 37 C.F.R. § 501.6(a).
171 Pub. L. No. 96-480, 94 Stat. 2311 (1980).
172 Pub. L. No. 99-502, 100 Stat. 1785 (1986).
173 See 15 U.S.C. § 3710(a) (“The Federal Government shall strive where appropriate to transfer federally owned or
originated technology to State and local governments and to the private sector.”); 35 U.S.C. § 209 (conditions for
licensing of federally owned inventions).
174 35 U.S.C. § 209(a).
175 Id. § 209(d)(1).
176 Compare id. § 209(d)(3)(A)-(D) with 35 U.S.C. § 203(a)(1)-(4); see discussion infra in “March-In Rights Under the
Bayh-Dole Act (35 U.S.C. § 203).”
177 Act of Dec. 12, 1980 to Amend the Patent and Trademark Laws (Bayh-Dole Act), Pub. L. No, 96-517, § 6, 94 Stat.
3015, 3018–27 (1980) (codified as amended at 35 U.S.C. ch. 18).
178 See 35 U.S.C. §§ 201(b), (e).
179 Id. § 202(a).
180 Id. § 202(c)(4).
181 Id. § 203; see generally Hickey et al., supra note 80, at 17.
182 37 C.F.R. § 401.1(b) (Bayh-Dole regulations apply “to all funding agreements with business firms regardless of
size”); Exec. Order No. 12591, Facilitating Access to Science & Technology, 52 Fed. Reg. 13,414, 13,414 (Apr. 10,
1987) (granting “to all contractors, regardless of size, the title to patents made in whole or in part with Federal funds, in
exchange for royalty-free use by or on behalf of the government”).
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equipment, IP, or other resources, but the federal government does not provide federal funding to
the nonfederal party.183 In this situation, ownership of IP rights may depend on the terms of the
agreement. That said, the federal laboratory generally has the authority to license existing
federally owned IP to a private party as part of a CRADA, as well as to license or assign
inventions made in whole or part by a federal employee working under a CRADA.184 In return,
the federal government retains a government-use license185 and compulsory-licensing authority
similar to Bayh-Dole march-in rights.186
These general rules for patent ownership are subject to various exceptions and waivers,
depending on the agency and circumstances. For example, some agencies (including BARDA and
National Institutes of Health [NIH]) have the authority to enter into transactions that are not
contracts, grants, or cooperative agreements, known as “other transaction” authority.187 Other
transactions are exempt from many statutory provisions and procurement regulations, including
Bayh-Dole’s requirements.188
Thus, for other transactions, the allocation of IP rights between the government and private
contracting entities will depend on the agreement. For example, BARDA’s template for other
transactions includes contractual patent provisions much like those of Bayh-Dole, including
march-in rights provisions.189 These patent provisions are “fluid and negotiable,” however, and
may be different for particular transactions.190 Based on the limited number of publicly available
federal contracts for COVID-19 vaccines (most of which are other transactions), some contracts
retain federal march-in rights under Bayh-Dole, while others eliminate or restrict the grounds for
march-in rights.191

183 15 U.S.C. § 3710a(a)(1) (CRADA authority); id. § 3710a(d)(1) (CRADA definition).
184 See id. § 3710a(a)(2), (b)(1)–(2); 35 U.S.C. §§ 207, 209.
185 15 U.S.C. § 3710a(b)(1)(A), (2).
186 See id. § 3710a(b)(1)(C)(i)–(iii) (grounds for compulsory licensing of inventions “made in whole or in part by a
[federal] laboratory employee” under a CRADA). In the case of inventions “made solely by [the private collaborating
party’s] employee” in the course of a CRADA, the federal agency retains a government-use license, but need not
impose march-in rights. Compare id. § 3710a(b)(1), with id. § 3710a(b)(2).
187 42 U.S.C. § 247d-7e(c)(5) (granting Secretary of HHS authority to enter into other transactions for BARDA
projects); id. § 282(n) (granting director of NIH other transaction authority in certain contexts). Because NIAID is one
of NIH’s research institutes, see id. § 281(b)(6), this authority could apply to NIAID projects approved by the Director
of NIH. In the case of COVID-19 projects, NIH authority for use of other transactions when “urgently required to
respond to a public health threat” appears applicable. See id. § 282(n)(1)(C). For a general overview of other
transactions, see U.S. GOVERNMENT ACCOUNTABILITY OFF., USE OF ‘OTHER TRANSACTION’ AGREEMENTS LIMITED AND
MOSTLY FOR RESEARCH AND DEVELOPMENT ACTIVITIES 3–12 (2016), https://www.gao.gov/assets/680/674534.pdf
[hereinafter GAO OTA REPORT].
188 See GAO OTA REPORT, supra note 187, at 4–5; 35 U.S.C. § 201(b) (defining “funding agreements” subject to
Bayh-Dole to include “any contract, grant, or cooperative agreement”).
189 See Other Transaction for Advanced Research (OTAR) Template, BIOMEDICAL ADVANCED RSCH. & DEV. AUTH.,
https://www.phe.gov/about/amcg/otar/Documents/otar-consortium.pdf (last visited May 31, 2020), at 16–21
[hereinafter BARDA OTA Template]; see generally Other Transaction Agreements, BIOMEDICAL ADVANCED RSCH. &
DEV. AUTH., https://www.phe.gov/about/amcg/otar/Pages/default.aspx (last visited May 31, 2020).
190 BARDA OTAR Template, supra note 189, at 16.
191 See Kathryn Ardizzone & James Love, Other Transaction Agreements: Government Contracts that Eliminate
Protections for the Public on Pricing, Access and Competition, Including in Connection with COVID-19 Vaccines and
Treatments, KNOWLEDGE ECOLOGY INT’L 3–5, 36–42 (June 29, 2020), https://www.keionline.org/wp-content/
uploads/KEI-Briefing-OTA-29june2020.pdf.
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Governmental Compulsory Patent Licenses
As explained above, a patent holder generally has the exclusive right to make, use, sell, and
import an invention.192 Thus, any other person who wishes to practice that invention will
ordinarily need a license (i.e., permission) from the patent holder, or else be exposed to legal
liability. In certain cases, however, patents may be subject to a “compulsory license,” which
allows another person to practice the invention without the consent of the patent holder.193
Compulsory licenses require the sanction of a governmental entity and the payment of
compensation to the patent holder.194 Compulsory licenses differ from ordinary licenses in two
important respects. First, the person seeking to use the invention need not obtain permission from
the patent holder.195 Second, the compensation paid to the patent holder is determined by
operation of law, not by private contractual negotiations between the licensee and the patent
holder.196
March-In Rights Under the Bayh-Dole Act (35 U.S.C. § 203)
Although Bayh-Dole generally allows federal contractors to take title to patents on inventions
created with federal funding,197 the federal government retains the authority to “march in” and
grant compulsory licenses to third parties in some circumstances.198 Specifically, the federal
agency that provided the funding may require the federal contractor to grant a patent license to a
third party if the agency determines that either:
(1) action is necessary because the contractor or assignee has not taken, or is not expected
to take within a reasonable time, effective steps to achieve practical application of the
subject invention in such field of use;
(2) action is necessary to alleviate health or safety needs which are not reasonably satisfied
by the contractor, assignee, or their licensees;
(3) action is necessary to meet requirements for public use specified by federal regulations
and such requirements are not reasonably satisfied by the contractor, assignee, or licensees;
or
(4) action is necessary because the agreement [to prefer U.S. manufacturing of the
invention by the contractor’s exclusive licensees] has not been obtained or waived or
because a licensee of the exclusive right to use or sell any subject invention in the United
States is in breach of its agreement [to prefer U.S. manufacturing].199
A license granted under Bayh-Dole’s march-in provisions must be “upon terms that are
reasonable under the circumstances,”200 which may require that the licensee pay compensation to
the patent holder (i.e., the federal contractor or its assignee).201

