Let’s Vaccinate like its 2021

When I decided to write a blog entry on Covax it was simply going to be about how fantastic it was, and how being immunized was a no-brainer. The need to talk about it popped in my head after a few conversations with colleagues and friends about the vaccine. I was surprised it was controversial, but I did understand why. Social media doesn’t help. Well let’s polish those issues off now, so we can get in to the really interesting thing about the vaccine. Here we go: 

• Yes, the vaccine was developed at break neck speed, but that was (1) because it was building on existing technology (2) manufactured and tested simultaneously (risking millions of pounds down the loo if it was rubbish) and (3) the regulatory bit was done in real-time along with the actual scientific studies. No corners were cut – I believe them!
• Nope, it doesn’t alter your DNA, give you long COVID, make you infertile or give you some other nasty disease. There is a much long answer to this question and most of that is around the difficulty in proving a negative, but at this stage there is nothing to suggest this vaccine is any different from any other commonly used one in those respects. 
• Yes it probably will stop you getting Covid, no it’s not 100% – not much in life is, but even if you catch Covid it will probably guarantee you won’t end up in hospital.

See, it’s a no brainer. Done and dusted and the précis probably better than a blogful of the technicalities. 

Let’s now look at the interesting bit. Who do we vaccinate, when and how? This is getting increasingly controversial as I write, which is a shame as it threatens to overshadow what is an amazingly good news story – the New No Brainer Covid Vaccine!

The first controversy was around the JCVI priority lists. Some questioned whether it was rational to immunize care home residents before health care workers. This is a bit of a storm in a tea cup, and Groups 1 & 2 are currently being immunized pretty much synchronously, and if anything it is group 1 that are lagging behind group 2. Personally I would have made it clear and simple and placed health and social care workers (including care home workers) and teachers in group 1, making it clear that “first do no harm” makes it essential we stop nosocomial, care setting and educational setting spread, albeit at the expense of delaying vaccination for the most vulnerable. You can debate it, but it’s probably not worth it. We have group 1 and 2 – now vaccinate everyone in those two groups and move on. 

Single doses (or delayed second doses) are where it gets interesting. We have a problem in the shape of a huge second wave that seems to have taken the country by surprise. It is New Year and we are already looking at the prospect of a near-lockdown and extended school closures. Will all the kids be back by 18^thJanuary? I suspect some may not. 

Faced with that, we need action and there are only two ways we can get the numbers down – stop people meeting and stop people carrying the virus. We are trying to stop people meeting, the fear is it is not working fast enough. I’d be surprised if the Tier 4 restrictions don’t prove effective soon, but equally it’s not like the March lockdown. If we did repeat the lockdown of last Spring I suspect we would see numbers plummet in just a few weeks, especially if key workers were rapidly vaccinated at the start of lockdown. Only allowing (vaccinated) key workers outside of their homes for a few weeks would come at significant social cost, but it’s the sort of measure that would have a huge impact. Will Tier 4 work? I just don’t know. 

If we assume that we won’t see a massive drop in infection levels to something similar to that which we saw last summer, then we have to resort to plan B to help our current crisis – rapid mass vaccination. 

The original plan with vaccinations was to work down the JCVI priority list, which is essentially in risk order (plus health and social care staff). Two vaccinations will be given at 21 or 28 day intervals, and that leads to significant protection (it’s a no-brainer, remember?) The problem is it takes too long. 

Too long means two things. Firstly, it is too long for the “pretty high risk” groups. Let’s take a hypothetical fit and well 72-year-old. There are some interesting online calculators that allow you to check when you are likely to be called for your vaccination. Assuming 1 Million vaccinations a week our theoretical citizen would be offered a first vaccination sometime between the end of March and the end of May. That’s an age away in Covid terms, and it’s a problem.

If we look at a hypothetical 50-year-old, we have a bigger problem. Their likely vaccination date is either in the summer (optimistic) or autumn (pessimistic) depending on how you model it. If we are really optimistic and assume they will be at the front of the queue by June of this year, the next question is whether they would accept a vaccine for a disease that is relatively mild in their age group at the time when disease prevalence is likely to be very low. Ask yourself a question – how many people “of my age” do you know who have died from Covid. Even as a doctor I only know two personally– one doctor and one patient. Most adults in this age group will not have personal contact with someone who has been badly impacted by Covid so it will remain a theoretical nuisance. 

If we roll forwards to September 2021, with a standard two vaccination strategy we are likely to have been able to vaccinate all our consenting health and social care workers and high risk patients down to the age of, say, 70. We may have patchy uptake below that, but below the age of say 55 we might be looking at very low vaccination levels. At such low levels disease resurgence next autumn may be a very real risk, and I hate to be the bringer of potential bad news, but it’s not impossible next New Year could also be a stay-at-home affair. 

A single initial vaccine strategy has two benefits. Firstly, it should allow much wider vaccination of the higher risk groups to help reduce the impact of the second wave. Secondly it potentially will allow greater penetration of the vaccine down the risk groups before the disease (hopefully) takes its summer holiday again. Potentially that could increase our herd immunity levels by the percentage points needed to prevent major issues next autumn. 

There is understandable concern around the timing of second immunisations, and whether some patients may only ever have one jab, if they fail to come back after 3 months. Certainly that would be risky, but it is worth remembering that the trials seem to show the large majority of vaccine benefit happening after the first injection, with the second “topping up” that immunity. We don’t know the optimal interval between the first and second injection. It may be 21 days, 3 months, or a year. The boosters were given at the prescribed interval in the studies because that was felt to be the most appropriate interval given the immune data and it’s a pandemic so we don’t have time to run a 6-month booster arm in the study. 

What we do know is – having some antibody is massively better than having none at all. It also matters that everyone has at least some antibody. So if you and I are the only inhabitants of Planet Covid and we have two vials of vaccine, it’s obvious that having one each is much more sensible than one of us having both vials. 

The message I take home from this whole debate is simply this: We have a problem, which is Covid. We only really have one route to normality, which is mass vaccination. In turn, and this is the interesting bit, its simply not about personal protection. What we are trying to achieve is not perfect 100% immunity for individuals to allow them, as individuals, to return to a normal life. This is about us as a community. We need, as a community, to suppress this virus, and that means as many people as possible developing some immunity for as long as possible. As time goes by we will learn about the optimal interval for boosters, and I suspect it will be part of the annual flu vaccine ritual for many of us. 

Now – well we have no time to lose. We need to vaccinate rapidly at massive volumes, the more people we vaccinate now the more likely our return to something nearing normality. 

Jonathan Inglesfield

January 2021