Abstract
As SARS-CoV-2 infection has spread in populations around the world, the original genetic code has acquired significant heterogeneity, with the emergence of multiple variants of concern. 1 Some of these, most notably the Beta and the Delta variants, show the ability to partially evade immunity conveyed by vaccination or previous infection.2,3 Increasing vaccination availability around the globe must be urgently supported, not only for the benefits to those populations, but also since each additional infection increases the likelihood of further genetic diversity developing. With global cases of SARS-CoV-2 still so high, we should anticipate and plan for the emergence of future strains which have increased resistance to vaccination-induced immunity.
The extraordinary efforts of healthcare workers and volunteers in delivering the SARS-CoV-2 vaccination programme across the UK has led politicians to ease lockdown restrictions. Even with high coverage, by highly efficacious vaccines, 4 new cases of COVID-19 remain high, but the link between infection and serious illness has been significantly weakened. Future variants that are more able to elude vaccine-induced immunity could, however, rebuild this connection, threatening the gains that have been made. With such a transmissible pathogen, serious illness and death could only be prevented by either re-imposing strict lockdowns, that come at a high social, economic and psychological cost, or by revaccinating the population with modified vaccines effective against the novel strains.
Modifying existing SARS-CoV-2 vaccines against new variants will carry considerable challenges, not least in identifying which variants to target. Designing the new vaccines, and ensuring safety and efficacy, will inevitably take time, during which infections may continue to spread. Nonetheless, it is likely that the production of vaccines will accelerate in the future, as facilities are built and strengthened, and experience in mass vaccine production increases. Vaccine availability, therefore, may not be the limiting factor in inoculating the UK population, but rather the capacity of the infrastructure to rapidly deliver revaccination with boosters. While it has been an extraordinary achievement that, by 19 September 2021, 89.4% of the adult population have received at least one dose in the nine months since the first COVID vaccine became available, 5 we must establish ambitious new pathways able to roll out boosters over a much shorter timescale. These pathways must reduce the burden of vaccine delivery on primary care, which is over-stretched, exhausted and needs to devote its energies to catching up with the clinical care of their patients that has been disrupted over the last 18 months. Furthermore, the logistical challenges of delivering the annual influenza vaccination programme alongside the COVID-19 booster programme would be considerable.
In order to achieve rapid revaccination of the population, there are a number of issues that should be urgently addressed, so that the UK is well-placed to be able to respond to future variants, while reducing the likelihood and severity of lockdowns. Below we outline a number of proposals which would facilitate a timely rollout and greatly reduce the burden on healthcare workers.
Consent
Ensuring informed consent is critical, and helps to build vaccine confidence. Unlike the annual influenza vaccination, consent for a COVID-19 vaccine can currently only be taken by a registered healthcare professional, which is a significant bottleneck to rapid rollout. We propose a legislative change to support obtaining informed consent in advance of attendance via an online process. Individuals booking a vaccination appointment would be presented with information in their preferred language about the process, the vaccine and the possible side effects. There would be the facility to allow people to ask questions by phone or text, with support from a national team of healthcare professionals, to ensure participants are happy to provide their consent. On attendance, the vaccinator would confirm that they had completed the consent form themselves and are still happy to continue with vaccination.
Reservist vaccinators
During the pandemic, the provision has already been made to allow non-healthcare staff to become vaccinators. 6 In order to reduce the burden on NHS staff, and increase the rate at which vaccines can be given, we would encourage the Government to consider identifying and training a large number of ‘reservists’ who could be called upon at short notice to deliver community vaccinations. Mirroring the long-established system for reservists within the army, the wages of individuals would be met by the Government and not the employer during their period of secondment. 7 Identification and training of reservists would be focussed, relevant, and comprise online modules and practical sessions. Companies would be incentivised to identify and support interested individuals who could be released for periods of vaccination work.
Community vaccination
At present there are around 2000 sites in England delivering COVID-19 vaccines. 8 If a new booster vaccine were recommended for all adults aged over 18 years, 9 this would require 22,000 doses to be given on average by each location, taking many months. Furthermore, it is likely that many of the large sites currently in use, such as stadia and conference centres, will be returned to their original purpose, and consequently be unavailable for vaccine administration. Consideration should be given to the benefits of increased use of community sites, such as village halls and places of worship. This approach would greatly reduce the numbers of vaccines that would have to be delivered at each site, and in combination with the removal of bottlenecks and increased staffing enabled by reservist vaccinators, has the potential to significantly reduce the duration of vaccine rollout.
Summary
We must shake off the belief that now that the majority of the population has been vaccinated, everything will settle back to normal in this country. Until immunity is achieved in populations around the globe, we may have waves of new COVID-19 variants for years to come. We must work to reduce barriers to rapid revaccination, and build a highly parallelised system based on a reservist workforce able to vaccinate our population rapidly in a greater number of vaccine delivery venues. This would best protect the population against future vaccine-resistant variants while freeing up our highly trained healthcare workers to concentrate on other health priorities. This will require legislation, effort and investment, but the benefits to the health of the nation, as well as to the economy, would be substantial.