192 35 U.S.C. § 271(a).
193 See generally Hickey et al., supra note 80, at 16–17.
194 Id. at 1.
195 See Hickey et al., supra note 80, at 16.
196 Id.
197 35 U.S.C. § 202(a)–(b).
198 Id. § 203.
199 Id. § 203(a)(1)–(4).
200 Id. § 202(a).
201 See id § 203(a); Jennifer Penman & Fran Quigley, Better Late than Never: How the U.S. Government Can and
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The federal government has never exercised march-in rights under Bayh-Dole.202 Advocacy
groups have petitioned NIH several times to exercise march-in rights based on the high prices of
certain drugs developed with federal funding, such as treatments for HIV/AIDS.203 NIH has
rejected these petitions, contending that pricing concerns alone are insufficient to exercise march-
in rights—so long as the invention is on the market and available to patients.204 In the context of a
pandemic like COVID-19, the “health or safety needs” language would appear to provide a
possible basis for the exercise of march-in rights, should the funding agency determine that
compulsory licensing is necessary to address public health needs unmet by a federal contractor.205
Governmental Use Rights (28 U.S.C. § 1498)
A broader statutory authority than march-in rights, 28 U.S.C. § 1498 (Section 1498), applies to
any patented invention—not just inventions made with federal funding.206 Under Section 1498,
sometimes described as an “eminent domain” provision for patents,207 the U.S. government has
the authority to use or manufacture any patented invention “without license.”208 In practice, this
means that if the U.S. government determines that it needs to practice an invention, it need not
ask permission from the patent holder to do so, and—despite the existence of the patent—courts
will not order the government to cease infringing activity.209 The patent holder, however, has the
right to sue in the U.S. Court of Federal Claims for “reasonable and entire compensation” for the
government’s use of the patented invention.210 In effect, then, Section 1498 allows the United
States to issue itself a compulsory license to make and use any patented invention without
obtaining permission from the patent holder, in exchange for consenting to liability in a suit
seeking reasonable compensation for the government’s use.211
In the context of COVID-19 vaccines, the U.S. government could rely on Section 1498 to make
and use any patented invention without the patent holder’s consent. Because Section 1498
extends to infringement “by a contractor, a subcontractor, or any person, firm, or corporation for
the [U.S.] Government and with the authorization or consent of the [U.S.] Government,”212 the

Should Use Bayh-Dole March-in Rights to Respond to the Medicines Access Crisis, 54 WILLAMETTE L. REV. 171, 178
(2017).
202 CRS Report R44597, March-In Rights Under the Bayh-Dole Act, at 8.
203 See id. at 8–10 (reviewing petitions to exercise march-in rights).
204 See, e.g., National Institutes of Health, Office of the Director, In the Case of Norvir Manufactured by Abbott
Laboratories, Inc. (July 29, 2004), https://www.ott.nih.gov/sites/default/files/documents/policy/March-In-Norvir.pdf, at
5–6.
205 35 U.S.C. § 203(a)(2). A federal contractor adversely affected by the exercise of march-in rights may challenge an
agency’s determination through an administrative process, see 37 C.F.R. § 401.6, and may appeal an adverse
determination through a petition in the U.S. Court of Federal Claims, see 35 U.S.C. § 203(b).
206 28 U.S.C. § 1498(a) (reaching “any invention described in and covered by a patent of the United States”). Section
1498 does not apply to patent rights granted by other nations.
207 See, e.g., Motorola, Inc. v. United States, 729 F.2d 765, 768 (Fed. Cir. 1984) (“The theoretical basis for [Section
1498] recovery is the doctrine of eminent domain.”).
208 28 U.S.C. § 1498(a).
209 Advanced Software Design Corp. v. Fed. Reserve Bank of St. Louis, 583 F.3d 1371, 1375 (Fed. Cir. 2009);
Motorola, 729 F.2d at 768 n.3.
210 28 U.S.C. § 1498(a); see generally Leesona Corp. v. United States, 599 F.2d 958, 966–69 (Ct. Cl. 1979).
211 See Amanda Mitchell, Tamiflu, the Takings Clause, and Compulsory Licenses: An Exploration of the Government’s
Options for Accessing Medical Patents, 95 CAL. L. REV. 535, 541–42 (2007) (analogizing Section 1498 to a
compulsory license).
212 28 U.S.C. § 1498(a).
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federal government could also extend its Section 1498 authority to the actions of private entities
by authorizing them to practice a patented invention on behalf of the government.
Targeted Legislation and the Takings Clause
U.S. patent rights were created by an act of Congress. Thus, should patent rights inhibit access to
or affordability of COVID-19 countermeasures such as a vaccine, and should Congress conclude
that existing legal authorities are insufficient, targeted legislation is a possible option. Although
the Constitution grants Congress the authority to create a patent system,213 it does not require
Congress to do so. Congress therefore has wide discretion in designing the patent system’s scope
and operation.214 Thus, Congress could consider, for example, excluding certain technologies
from patent protection, or creating broader systems for compulsory licensing.
As discussed below, there are both constitutional and treaty-based constraints on these
possibilities. Moreover, a critical policy consideration for Congress to evaluate is whether
limitations on patent rights would reduce incentives for industry to create and develop vaccines to
prevent COVID-19.215 Indeed, some argue that Congress should consider strengthening patent
protections in order to protect greater incentives to invest in COVID-19 countermeasure
development.216
In general, Congress may exclude certain technologies from patent protection, so long as the
legislation operates prospectively and consistent with U.S. international treaty obligations.217 For
example, a provision in the 2011 Leahy-Smith America Invents Act prohibits the PTO from
issuing a patent on inventions “directed to or encompassing a human organism.”218
When legislation operates retroactively to invalidate a patent or diminish patent rights, however,
it raises issues under the Takings Clause of the Fifth Amendment to the Constitution. The Takings
Clause states that if “private property [is] taken for public use” by the U.S. government, it must
provide “just compensation.”219 The Supreme Court has suggested several times that patents are
private property under the Takings Clause,220 although it has never held so explicitly. Presuming

213 U.S. CONST. art. I, § 8, cl. 8.
214 See, e.g., McClurg v. Kingsland, 42 U.S. 202, 206 (1843) (“[T]he powers of Congress to legislate upon the subject
of patents is plenary by the terms of the Constitution, and as there are no restraints on its exercise, there can be no
limitation of their right to modify them at their pleasure, so that they do not take away the rights of property in existing
patents.”). There are, of course, some limits on the power granted Congress in the IP Clause. See generally, e.g., Eldred
v. Ashcroft, 537 U.S. 186, 199–208 (2003); Graham v. John Deere Co. of Kan. City, 383 U.S. 1, 5–10 (1966).
215 See, e.g., Fred Reinhart, Exercising Bayh-Dole March-in Rights Would Handicap Covid-19 Innovation, STAT (May
4, 2020), https://www.statnews.com/2020/05/04/bayh-dole-march-in-rights-handicap-covid-19-innovation/; James
Edwards, We Won’t Stop Coronavirus Without IP, IPWATCHDOG (Mar. 10, 2020), https://www.ipwatchdog.com/2020/
03/10/wont-stop-coronavirus-without-ip/id=119735/.
216 See, e.g., Adam Mossoff, Patent Term Extensions Will Help Speed up Development of Coronavirus Drugs, WASH.
TIMES (Mar. 12, 2020).
217 See infra note 224 and accompanying text.
218 Pub. L. No, 112-29, § 33, 125 Stat. 284, 340 (2011).
219 U.S. CONST. amend. V.
220 Compare James v. Campbell, 104 U.S. 356, 357–58 (1881) (“[By issuing a patent, the United States] confers on the
patentee an exclusive property in the patented invention which cannot be appropriated or used by the government itself,
without just compensation . . . .”), with Oil States Energy Servs. v. Greene’s Energy Grp., 138 S. Ct. 1365, 1379 (2018)
(holding that the grant of a patent is matter of public rights, but stating that “our decision should not be misconstrued as
suggesting that patents are not property for purposes of the Due Process Clause or the Takings Clause”).
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that patents are private property under the Fifth Amendment,221 legislation that retroactively
impairs patent rights could give rise to a constitutional claim for just compensation.222
Recognizing this, Congress has often provided for compensation in past legislation that has
retroactively invalidated patents. For example, the Atomic Energy Act of 1954 “revoked” existing
patents on “any invention or discovery which is useful solely in the utilization of special nuclear
material or atomic energy in an atomic weapon,” while providing a process to provide just
compensation to any such patent holder.223
If Congress seeks to preclude the exercise of exclusive patent rights over COVID-19 vaccines, it
could pass legislation preventing the PTO from issuing such patents, or invalidating already
issued patents relating to countermeasures. In the latter case, some mechanism for compensation
to the patent holder might be required under the Takings Clause. In either case, such legislation
could raise issues under the United States’ treaty obligations, including the treaty on Trade-
Related Aspects of Intellectual Property Rights (TRIPS) of the Marrakesh Agreement establishing
the World Trade Organization (WTO), in which WTO members agree to make patents available
in “all fields of technology,” with some exceptions.224
State and Federal Authority to Mandate Vaccination
Even if widely available, a COVID-19 vaccine can only prevent outbreaks if a sufficient
percentage of a population is vaccinated to achieve herd immunity.225 Herd immunity occurs
when a high percentage of a community becomes immune to a disease (either through exposure
to the disease or a vaccine) to provide indirect protection to those who are not immune, thereby
protecting the whole community.226 The more contagious a disease, the higher the percentage of
the population must have immunity to achieve herd immunity.227 Based on early estimates of

