Tackling the big four vaccine challenges

By Jim McManus | 24 February 2021

I often have colleagues say to me that six months ago everyone was asking why the vaccine was taking so long, and here we are with nearly 15 million people given their first dose and counting. People are now asking why it was developed so quickly and surely that means it’s unsafe. ‘Twas ever thus with vaccines’, is my default response after many years of work on this.

We need a proper and nuanced debate about the vaccines, and in the speed and rush to move, that hasn’t always been visible, and that’s nobody’s fault. The fact that we have gone from no vaccine to three and counting in under a year remains one of the greatest scientific achievements of the last 80 years. And the fact so many have had their first dose is one of the greatest logistical triumphs I will live to see, despite the fact there are always challenges. We should celebrate this, and everyone who made it happen.

But while this is going on, let’s take stock of what we know about vaccines and what this means for the next year.  To cut to the chase, councils are crucial to a proper nuanced strategy for the use of the vaccine.

Firstly, let’s understand the vaccine’s place in an exit strategy for COVID; unlike many diseases, it seems we’re still uncertain about whether the vaccine eliminates transmission. It does prevent serious illness and death, so currently it’s a bit like a seatbelt - it may not prevent the accident happening, but could save your life. Let’s take that as a victory and not a reason to quibble. But it does mean the exit from the pandemic is not as simple as exiting with a vaccine which eradicates the virus.

Secondly, this virus will be around for some time. It’s not going away soon. And while a virus circulates, it does what viruses do: variants emerge because of biological pressure on the virus to become as efficient as possible at replicating itself. The B.117 variant (otherwise known as the ‘Kent’ variety) is now so prominent, it is essentially the predominantly naturally occurring or ‘wild’ type.

So we will be living with SARS-CoV-2 circulating for some time, not eradicating it like we did with some other viruses. That means we need to think carefully about our strategies for a virus we haven’t quite seen anything like before. What should our approach be then?

Well, we have enormous learning about vaccine uptake and we also have huge learning from other diseases that we can apply here, and there are lessons in the SARS-CoV-2 response already making an impact from this public health treasury. Firstly, we need to ditch ‘all or nothing’ thinking; the idea that test, trace and isolate must be utterly perfect before lockdown, or the idea that lockdown is a perfect tool.  Why? Because where we have had major successes in the past with diseases, it has been on the basis of multiple imperfect strategies that all make a contribution, rather than a ‘silver bullet’. Penicillin needed nutrition and nursing care alongside it for people to recover from what was otherwise then a deadly infection.

Combination Prevention not ‘all or nothing’

So, we must ditch ‘all or nothing’ for the idea of Combination Prevention – a series of interventions, all of them by themselves imperfect but together effective. It has served well in many diseases. For SARS-CoV-2 that means physical distance, plus face coverings, plus test, trace and isolate, plus vaccines, plus safe working procedures; no one alone is sufficient, but all are necessary. 

Each working imperfectly but improving the overall outcome has better results than one alone. While not a virus, malaria is a good example; we haven’t eradicated it, by any means, but a combination strategy of draining stagnant bodies of water, mosquito nets, prophylactic drugs, releasing infertile mosquitos into the wild, pesticides and more, put together, are more effective than any one alone.

So the vaccine is one part of our effort, not the whole thing. Even if it does prove that the vaccine stops transmission, the existence of those pesky variants may well mean the vaccine will be updated for new variants and populations re-vaccinated annually. This virus plans to outstay its welcome and we need to have plans ready for that.

That also means we need to have as many people take up vaccination as possible. A large slice of the population unvaccinated means the virus will still kill and harm in those populations, and means our success in negotiating how we work, live and study while SARS-CoV-2 remains a reality, has an unacceptably large Achilles’ heel.

So how do we make the vaccine as effective as possible? Well there’s the science of making it effective, but we have decades of knowledge about making vaccines punch above their weight, and directors of public health are your go-to anoraks at a local level on this. Here are some key principles and actions:

First, realise that any large healthcare push creates inequalities because of the size of the task. That’s not a criticism, it’s just fact; those with fewest barriers to care find it easiest to take up. That’s one way of expressing the inverse care law that governs inequity in healthcare. 

Focus on the Big Four

Secondly, combatting this depends on what I call ‘The Big Four’ sets of issues being resolved. Each set is complex and needs careful thinking through, but we have decades of experience on this, so we need to learn from what works already, not reinvent the wheel:

  • Structural Barriers to Equitable Access – is the centre accessible? How will you remind people? Are NHS and employer lists accurate? What about folk not registered with GPs?
  • Hesitancy – this is equally complex from questions of safety to cultural issues, ethical acceptability of the vaccine and attitudes to health. We have  40 years, there is a wealth of knowledge and research on this.  You can read a summary of our local research on this here[1].
  • Data – granular data which lets us pinpoint inequalities in take-up and monitor them is crucial; it’s coming, but it’s a work in progress still.
  • Disinformation – this is one area where you need to be really careful. The best way to combat this is to be confident about the facts and articulate them calmly. Don’t get drawn into debate about the conspiracy theory du jour.

Recently several countries have moved beyond vaccine hesitancy to the concept of ‘vaccine confidence’, staff and community leaders people can identify with – ‘people like me’. Those who are confident in giving accurate, dispassionate information on vaccines can significantly reduce hesitancy and questions and increase uptake. Put pro-active, visible, confident, knowledgeable champions in communities and workplaces and take-up will improve.   

Councils are indispensible in this; from site identification, to finding communities of unregistered people, to creating vaccine-confident community leaders. Logistics teams in councils, like my amazing colleagues here at Hertfordshire CC, have proven themselves allies to the huge work by NHS on vaccine roll-out. My colleagues running the Herts logistics team identify, kit-out and manage sites for the NHS and HR, even recruit staff for NHS colleagues. Logistics, resources, Fire Service and LRF capabilities here are unparalleled.

Public Health, social care, children’s services and EHOs working together with elected members meanwhile are focusing on other aspects of the Big Four. By the time you read this we will have delivered over 50 live sessions to local communities and workforces about the vaccine, based on vaccine confidence, and we already have a coalition of voluntary, faith and community organisations producing information in multiple languages.

We’ve learned through this pandemic that councils are indispensable public health organisations. We have learned that Combination Prevention is the best viable strategy going forward for now. We now have the opportunity to show that councils, by creatively taking on “The Big Four”, alongside the NHS and communities can create vaccineconfident communities.

You want to recover and build back fairer? Create vaccine confident communities and services. Councils Can.

Jim McManus is vice-president of the Association of Directors of Public Health and director of public health at Hertfordshire CC

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