What next for the UK’s COVID-19 vaccination programme?

INSIGHT –

The UK’s coronavirus (COVID-19) vaccination programme has made impressive progress since launch, with around 30% of the population given their first dose by the end of February. Despite the fact the programme has broadly been a success to date, there are a number of challenges and questions that remain.

The UK vaccination programme so far…

As of 24 February 2021 the UK had given a first dose to 28% of its population; no other European country had managed more than 5%. The Government’s ambitious targets for 15 February were met, with over 15 million people vaccinated, and almost everybody in the four highest priority groups offered a vaccine. The UK is on track to vaccinate all those over the age of 50 by early May and for all adults to be offered their first dose by the end of July.

However, whilst the programme has broadly been labelled a success, some challenges and queries remain: how quickly will the programme translate into reductions in deaths and hospitalisations? How do we ensure people have equal access to the vaccine? How can we continue to scale-up the roll-out of the programme? How do we manage supply and demand of the second dose.

In England, around 28 million eligible individuals are yet to be vaccinated – around two-thirds of the population
Cumulative vaccine up-take as at 21 February 2021, 17,723,840 administered

Source: UK Government, 2021

Challenge 1: The effect on deaths and hospitalisations will be slow

The Government’s 15 February target was a promise to offer a first dose to the 15 million individuals at highest risk – not a promise to vaccinate everyone, nor a promise of maximum benefit (which would require second doses to have been administered). This and the lag between vaccination and an individual developing immunity, means it will take some time to see evident changes in the main statistics that are used to track the pandemic.

The degree to which the vaccine will affect each of the performance indicators (number of cases, hospitalisations and patients requiring critical care, and deaths) will vary – primarily due to the demographic of those being vaccinated. Deaths from COVID-19 have been more prevalent in the population aged 70 or over, many of whom have now been vaccinated, so we should expect to see deaths fall quickly assuming people built immunity in a reasonable time and maintain the social distancing measures. Cases, however, are likely to be more prevalent in the younger population, and so change in these metrics is likely to be slower.

  1. Number of cases. This will be the last metric to be noticeably affected by the UK’s vaccination programme – primarily because most cases and the spread of COVID-19 are among those younger than 50, while almost all vaccinations until May will be those older than 50. Though vaccination will avoid some cases immediately (for example, those resident in care homes and communities), the national lockdown is going to be pivotal in managing cases in the younger population.
  2. Number of hospitalisations and patients requiring critical care. These two indicators are central to the NHS’s ability to cope and our ability to exit lockdown measures safely – the impact of the vaccination programme will be different on each. Patients in critical care are primarily younger (nearly half are younger than 60, fewer than 5% are older than 80), whereas overall hospitalisations are primarily of older people (two-thirds are older than 60; a third older than 80). We can therefore expect hospitalisations (especially if we look specifically at those in their 70s) to begin falling; critical care capacity will take much longer to recover.
  3. Deaths. This is the indicator that should be most quickly affected by the vaccination programme, as those older than 70 account for 84% of the deaths from COVID-19 (this rises to 88% for all those in the top four priority groups). Because we do not know how many deaths there would have been had we not had a vaccine, assessing the precise effect of vaccination on deaths (and in particular the difference between one and two doses) is difficult. Falls in the number of deaths cannot just be attributed to the vaccine. One approach being taken is to compare the reduction in deaths among those in their 80s with the reduction in deaths among those aged 60–69, the majority of whom have not yet been vaccinated.

Challenge 2: Inequity of access to the vaccine will create (and worsen) health inequalities

We have long known that the inverse care law applies to accessing health care in the UK – those that most need care (such as those from deprived areas) are often the least likely to be able to access it. We also know that COVID-19 has disproportionately affected individuals from certain minority ethnic groups, and from more deprived areas – and that these groups tend to be more vaccine-hesitant, and can find it harder to access health services.

The Joint Committee on Vaccines and Immunisation’s (JCVI) prioritisation advice to the Government is largely based on age, because the risk of death increases with age. Clinical risk is also taken into account (the ‘clinically extremely vulnerable/shielders’), with the NHS’s new model for this (released on 16 February) also accounting for an individual’s socioeconomic background (via their postcode) and ethnicity.

Within age groups, the NHS is trying to ensure that all people – regardless of deprivation, geography, or ethnicity – have equal uptake of the vaccine. This is important not just from an equity perspective, but for practical reasons too – until protection is widespread, we all remain at risk. However, despite this approach, early data suggests that inequalities are emerging.

Challenge 3: The supply and demand of vaccines (and vaccinators)

The Government has been very quiet on sharing information about the projected supply of Pfizer and Oxford/AstraZeneca vaccines – and we know that both companies had warned the EU to expect short-term shortfalls in doses. Without this information, it is hard to know both whether the current rate of vaccination of around 500,000 a day can be maintained, or even if it could be increased. Although supply has been a rate limiting factor, it is unclear to what extent workforce, space and time would be sufficient to deliver the vaccine.

The need to offer second doses

In February, England has been vaccinating at the rate of up to 2.4 million doses per week. 99.5% of these are first doses. By the end of March, the million people given their dose in the first week of January will have to have had their second dose; by late April, all of the 2.4 million given their first dose at the beginning of February will need to have their second dose.

If the dose rate averages 2.5 million doses per week, by the end of April all vaccination capacity will be focused on second doses. The next round of first doses will then start ramping up during June with everyone being offered their first dose by the end of July. Only by the middle of September will everyone 16 and older have been given two doses. To begin vaccinating new people the supply of vaccines will have to increase, as well as the capacity to deliver them. Given that the Government has now committed to offering a first dose to all adults by 31 July, we can assume that there is a level of confidence that supply will be sufficient.

Conclusion

The UK’s vaccination programme has delivered vaccinations at a higher rate than almost any other country in the world. Any programme rolled out at this scale and pace would be imperfect and not always be fair. But, thanks to its rollout led by the NHS – with the principle of equity at its heart, the shortcomings of this programme, when weighed against its successes (and the failures of other countries), are relatively minor.

That said, there are new challenges ahead. Differences in vaccine uptake that may look minor on a local level multiply when echoed across the nation, and on top of a crisis that has already disproportionately affected those from minority ethnic groups, and from more deprived areas only exacerbates the issue.

System planners should think about which inequities are most important, and address these through policy and system design, including how vaccines are allocated to different parts of the country, and increasing uptake among under-represented groups. For example, while it may be unfair that 80-year-old Londoners are receiving their vaccine a few weeks behind those in the north of England, it may be that the focus should be on addressing the systemic and ongoing lower uptake among more deprived populations, or certain minority ethnic groups. The latter is likely to require a substantial investment of time and in the workforce.

Of course, equitable uptake requires sufficient supply. The ability to offer vaccines to ‘new’ recipients after April will depend on how quickly new vaccines are approved and manufactured, and on the ongoing success of current supply chains.

Statistical and Contextual Sources:
UK Government, 2021
NHS England and NHS Improvement, 2021
Office for National Statistics, 2021
The Health Foundation, 2021