221 Legal academics have debated this point. Compare Adam Mossoff, Patents as Constitutional Private Property: The
Historical Protection of Patents Under the Takings Clause, 87 B.U. L. REV. 689 (2007), with Davida H. Isaacs, Not All
Property Is Created Equal: Why Modern Courts Resist Applying the Takings Clause to Patents, and Why They Are
Right to Do So, 15 GEO. MASON L. REV. 1 (2007). Notably, in a recent Federal Circuit case, the PTO conceded that
patents were “private property” under the Takings Clause. See Celgene Corp. v. Peter, 931 F.3d 1342, 1358 (Fed. Cir.
2019), petition for cert. filed, No. 19-1074 (U.S. Feb. 26, 2020).
222 See, e.g., Celgene, 931 F.3d at 1358 (rejecting claim that retroactive application of inter partes review procedures is
an unconstitutional taking of patent rights). For analyses of potential Takings Clause claims as applied to patents, see
generally, e.g., Gregory Dolin & Irina D. Manta, Taking Patents, 73 WASH. & LEE L. REV. 719 (2016); Joshua I. Miller,
28 U.S.C. § 1498(a) and the Unconstitutional Taking of Patents, 13 YALE J.L. & TECH. 1 (2010); Christopher S. Storm,
Federal Patent Takings, 2 J. BUS. ENTREPRENEURSHIP & L. 1 (2008); Justin Torres, The Government Giveth, and the
Government Taketh Away: Patents, Takings, and 28 U.S.C. § 1498, 63 N.Y.U. ANN. SUR. AM. L. 315 (2007); Jesse S.
Chui, To What Extent Can Congress Change the Patent Right Without Effecting a Taking?, 34 HASTINGS CONST. L.Q.
447 (2007); Shubha Ghosh, Toward A Theory of Regulatory Takings for Intellectual Property: The Path Left Open
After College Savings v. Florida Prepaid, 37 SAN DIEGO L. REV. 637 (2000).
223 42 U.S.C. §§ 2181(a), 2187.
224 TRIPS: Agreement on Trade-Related Aspects of Intellectual Property Rights, Apr. 15, 1994, Marrakesh Agreement
Establishing the World Trade Organization, Annex 1C, 1869 U.N.T.S. 299 (1994), https://www.wto.org/english/
docs_e/legal_e/27-trips_01_e.htm, at art. 27. For analysis of how the limits of TRIPS might apply to exclusions from
patent protection or compulsory licensing in the COVID-19 pandemic, see CRS Legal Sidebar LSB10436, COVID-19:
International Trade and Access to Pharmaceutical Products, by Nina M. Hart.
225 Michelle M. Mello et al., Ensuring Uptake of Vaccines Against SARS-CoV-2, NEW ENGLAND J. MED. (June 26,
2020), https://www.nejm.org/doi/full/10.1056/NEJMp2020926.
226 See Herd Immunity and COVID-19 (Coronavirus): What You Need to Know, MAYO CLINIC (June 6, 2020),
https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808.
227 Id.
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COVID-19’s infectiousness, some experts have estimated that about 60% to 70% of the
population needs to be immune to prevent outbreaks.228 One early poll indicated that the
voluntary vaccination rate for a potential COVID-19 vaccine may be lower than necessary to
achieve herd immunity.229 While a discussion of the potential public health and policy tools to
increase vaccine uptake is beyond the scope of this report, one legal tool for increasing
vaccination rates is for the government to require it.
Under the United States’ federalist system, states and the federal government share regulatory
authority over public health matters, with states traditionally exercising the bulk of the authority
in this area pursuant to their general police power.230 This power authorizes states, within
constitutional limits, to enact laws “to provide for the public health, safety, and morals” of the
states’ inhabitants.231 In contrast to this general power, Congress’s power to legislate is confined
to those powers enumerated in the Constitution.232 This section provides an overview of state and
federal authority to mandate vaccination.
State and Local Authority to Mandate Vaccination
The states’ general police power to promote public health and safety encompasses authority to
mandate vaccination.233 In the early part of the 20th century, the Supreme Court twice considered
constitutional challenges to such mandates.234 Each time, the Court rejected the challenges and

228 See, e.g., What is Herd Immunity and How Can We Achieve It with COVID-19?, JOHNS HOPKINS BLOOMBERG SCH.
OF PUB. HEALTH (Apr. 10, 2020), https://www.jhsph.edu/covid-19/articles/achieving-herd-immunity-with-
covid19.html; COVID-19 Herd Immunity: 7 Questions, Answered, M.D. ANDERSON CTR. (July 17, 2020),
https://www.mdanderson.org/cancerwise/what-is-covid-19-coronavirus-herd-immunity-when-will-we-achieve-herd-
immunity.h00-159383523.html. At least one study found that herd immunity could be as low as 43% when considering
differences in age and social activity level. COVID-19 Herd Immunity Threshold Could Be Lower, Study Finds,
SCIENCE DAILY (June 23, 2020), https://www.sciencedaily.com/releases/2020/06/200623111329.htm.
229 Expectations for a COVID-19 Vaccine, ASSOCIATED PRESS-NORC CTR. FOR PUBLIC AFF. RSCH.,
https://apnorc.org/projects/expectations-for-a-covid-19-vaccine/ (last accessed Sept. 2, 2020) (summarizing polling
results in which 49% of those surveyed stated that they plan to get vaccinated if a COVID-19 vaccine becomes
available to the public, and another 31% stated that they were not sure whether they would get vaccinated).
Moreover, under current FDA guidance, FDA would authorize or license a COVID-19 vaccine if it concludes from the
clinical trial results that the vaccine “would prevent disease or decrease its severity in at least 50% of people who are
vaccinated.” See Coronavirus (COVID-19) Update: FDA Takes Action to Help Facilitate Timely Development of Safe,
Effective COVID-19 Vaccines, U.S. FOOD & DRUG ADMIN. (June 30, 2020), https://www.fda.gov/news-events/press-
announcements/coronavirus-covid-19-update-fda-takes-action-help-facilitate-timely-development-safe-effective-covid;
see also U.S. FOOD & DRUG ADMIN., DEVELOPMENT AND LICENSURE OF VACCINES TO PREVENT COVID-19: GUIDANCE
FOR INDUSTRY 14 (June 2020); U.S. FOOD & DRUG ADMIN., EMERGENCY USE AUTHORIZATION FOR VACCINES TO
PREVENT COVID-19: GUIDANCE FOR INDUSTRY 9 (Oct. 2020). This means that, potentially, an authorized or licensed
vaccine may not be effective for many of its recipients, which may increase the number of people who must be
vaccinated to achieve herd immunity. As of November 2020, however, several manufacturers participating in
Operation Warp Speed have announced interim results from the Phase 3 trials of their vaccines. See supra note 14 and
accompanying text. According to the manufacturers, these preliminary results show that some vaccine candidates may
be over 90% effective at preventing COVID-19. See id.
230 See Elizabeth Y. McCuskey, Body of Preemption: Health Law Traditions and the Presumption Against Preemption,
89 TEMPLE L. REV. 95, 113–20 (2016).
231 Barnes v. Glen Theatre, Inc., 501 U.S. 560, 569 (1991).
232 See CRS Report R45323, Federalism-Based Limitations on Congressional Power: An Overview, coordinated by
Andrew Nolan and Kevin M. Lewis, at 1.
233 See Jacobson v. Massachusetts, 197 U.S. 11, 39 (1905).
234 Id. at 39; Zucht v. King, 260 U.S. 174 (1922).
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recognized such laws as falling squarely within the states’ police power.235 In 1905, the Supreme
Court in Jacobson v. Massachusetts upheld a state law that gave municipal boards of health
authority to require the vaccination of persons over the age of 21 against smallpox, determining
that the vaccination program had a “real [and] substantial relation to the protection of the public
health and safety.”236 In doing so, the Court rejected an argument that such a program violated a
liberty interest that, under more modern jurisprudence, the plaintiff might have asserted as a
substantive due process right.237 Less than two decades later, in Zucht v. King, parents of a child
who was excluded from school due to her unvaccinated status challenged the local ordinance
requiring vaccination for schoolchildren, arguing that the ordinance violated the Fourteenth
Amendment’s Equal Protection and Due Process Clauses.238 Relying on Jacobson, the Supreme
Court rejected the constitutional challenges, concluding that “it is within the police power of a
State to provide for compulsory vaccination” and that the ordinance did not bestow “arbitrary
power, but only that broad discretion required for the protection of the public health.”239
Based on this authority recognized by the Court, states and localities have enacted various
compulsory vaccination laws for certain populations and circumstances. All fifty states and the
District of Columbia, for instance, currently have laws requiring specified vaccines for
students.240 With respect to adults, states have primarily limited vaccination mandates to health
care workers, with wide variations in the mandates’ scope.241 These vaccination requirements are
generally subject to certain exemptions, which vary from state to state.242 While all vaccination
mandates provide for at least some degree of medical exemption (e.g., if one is allergic to
vaccines or immunocompromised), some mandates also include religious exemptions for those
whose beliefs counsel against immunization.243 In the case of student vaccination mandates,
several states also provide a broader philosophical exemption for those who object to
immunizations because of personal, moral, or other beliefs.244
These vaccination mandates—including ones that do not provide a religious exemption—have
withstood more recent legal challenges.245 While the Supreme Court’s constitutional

235 Jacobson, 197 U.S. at 39; Zucht, 260 U.S. at 175–77.
236 Jacobson, 197 U.S. at 31.
237 See Dorit Rubinstein Reiss & Lois A. Weithorn, Responding to the Childhood Vaccination Crisis: Legal
Frameworks and Tools in the Context of Parental Vaccine Refusal, 63 BUFF. L. REV. 881, 897–98 (2015). Since
Jacobson, for instance, the Supreme Court has recognized that “a competent person has a constitutionally protected
liberty interest in refusing unwanted medical treatment” under the Fourteenth Amendment. Cruzan v. Dir., Mo. Dep’t
of Health, 497 U.S. 261, 278 (1990).
238 Zucht, 260 U.S. at 175–77.
239 Id. at 176–77.
240 States with Religious and Philosophical Exemptions From School Immunization Requirements, NAT’L CONF. OF
STATE LEGISLATURES (NCSL) (June 26, 2020), https://www.ncsl.org/research/health/school-immunization-exemption-
state-laws.aspx.
241 See Brian Dean Abramson, Vaccine Law in the Health Care Workplace, 12 J. HEALTH & LIFE SCI. L. 22, 24–27
(2019) (describing how three states require health care workers to receive annual flu vaccines; several others require
hospitals or other health care facilities to ensure that their employees have been vaccinated against certain vaccine-
preventable diseases, including hepatitis B, rubella, and mumps; and other states require hospital employees to provide
proof of immunization against certain vaccine-preventable diseases).
242 See id. at 28–31 (describing scope of medical and religious exemptions for vaccination mandates for health care
workers); NCSL, supra note 240 (describing exemptions for student vaccination mandates).
243 Abramson, supra note 241, at 28–31; NCSL, supra note 240.
244 NCSL, supra note 240.
245 See, e.g., Phillips v. City of New York, 775 F.3d 538, 542–44 (2d Cir. 2015); Workman v. Mingo Cty. Bd. of Edu.
419 F. App’x 348 (4th Cir. 2011); Whitlow v. California, 203 F. Supp. 3d 1079, 1085–89 (S.D. Cal. 2016); Boone v.
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jurisprudence has evolved substantially since Jacobson and Zucht,246 modern courts have
continued to rely on these cases to reject due process and equal protection claims against the
mandates, giving considerable deference to the states’ use of their police power to require
immunizations to protect public health.247 In cases that also challenge a mandate’s lack of
religious exemption, plaintiffs have typically asserted a claim under the Free Exercise Clause of
the First Amendment.248 Courts have generally rejected this claim—which was not available to
the plaintiffs in Jacobson or Zucht because the Supreme Court had not yet held that the First
Amendment applied to the states249—and concluded that a state is not constitutionally required to
provide a religious exemption.250 The courts reasoned that under Employment Division,
Department of Human Resources of Oregon v. Smith and its progeny, a vaccination mandate is a
neutral, generally applicable law (i.e., one that does not target specific religious groups) that is
not subject to heightened scrutiny.251 Under the lenient rational basis review, courts have held that
“the right to free exercise of religion . . . [is] subordinated to society’s interest in protecting
against the spread of disease.”252

Boozman, 217 F. Supp. 2d 938, 952–57 (E.D. Ark. 2002). Challenges against state vaccination mandates have
primarily occurred in the context of student vaccination requirements. However, in 2009, following the emergence of a
new strain of type A influenza (H1N1), New York State issued a regulation that made vaccination against seasonal and
H1N1 influenza a condition of employment for health care workers who have direct contact with patients or who may
expose patients to disease. This directive drew several legal challenges from local health care workers, who argued that
the regulation violated the Fourteenth Amendment’s Due Process Clause, the First Amendment’s Free Exercise Clause,
and the right to “freedom of contract” guaranteed by the Fifth and Fourteenth Amendments. See Alexander M. Stewart,
Mandatory Vaccination of Health Care Workers, NEW ENG. J. OF MED. (Nov. 19, 2009), https://www.nejm.org/doi/full/
10.1056/nejmp0910151. The litigation, however, was mooted in its early stages after the governor suspended the
regulation due to a vaccine shortage. See Joe Nocera, When New York Mandated Vaccinations, Nurses Sued,
BLOOMBERG BUSINESSWEEK (Mar. 23, 2020), https://www.bloomberg.com/news/articles/2020-03-23/can-states-
mandate-vaccinations-for-health-care-workers.
246 Commentators, for instance, have observed that the Supreme Court decided Jacobson and Zucht before the advent
of tiered scrutiny, which subjects regulations that infringe upon certain fundamental liberty interests to heightened
scrutiny. Rubinstein Reiss & Weithorn, supra note 237, at 896–97. A regulation survives this heightened scrutiny only
if it is narrowly tailored to serve a compelling government interest. See Reno v. Flores, 507 U.S. 292, 301–02 (1993).
247 See, e.g., Phillips v. City of New York, 775 F.3d 538 (2d Cir. 2015); Workman v. Mingo Cty. Bd. of Edu. 419 F.
App’x 348 (4th Cir. 2011); Whitlow v. California, 203 F. Supp. 3d 1079 (S.D. Cal. 2016).
248 See, e.g., Phillips, 775 F.3d at 543; Workman, 419 F. App’x at 352–54; Whitlow, 203 F. Supp. 3d at 1085–87;
Boone, 217 F. Supp. 2d at 952–55.
249 See Phillips, 775 F.3d at 543.
250 See, e.g., id. at 543; Workman, 419 F. App’x at 352–54; Whitlow, 203 F. Supp. 3d at 1085–87; Boone, 217 F. Supp.
2d at 952–55.
251 See, e.g., Phillips, 775 F.3d at 543; Workman, 419 F. App’x at 352–54; Whitlow, 203 F. Supp. 3d at 1085–87;
Boone, 217 F. Supp. 2d at 952–55. The Supreme Court heard oral argument on November 4, 2020 in Fulton v. City of
Philadelphia, a case in which the petitioners have asked the Court to, among other issues, revisit Smith. See Pet. for a
Writ of Cert. 31, Fulton v. City of Philadelphia, No. 19-123 (2020).
252 Boone, 217 F. Supp. 2d at 954; see also Phillips, 775 F.3d at 543; Workman, 419 F. App’x at 352–54; Whitlow, 203
F. Supp. 3d at 1085–87. In cases in which a vaccination mandate includes a religious exemption, plaintiffs have also
filed suit to challenge their unsuccessful invocation of the exemption. In these cases, courts, applying the relevant state
law, typically considered whether the plaintiffs’ objections to vaccination are based on a sincere religious belief. See,
e.g., N.M. v. Hebrew Acad. Long Beach, 155 F. Supp. 3d 247, 257–58 (E.D.N.Y. 2016) (finding that plaintiff failed to
establish her objections to vaccination were religious in nature); In re Matter of Christine M., 157 Misc.2d 4, 21 (N.Y.
1992) (finding that plaintiff’s objections to vaccination were based on plaintiff’s personal and medical, rather than
religious, beliefs); Lewis v. Sobol, 710 F. Supp. 506, 516 (S.D.N.Y. 1989) (finding that plaintiffs’ objections to
vaccination stemmed from their religious beliefs, which entailed “views of spiritual perfection” that they apply in their
dietary and medical practices).
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Federal Authority to Mandate Vaccination
Executive Branch Authority to Mandate Vaccination
Except in certain limited circumstances, including in the immigration253 and military254 contexts,
no existing federal law expressly imposes vaccination requirements on the general populace.
Certain existing authorities, however, could potentially form the basis of such executive action in
the context of COVID-19. One such law could be Section 361 of the PHSA.255 This provision,
which has been characterized as “broad [and] flexible,”256 grants the Secretary of HHS the
authority—delegated in part to the Centers for Disease Control and Prevention (CDC)257—to
make and enforce regulations necessary “to prevent the introduction, transmission, or spread of
communicable diseases from foreign countries into the States or possessions, or from one State or
possession into any other State or possession.”258 A broad construction of this authority may
permit the CDC to issue regulations requiring vaccination in circumstances that would prevent
the foreign or interstate transmission of COVID-19.259 CDC’s exercise of this authority would
nevertheless be restricted by the Constitution and other generally applicable statutory
requirements, such as the Administrative Procedure Act260 or the Religious Freedom Restoration
Act of 1993.261 The latter statute requires courts to grant certain religious exemptions from a
generally applicable rule that imposes a substantial burden on a regulated person’s religious
exercise.262
On the other hand, Section 361’s structure and language may subject it to a narrower
construction. Following the broad statement of authority identified above, Section 361 provides
that “[f]or purposes of carrying and enforcing such regulations,” the agency “may provide for
such inspection, fumigation, disinfection, sanitation, pest extermination, destruction of animals or
articles found to be so infected or contaminated as to be sources of dangerous infection to human
beings, and other measures, as in [its] judgment may be necessary.”263 Section 361’s remaining
subsections further contemplate the issuance of regulations related to the apprehension, detention,
examination, and conditional release of individuals for purposes of preventing the spread of

253 Under 8 U.S.C. § 1182(a)(1)(A), for instance, immigrants seeking permanent residence in the United States must
present documentation showing they have been vaccinated against certain specified vaccine-preventable diseases.
254 The Department of Defense’s Immunization Program, for instance, requires all health care personnel working in the
Department’s medical treatment facilities, as well as all active duty and selected reserve personnel, to receive annual
seasonal influenza vaccines or to obtain a medical or administrative exemption. DEP’T OF DEFENSE INSTRUCTION
6205.02 § 1.2b (July 23, 2019), https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/620502p.pdf?ver=
2019-07-23-085404-617.
255 42 U.S.C. § 264.
256 Louisiana v. Matthews, 427 F. Supp. 174, 176 (E.D. La. 1977).
257 See Legal Authorities for Isolation and Quarantine, CTRS. FOR DISEASE CONTROL & PREVENTION (Feb. 24, 2020),
https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html.
258 42 U.S.C. § 264(a).
259 See Christopher T. Robertson, Vaccines and Airline Travel: A Federal Role to Protect the Public Health, 42 AM.
J.L. & MED. 543, 566 (2016) (suggesting the CDC has authority under Section 361 “to require vaccinations as a
condition of airline travel”).
260 See, e.g., CRS Legal Sidebar LSB10523, Administrative Law Reform Legislation in the 116th Congress, by Daniel
J. Sheffner.
261 See, e.g., CRS In Focus IF11490, The Religious Freedom Restoration Act: A Primer, by Whitney K. Novak.
262 42 U.S.C. § 2000bb-1.
263 Id. § 264(a).
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communicable diseases.264 Given this structure and language, regulations issued pursuant to this
authority have primarily been confined to two general types of control measures: (1) quarantine
and isolation measures of people and goods (administered by the CDC); 265 and (2) measures that
control or treat areas, animals, or articles that are susceptible of or subject to contamination or
infection (administered by the FDA).266 This limited construction may be consistent with a canon
of statutory interpretation—ejusdem generis—that confines the meaning of a general term (e.g.,
“other measures” deemed necessary by the agency) to matters comparable to the more specific
terms enumerated in the statute.267 Further complicating the analysis is the potentially significant
economic and political considerations at issue for a federal vaccination mandate.268 In assessing
an agency’s statutory authority, the Supreme Court has cautioned that courts must “be guided to a
degree by common sense as to the manner in which Congress is likely to delegate a policy
decision of [significant] economic and political magnitude to an administrative agency.”269 In
light of these considerations, it is difficult to predict whether courts would conclude that the
CDC’s authority under Section 361 would extend to a federal vaccination mandate.
Congress’s Authority to Mandate Vaccination
Although states have traditionally exercised the bulk of authority over public health matters,
including vaccination, Congress shares certain concurrent authority in this area emanating from
its enumerated powers in the U.S. Constitution.270 This authority derives from, among other
sources, the Constitution’s Spending Clause and the Commerce Clause.271
The Spending Clause empowers Congress to tax and spend for the general welfare.272 Under this
authority, which is subject to several limitations, Congress may offer federal funds to nonfederal
entities and prescribe the terms and conditions under which the funds are accepted and used by
recipients.273 Over the past century, Congress has frequently invoked this authority in the public
health context, including for purposes of controlling specified diseases, establishing
neighborhood or community health centers, and creating federal health insurance programs,
including Medicare and Medicaid.274

264 See id. § 264(b)–(d).
265 See 42 C.F.R. §§ 70.1–70.18 (regulations on interstate quarantine); §§ 71.1–71.63 (regulations on foreign
quarantine).
266 See 21 C.F.R. §§ 1240.3–1240.95.
267 See, e.g., CRS Report R45153, Statutory Interpretation: Theories, Tools, and Trends, by Valerie C. Brannon, at 54.
268 Vaccine mandates and campaigns can implicate, for instance, complex issues of supply and distribution, as well as
issues of vaccine hesitance stemming in part from prior governmental vaccine campaigns. See discussion supra note
245; Wendy E. Parmet, Pandemics, Populism and the Role of Law in the H1N1 Vaccine Campaign, 4 ST. LOUIS UNIV.
L. J. 113, 115–24 (2010) (describing the history of pandemic influenza responses in the United States and issues related
to the 2009 H1N1 vaccine campaign); Kat Eschner, The Long Shadow of the 1976 Swine Flu Vaccine ‘Fiasco’,
SMITHSONIAN MAG. (Feb. 6, 2017), https://www.smithsonianmag.com/smart-news/long-shadow-1976-swine-flu-
vaccine-fiasco-180961994/.
269 FDA v. Brown & Williamson Tobacco Corp., 529 U.S. 120, 133 (2000).
270 McCuskey, supra note 230, at 113–20.
271 See id. at 116–19.
272 U.S. CONST. art. I, § 8, cl. 1.
273 See CRS Report R45323, supra note 232, at 29–31 (discussing South Dakota v. Dole, 483 U.S. 203, 207–08
(1987)).
274 See James G. Hodge, Jr., The Role of New Federalism and Public Health Law, 12 J.L. & HEALTH 309, 335–37
(1998); McCuskey, supra note 230, at 118–19.
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Applying its authority in the context of a vaccination mandate, Congress could incentivize states
to enact a vaccination mandate meeting certain federal requirements by imposing it as a condition
of receiving certain federal funds.275 This use of the Spending Clause authority, assuming it falls
within the broad parameters of being for the “general welfare,” would be permissible so long as
(1) Congress provides clear notice of the vaccination mandate that states must enact; (2) the
mandate is related to the purpose of the federal funds; (3) this conditional grant of funds is not
otherwise barred by the Constitution; and (4) the amount of federal funds offered is not “so
coercive as to pass the point at which pressure turns into compulsion.”276
The Commerce Clause grants Congress the power “[t]o regulate Commerce with foreign Nations,
and among the several States, and with the Indian Tribes.”277 This authority empowers Congress
to regulate “three broad categories of activities”: (1) “channels of interstate commerce,” like
roads and canals; (2) instrumentalities of, or persons or things in, interstate commerce; and
(3) activities that substantially affect interstate commerce.278 Congress relied on the Commerce
Clause to enact some of the earliest federal health laws aimed at protecting the public from
contagion and products posing health concerns.279 As the federal government increased its role in
public health, Congress relied on the Commerce Clause to pass more comprehensive national
health regulations, beginning with the Food and Drug Act of 1906.280
While Congress’s authority under the Commerce Clause is expansive, a majority of the Supreme
Court in National Federation of Independent Business (NFIB) v. Sebelius agreed that there is a
discrete limit to this authority—that it cannot compel individuals to engage in commercial
activity.281 According to Chief Justice Roberts, in a portion of the opinion not joined by other
Justices, but largely echoed in the view of the four dissenting Justices, the Commerce Clause did
not empower Congress “to regulate individuals precisely because they are doing nothing.”282
While it is uncertain whether this conclusion constitutes binding precedent,283 it suggests that a
direct federal mandate on individuals to receive a vaccine may be susceptible to challenge
because such mandates could be construed as compelling individuals who are “doing nothing” to
engage in the commercial activity of receiving a specified health care service.284 On the other
hand, a federal mandate that requires vaccination as a condition to engage in existing economic
activities, such as employment, may raise fewer constitutional concerns.285

275 See Dole, 483 U.S. at 211–12 (holding that 23 U.S.C. § 158, which conditioned the provision of certain federal
highway funds upon a state’s enactment of a minimum drinking age of twenty-one, was a valid exercise of Congress’s
spending clause authority).
276 See id. at 207–08, 211 (internal quotations omitted).
277 U.S. CONST. art. I, § 8, cl. 3.
278 United States v. Lopez, 514 U.S. 549, 558–59 (1995).
279 McCuskey, supra note 230, at 116–19 (noting that the Commerce Clause enabled several early federal health laws,
including a law that authorized the quarantine of diseased livestock and people, and a law that regulated certain drugs
and food products posing health concerns).
280 See id.; see also Medtronic, Inc. v. Lohr, 518 U.S. 470, 475 (1996); Hodge, supra note 274, 335–36 (noting that
“[f]ederal regulation now reaches broad aspects of public health such as air and water quality, food and drug safety,
tobacco advertising, pesticide production and sales, consumer product safety, occupational health and safety, and
medical care”).
281 See CRS Report R45323, supra note 232, at 10.
282 See id. at 10–11 (quoting NFIB v. Sebelius, 567 U.S. 519, 551 (2012) (opinion of Roberts, C.J.)).
283 See id. at 11.
284 See NFIB, 567 U.S. at 551.
285 See Liberty Univ., Inc. v. Lew, 773 F.3d 72, 93 (4th Cir. 2013) (rejecting a Commerce Clause challenge to an
Affordable Care Act requirement that certain employers offer a minimum level of health insurance coverage to their
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Even if within Congress’s enumerated powers, other constitutional provisions may constrain
governmental action.286 In the context of public health regulations, the key constraints are those
grounded in federalism and the protection of individual rights.287 For example, the Supreme Court
has interpreted the Tenth Amendment to prevent the federal government from commandeering or
requiring states or localities to adopt or enforce federal policies.288 In the context of vaccination,
this principle prevents Congress from directly requiring states or localities to pass mandatory
vaccination laws or implement federal vaccination laws.289 It does not, however, impede Congress
from using its Spending Clause authority to incentivize states to do so, as long as the amount
offered is not so significant as to effectively coerce, or functionally commandeer, states into
enacting the mandate.290
As to protection of individual rights, courts have recognized few rights-based constraints on the
ability to impose mandatory vaccination requirements.291 As noted above, courts have largely
rejected due process and equal protection challenges to compulsory vaccination under Jacobson
and Zucht, and potential free exercise concerns are limited under Smith and its progeny.292
To date, the federal government has generally limited its role with respect to vaccination to
promoting, facilitating, or monitoring the use and manufacture of vaccines. For instance, federal
laws and agencies require insurance coverage for recommended vaccinations293 and the purchase
of certain vaccines,294 provide clinical guidance on vaccinations,295 and ensure vaccine safety.296
As discussed above, there may be an open question as to whether the federal government has
existing authority to mandate vaccination in the context of COVID-19.297 Thus, inasmuch as
Congress determines that a federal vaccination mandate may be necessary to address the COVID-
19 pandemic, legislative action—grounded in Congress’s enumerated authorities described
above—may be required to implement such a mandate.

employees and dependents on the grounds that the requirement merely regulates an existing commercial activity).
286 See CRS Report R45323, supra note 232, at 24–25.
287 See id. at 19, 24–25.
288 Id. at 25.
289 See id.
290 See id.
291 See text accompanying supra notes 234–252.
292 See id.
293 See 42 U.S.C. § 300gg-13(a) (requiring private health insurance plans to cover certain recommended
immunizations); id. § 1396s(a) (requiring coverage of certain recommended pediatric vaccines under a state Medicaid
plan).
294 See discussion supra note 145.
295 See Advisory Committee on Immunization Practices (ACIP) Charter, CTRS. FOR DISEASE CONTROL & PREVENTION, ,
https://www.cdc.gov/vaccines/acip/committee/charter.html.
296 See discussion supra in “FDA Law Considerations: Bringing a New Vaccine to Market.”
297 See discussion supra in “Executive Branch Authority to Mandate Vaccination.”
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Liability and Compensation for COVID-19 Vaccine
Injuries
To encourage the expeditious development and deployment of medical countermeasures during a
public health emergency, the PREP Act298 authorizes the Secretary of HHS (the Secretary) to limit
legal liability for losses relating to the administration of medical countermeasures, including
diagnostics, treatments, and vaccines.299 In a declaration effective February 4, 2020 (the COVID-
19 PREP Act Declaration), the Secretary invoked the PREP Act and declared COVID-19 to be a
public health emergency warranting liability protections for covered countermeasures.300 Under
the COVID-19 PREP Act Declaration, covered persons are generally immune from legal liability
for losses relating to the administration or use of covered countermeasures against COVID-19.301
The sole exception to PREP Act immunity is for death or serious physical injury caused by
“willful misconduct.”302 However, individuals who die or suffer serious injuries directly caused
by the administration of covered countermeasures may be eligible to receive compensation
through an HHS administrative process called the Countermeasures Injury Compensation
Program (CICP).303
Courts have characterized PREP Act immunity as “sweeping.”304 It applies to all types of legal
claims under state and federal law.305 For example, under state tort law, individuals who suffer
injuries caused by another person’s intentional or negligent acts or omissions may generally sue
that person to recover monetary compensation.306 Thus, in the health care context, if a health care
provider negligently administers a drug or device that causes a foreseeable injury to a patient, the
injured person may be able to sue the provider for compensation.307
Federal laws such as the PREP Act may preempt state tort laws—as well as other state and federal
laws—in certain contexts.308 Preemptive federal legislation displaces state law to alter the usual
liability rules or immunize certain individuals from liability.309 In the PREP Act, Congress made
the judgment that, in the context of a public health emergency, immunizing certain persons and
entities from liability was necessary to ensure that potentially life-saving countermeasures will be
efficiently developed, deployed, and administered.310

298 Pub. L. 109-148, div. C, 119 Stat. 2680, 2818–32 (2005) (codified as amended at 42 U.S.C. §§ 247d-6d, 247d-6e).
299 42 U.S.C. § 247d-6d(b)(1).
300 Declaration Under the Public Readiness and Emergency Preparedness Act for Medical Countermeasures Against
COVID-19, 85 Fed. Reg. 15,198 (Mar. 17, 2020) (effective Feb. 4, 2020) [hereinafter COVID-19 PREP Act
Declaration].
301 Id. at 15,201–02; 42 U.S.C. § 247d-6d(a)(1).
302 42 U.S.C. § 247d-6d(d)(1).
303 Id. § 247d-6e; 42 C.F.R. pt. 110.
304 See Parker v. St. Lawrence Cty. Pub. Health Dep’t, 102 A.D.3d 140, 143 (N.Y. App. Div. 2012).
305 42 U.S.C. § 247d-6d(a)(1).
306 See generally CRS In Focus IF11291, Introduction to Tort Law, by Kevin M. Lewis.
307 Id. at 1.
308 See generally CRS Report R45825, Federal Preemption: A Legal Primer, by Jay B. Sykes and Nicole Vanatko.
309 See, e.g., CRS Legal Sidebar LSB10461, Federal Legislation Shielding Businesses and Individuals from Tort
Liability: A Legal and Historical Overview, by Kevin M. Lewis (summarizing federal statutes that either insulate
particular entities from tort liability or otherwise displace state tort law).
310 See, e.g., 151 CONG. REC. H12264 (daily ed. Dec. 18, 2005) (statement of Rep. Deal) (“Unfortunately, there is no
business model that would have vaccine manufacturers take on the tremendous liability risks to produce [a pandemic
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So long as the COVID-19 PREP Act Declaration remains in effect, COVID-19 vaccine
manufacturers, distributors, and qualified health care providers are generally immune from legal
liability for losses relating to the use or administration of that vaccine. Instead, compensation
through CICP may be available for individuals who are injured or die as a result of receiving a
COVID-19 vaccine. This section explains the scope of this PREP Act immunity as it applies to
COVID-19 countermeasures, including vaccines, as well as the contours and availability of CICP
compensation.
The Public Readiness and Emergency Preparedness Act
Scope of Immunity from Liability
For the PREP Act to apply, the Secretary must determine that a disease or other threat to health
constitutes a public health emergency, or that there is a credible risk of such an emergency.311 The
Secretary shall consider the desirability of encouraging the design, development, testing,
manufacture, and use of countermeasures in determining whether to issue a PREP Act
declaration.312 The Secretary must publish the PREP Act declaration in the Federal Register and
identify, for each countermeasure, the particular disease, time period, population, and
geographical area that the declaration covers.313
If within the scope of the declaration, the PREP Act immunizes a covered person from legal
liability for all claims for loss relating to the administration or use of a covered
countermeasure.314 The requirements for PREP Act immunity thus break down into four elements:
(1) the individual or entity must be a “covered person”; (2) the legal claim must be for a “loss”;
(3) the loss must have a “causal relationship” to the administration or use of a covered
countermeasure; and (4) the medical product that caused the loss must be a “covered
countermeasure.”
“Covered Persons”
The PREP Act defines covered persons to include (i) the United States; (ii) manufacturers and
distributors of covered countermeasures; (iii) “program planners”; and (iv) “qualified persons”
who prescribe, administer, or dispense covered countermeasures.315 Program planners include
Indian Tribes, state governments, and local governments who supervise programs that dispense,
distribute, or administer covered countermeasures, or provide policy guidance, facilities, and

flu] vaccine. We must address this concern or we will have none. It’s really that simple. . . . What the [PREP Act] does
is provide authority to the Secretary[:] the ability to declare limited liability protection. The Secretary can use these
declarations to make sure the vaccine gets developed and to make sure doctors are willing to give it when the time
comes.”).
311 42 U.S.C. § 247d-6d(b)(1).
312 Id. § 247d-6d(b)(6). A PREP Act declaration is distinct from the Secretary’s power to declare a public health
emergency under Section 319 of the PHSA, which has a separate set of legal implications. Id. § 247d; see generally
U.S. Dep’t of Health & Human Servs., Off. of the Assistant Sec. for Preparedness & Response, Public Health
Emergency Declaration (Nov. 26, 2019) (describing powers of Secretary under Section 319). The Secretary made the
Section 319 declaration for COVID-19 on January 31, 2020. Alex M. Azar II, Sec’y of the Dep’t of Health & Human
Servs., Determination that a Public Health Emergency Exists, https://www.phe.gov/emergency/news/healthactions/phe/
Pages/2019-nCoV.aspx (Jan. 31, 2020).
313 42 U.S.C. § 247d-6d(b)(1)–(3).
314 Id. § 247d-6d(a)(1).
315 Id. § 247d-6d(i)(2).
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scientific advice on the administration or use of such countermeasures.316 Qualified persons
include licensed health professionals and other individuals authorized to prescribe, administer, or
dispense covered countermeasures under state law, as well as other categories of persons
identified by the Secretary in a PREP Act declaration.317 Employees and agents of all these
persons and entities are also covered persons.318
Covered “Claims for Loss”
PREP Act immunity reaches “all claims for loss” under federal and state law.319 Loss is broadly
defined to mean “any type of loss,” including (i) death; (ii) physical, mental, or emotional injury,
illness, disability, or condition; (iii) fear of such injury, including medical monitoring costs; and
(iv) loss of or damage to property, including business interruption loss.320 This language would
seem to include, at a minimum, most state law tort, medical malpractice, and wrongful death
claims resulting from the administration of covered countermeasures.
Causal Relationship Between the Loss and the Countermeasure
To be preempted by the PREP Act, the claims for loss must have a causal relationship to the
administration and use of a covered countermeasure.321 As with the other elements, the PREP
Act’s causation language sweeps broadly. PREP Act immunity applies to any claim for loss that
has “a causal relationship with the design, development, clinical testing or investigation,
manufacture, labeling, distribution, formulation, packaging, marketing, promotion, sale, purchase,
donation, dispensing, prescribing, administration, licensing, or use” of a covered
countermeasure.322
“Covered Countermeasures”
Finally, the medical product at issue must be a covered countermeasure. The PREP Act specifies
three types of covered countermeasures: (i) a qualified “pandemic or epidemic product”; (ii) a
“security countermeasure”; (iii) a drug, biological product, or device that FDA has authorized for
emergency use; and (iv) a “respiratory protective device” that is approved by the National
Institute for Occupational Safety and Health (NIOSH) that the Secretary determines to be a
priority for use during a public health emergency.323
A pandemic or epidemic product includes any drug, biological product, or device developed “to
diagnose, mitigate, prevent, treat, or cure a pandemic or epidemic.”324 In addition, drugs,
biological products, or devices used to treat the side effects of a pandemic or epidemic product, or
to enhance their effects, may themselves be covered countermeasures.325 In either case, to be a

316 Id. § 247d-6d(i)(6).
317 Id. § 247d-6d(i)(8).
318 Id. § 247d-6d(i)(2)(B)(v).
319 Id. § 247d-6d(a)(1).
320 Id. § 247d-6d(a)(2)(A)(i)–(iv).
321 Id. § 247d-6d(a)(1).
322 Id. § 247d-6d(a)(2)(B).
323 Id. § 247d-6d(i)(1)(A)–(C).
324 Id. § 247d-6d(i)(7)(A)(i). The PREP Act incorporates the general definitions of “drug,” “biological product,” and
“device” from the FD&C Act and PHSA. See 21 U.S.C. § 321(g)(1), (h); 42 U.S.C. § 262(i).
325 42 U.S.C. § 247d-6d(i)(7)(A)(ii)–(iii).
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covered countermeasure, the pandemic or epidemic product must be approved, licensed, or
authorized for emergency use by FDA.326
A security countermeasure refers to a drug, biological product, or device used “to diagnose,
mitigate, prevent, or treat harm from any biological, chemical, radiological, or nuclear agent”
identified by the Secretary of Homeland Security as a material threat to national security.327
The emergency use category of covered countermeasure includes drugs, biological products, and
devices that FDA has authorized for use outside its ordinary regulatory process through an
EUA.328 FDA has made wide use of its emergency authorities in response to the COVID-19
pandemic, issuing EUAs for certain in vitro diagnostic products (i.e., tests for COVID-19),
antibody tests, personal protective equipment (e.g., respirators and face shields), devices modified
for use as ventilators, and therapeutic drugs.329
Section 6005 of the Families First Coronavirus Response Act330 and Section 3103 of the CARES
Act331 amend the PREP Act to clarify that certain “personal respiratory protective devices” (such
as N95 respirators) are covered countermeasures. To be covered by the PREP Act, the respiratory
protective device must be (i) approved by the NIOSH under 42 C.F.R. part 84; and (ii) determined
by the Secretary of HHS to be a priority for use during a public health emergency.332
In sum, so long as FDA licensed or authorized a COVID-19 vaccine, it would be a covered
countermeasure within the PREP Act’s scope, either as a “pandemic or epidemic product” or
through the emergency use category, in the case of authorization through an EUA. Prior to
licensure or authorization of a COVID-19 vaccine, the PREP Act would also afford liability
protections for injuries that may occur in the clinical testing process, if the vaccine is “the object
of research for possible use” as a pandemic or epidemic product and subject to an investigational
use exemption.333
The Willful Misconduct Exception
If a claim for loss is within the PREP Act’s scope, a covered person is generally immune from
legal liability.334 The “sole exception” to immunity is when a covered person proximately causes
death or serious physical injury to another person through willful misconduct.335 A serious

326 Id. § 247d-6d(i)(7)(B)(i), (iii).
327 Id. §§ 247d-6b(c)(1)(B), 247d-6d(i)(1)(B).
328 Id. § 247d-6d(i)(1)(C); see discussion supra in “Emergency Use Authorizations Before Approval.”
329 Emergency Use Authorization: Coronavirus Disease 2019 (COVID-19) EUA Information, U.S. FOOD & DRUG
ADMIN., https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-
framework/emergency-use-authorization#covid19euas (last updated June 1, 2020) (listing FDA’s current EUAs for
COVID-19 diagnostics, antibody tests, personal protective equipment, therapeutics, and ventilators).
330 Pub. L. No. 116-127, § 6005, 134 Stat. 178, 207 (2020).
331 Pub. L. No. 116-136, § 3103 (2020).
332 42 U.S.C. § 247-6d(i)(1)(D). Prior to these amendments, FDA issued an EUA on March 2, 2020 for the use of
NIOSH-approved filtering respirators intended for general use in health care settings, and expressed its view that the
PREP Act covered these respirators prior to the amendment because of their medical use. See Letter from Denise M.
Hinton, Chief Scientist, FDA, to Robert R. Redfield, Dir. Ctrs. for Disease Control & Prevention (Mar. 28, 2020),
https://www.fda.gov/media/135763/download.
333 42 U.S.C. § 247d-6d(i)(7)(B)(ii).
334 Id. § 247d-6d(a)(1).
335 Id. § 247d-6d(d)(1). In the case of actions by or against the United States, the PREP Act shall not “be construed to
abrogate or limit any right, remedy, or authority that the United States or any agency thereof may possess under any
other provision of law or to waive sovereign immunity or to abrogate or limit any defense or protection available to the
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physical injury must be life threatening, permanently impair a body function, permanently
damage a body structure, or require medical intervention to avoid such permanent impairment or
damage.336 Willful misconduct requires that the covered person acted (i) intentionally to achieve a
wrongful purpose; (ii) knowingly without legal or factual justification; and (iii) in disregard of a
known or obvious risk that is so great as to make it highly probable that the harm will outweigh
the benefit.337
The process by which an injured person (or their representative) may prove willful misconduct
under the PREP Act is limited in several ways. Before filing a suit claiming willful misconduct,
the injured person must first seek compensation through CICP, and they cannot sue if they elect to
receive that compensation.338 If they choose to file a lawsuit, injured persons may sue only in the
U.S. District Court for the District of Columbia.339 Such lawsuits are assigned to a three-judge
panel, must meet heightened standards for pleading and discovery, and are subject to procedural
provisions generally favorable to defendants.340 Injured persons must prove willful misconduct by
clear and convincing evidence,341 a higher standard of proof than a typical civil case. Recovery
for noneconomic damages such as pain and suffering is limited.342
In addition to these procedural and substantive limitations, the PREP Act contains two statutory
defenses to claims of willful misconduct. First, program planners and qualified persons cannot be
found to have engaged in willful misconduct if they “acted consistent with applicable directions,
guidelines, or recommendations by the Secretary regarding the administration or use of a covered
countermeasure,” and notify either the Secretary or a state or local health authority of the injury
or death allegedly caused by the countermeasure within seven days.343 Second, countermeasure
manufacturers and distributors may rely on regulatory compliance as a complete defense to a
“willful misconduct” allegation.344 When the act or omission alleged to be willful misconduct is
“subject to regulation” under the PHSA or the FD&C Act, an injured person cannot succeed on a
willful misconduct claim unless the Secretary or the Attorney General has brought certain
“enforcement actions” against the manufacturer or distributor that result in the imposition of
particular penalties.345

United States or its agencies, instrumentalities, officers, or employees under any other law.” Id. § 247d-6d(f).
336 Id. § 247d-6d(i)(10).
337 Id. § 247d-6d(c)(1)(A).
338 Id. § 247d-6e(d)(1), (5).
339 Id. § 247d-6d(e)(1).
340 See id. § 247d-6d(e)(3)–(6), (10).
341 Id. § 247d-6d(c)(3).
342 Id. § 247d-6d(e)(7)–(8).
343 Id. § 247d-6d(c)(4).
344 Id. § 247d-6d(c)(5).
345 Id. § 247d-6d(c)(5)(A)(i)–(ii). The necessary “enforcement actions” include criminal prosecutions, civil monetary
proceedings based on willful misconduct, mandatory product recalls, or revocations, suspensions, or withdrawals,
based on willful misconduct, of FDA approval, licensure, or authorization. Id. § 247d-6d(c)(5)(B)(i). Before a willful
misconduct claim can proceed, the enforcement action must conclude with the imposition of a “covered remedy,” such
as a criminal conviction, an injunction, a civil monetary payment, a product recall, or a suspension or withdrawal of
FDA approval or licensure. Id. § 247d-6d(c)(5)(B)(ii).
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The Countermeasures Injury Compensation Program
An individual seriously injured or killed by the administration of a covered countermeasure,
whether or not as a result of willful misconduct, may seek compensation through CICP.346 CICP
is a regulatory process administered by HHS’s Health Resources and Services Administration.347
HHS regulations govern CICP’s procedures and eligibility determinations.348 In general, eligible
individuals (or their survivors) who suffer death or serious physical injury directly caused by the
administration of a covered countermeasure may receive reimbursement through CICP for
reasonable medical expenses, loss of employment income, and survivor benefits in the case of
death.349 Serious physical injuries under CICP are generally limited to those that warrant
hospitalization or lead to a significant loss of function or disability.350 Congress funds CICP
compensation through emergency appropriations to the Covered Countermeasure Process
Fund.351
Both the CARES Act and CPRSA appropriate funding that HHS may use for the Covered
Countermeasure Process Fund, upon which CICP relies. CPRSA appropriates $3.1 billion to the
Secretary to respond to COVID-19, including the development and purchase of countermeasures
and vaccines, while allowing these funds to “be transferred to, and merged with” the Covered
Countermeasure Process Fund.352 The CARES Act appropriates $27 billion to the Secretary for
similar purposes, again providing that the Secretary may transfer these funds to the Covered
Countermeasure Process Fund.353
CICP is distinct from the National Vaccine Injury Compensation Program,354 which provides
compensation for injuries caused by most vaccines routinely administered in the United States,
such as childhood vaccines (e.g., MMR, polio, hepatitis A) and nonpandemic seasonal influenza
vaccines.355 By contrast, CICP only applies to countermeasures covered by a PREP Act
declaration of a public health emergency, such as those issued for COVID-19, pandemic influenza
(e.g., the 2009 H1N1 “swine flu”), and the Ebola virus.356
The COVID-19 PREP Act Declaration
On March 10, 2020, the Secretary invoked the PREP Act and determined that COVID-19
constitutes a public health emergency.357 The COVID-19 PREP Act Declaration therefore
authorizes PREP Act immunity for the “manufacture, testing, development, distribution,

346 Id. § 247d-6e(a)–(b).
347 See generally Countermeasure Injury Compensation Program, HEALTH RESOURCES & SERVS. ADMIN.,
https://www.hrsa.gov/cicp/index.html (last visited May 28, 2020).
348 See 42 C.F.R. pt. 110.
349 42 U.S.C. § 247d-6e(a), (b), (e)(3), (e)(5); 42 C.F.R. § 110.2(a).
350 42 C.F.R. § 110.3(z).
351 42 U.S.C. § 247d-6e(a).
352 Pub. L. No. 116-123, tit. III, 134 Stat. 146, 149 (2020).
353 Pub. L. No. 116-136, tit. VIII.
354 See 42 U.S.C. §§ 300aa-10 to 300aa-34; 42 C.F.R. pt. 100.
355 See National Vaccine Injury Compensation Program: Covered Vaccines, HEALTH RES. & SERVS. ADMIN,
https://www.hrsa.gov/vaccine-compensation/covered-vaccines/index.html (last updated Mar. 2020).
356 See HEALTH RES. & SERVS. ADMIN, COUNTERMEASURES INJURY COMPENSATION PROGRAM: FACT SHEET (Oct. 2017),
https://www.hrsa.gov/sites/default/files/hrsa/cicp/cicpfactsheet.pdf.
357 COVID-19 PREP Act Declaration, supra note 300, at 15,201.
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administration, and use” of covered countermeasures.358 This immunity applies to all covered
persons as defined in the PREP Act, including any person authorized by state and local public
health agencies (or an EUA) to “prescribe, administer, deliver, distribute or dispense” covered
countermeasures.359 Covered countermeasures include “any antiviral, any other drug, any
biologic, any diagnostic, any other device, or any vaccine, used to treat, diagnose, cure, prevent,
or mitigate COVID-19.”360 The “administration” of a covered countermeasure includes “physical
provision of the countermeasures” to patients, as well as “activities and decisions directly relating
to . . . delivery, distribution and dispensing of” the countermeasures.361 The declaration provides
PREP Act immunity “without geographic limitation” beginning on February 4, 2020, and ending
as late as October 1, 2025.362
The HHS Declaration has been amended three times, each time broadening the scope of PREP
Act immunity. First, on April 10, 2020, the Secretary amended the declaration to explicitly
include NIOSH-approved respiratory protective devices as covered countermeasures pursuant to
the CARES Act’s amendments to the PREP Act.363 Second, on June 4, 2020, the Secretary
amended the declaration to clarify that drugs, biological products, and devices that “limit the
harm COVID-19 . . . might otherwise cause” are covered countermeasures, and that the HHS
Declaration reaches “all qualified pandemic and epidemic products defined under the PREP
Act.”364 Third, on August 19, 2020, the Secretary expanded the definitions of covered diseases to
reach not only COVID-19, but also “other diseases, health conditions, or threats that may have
been caused by COVID-19, SARS-CoV-2, or a virus mutating therefrom,” including “the
decrease in the rate of childhood immunizations, which will lead to an increase in the rate of
infectious diseases.”365 The amendment thus declares that pediatric vaccines (if licensed by FDA
and recommended by the Advisory Committee on Immunization Practices (ACIP)) are “covered
countermeasures” and relies on the PREP Act’s preemption provisions to authorize state-licensed
pharmacists to administer ACIP-recommended vaccines to children aged three to eighteen,
notwithstanding state laws to the contrary.366

358 Id.
359 Id. at 15,201–02.
360 Id. at 15,202.
361 Id.
362 See id.
363 Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical
Countermeasures Against COVID-19, 85 Fed. Reg. 21,012, 21,013–14 (Apr. 10, 2020).
364 Second Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical
Countermeasures Against COVID-19, 85 Fed. Reg. 35,100, 35,101–02 (June 2, 2020).
365 Third Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical
Countermeasures Against COVID-19, 85 Fed. Reg. 52,136, 52,141 (Aug. 19, 2020),
366 Id. at 52,139–40.
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Author Information

Kevin J. Hickey
Erin H. Ward
Legislative Attorney
Legislative Attorney

Wen W. Shen

Legislative Attorney

Disclaimer
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under the direction of Congress. Information in a CRS Report should not be relied upon for purposes other
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