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The COVID-19 wrap: boosters and equity concerns, UK lessons, and a case study of pandemic communications

Since March 2020, public health researcher Alison Barrett has spent many long hours compiling the COVID-19 wrap for Croakey readers. Below, she reports on a recent presentation about this column, and also investigates the rollout of booster vaccinations, equity concerns and some wide-ranging COVID lessons from the UK.


Alison Barrett writes:

The rollout of booster vaccination in Australia and other countries is highlighting concerns about global vaccine equity at a time when some countries have vaccinated less than five percent of their eligible population.

On 28 October 2021, the Australian Government announced that all Australians who are 18 years and older could book a COVID-19 vaccine booster dose when at least six months has passed since the second dose of their primary COVID-19 vaccine regime. This will take effect on 8 November 2021.

Based on recommendations by the Australian Technical Advisory Group on Immunisations (ATAGI), the Pfizer-Comirnaty vaccine will be administered for the booster dose regardless of the primary vaccine used.

This means that people who were immunised with Vaxzevria (AstraZeneca) in their first round of vaccines, will be given Pfizer-Comirnaty for their booster, unless they experienced an adverse reaction to a previous mRNA vaccine (Moderna or Pfizer-Comirnaty). In this situation, Vaxzevria will be administered as the booster.

As with the initial vaccine roll-out, ATAGI recommend that people at greater risk of severe COVID-19 or occupational risk of COVID-19 will be in the highest priority groups for the booster dose.

Countries including, but not limited to, Canada, Singapore and Germany have begun administering booster doses to specific population groups, including immunocompromised and older age groups.

Australia and Israel are the only two countries offering booster doses to a large majority of their populations. Australia’s booster dose is currently only for people aged 18 and over; since 29 August, Israel’s booster program has included everyone 12 years and older.

Following months of decreasing COVID-19 cases and loosened restrictions, Israel’s case numbers increased from late June to September 2021.

It is likely the increase in case numbers was due to a number of factors: the more-infectious Delta variant; lifting restrictions before 80 percent of the entire population were vaccinated; and waning immunity amongst those vaccinated.

Amid concerns about an increasing number of vaccinated people in Israeli hospitals and waning vaccine immunity, the Israeli Government began a booster dose program for people aged 60 and older on 30 July 2021.

Case numbers in Israel have dropped considerably since reaching a peak of 11,026 cases in September 2021. On 30 October, they reported 625 confirmed cases of COVID-19

It is important to note that the huge decrease in cases in Israel could be due a combination of factors, including the booster program, which has since been rolled out to everyone aged 12 years and older.

In addition to the booster program other measures employed to manage COVID-19 in Israel include mask mandates, rapid antigen testing combined with widespread PCR testing and changes to their “green pass” so that only those who have received a booster dose can enter indoor venues.

Much of the research about the duration of vaccine immunity in real-world settings is still in its infancy and some studies not yet peer-reviewed.

However, last week a peer-reviewed analysis of COVID-19 infection and disease data in Israel was published in The New England Journal of Medicine. The study found that while the Pfizer vaccine provided protection after six months from the vaccination date, the vaccine effectiveness was lower than when closer to the vaccination date.

This finding indicates that vaccine immunity from Pfizer in the real world does wane, and is consistent with the six-month follow up of the Pfizer randomised controlled trial.

A study has recently been published, again in The New England Journal of Medicine, with results from Israel’s initial booster program for people aged 60 years and over.

When the authors compared data from people who received a booster with those who had not, they found that those who had not received a booster dose were 11.3 times more likely to acquire COVID-19 than those who had received a booster.

They also found that those who had not received a booster were 19.5 times more likely to get severe COVID-19 than those who received a booster.

The authors included a large sample size, which increases confidence in the effect and they were able to account for some known variables that may explain the outcome.

However, the study limitations include that the authors acknowledge they may not have measured or adequately corrected for some sources of bias, such as different healthcare-seeking behaviours between people who receive a booster and people who did not.

They also did not adjust for pre-existing conditions that may influence severe COVID-19, and the follow-up period was short.

Dr Susan Ellenberg, a biostatistician at the University of Pennsylvania, and Dr Ellie Murray, an epidemiologist at Boston University, shared caution about the findings of observational studies such as this, as it is difficult to identify and adjust for all types of biases.

However, “even if not all biases have been eliminated,” Dr Ellenberg said, “the magnitude of the effect suggests that the booster offers some protection, at least in the short term.”.

On 4 August 2021, the World Health Organization’s Director-General, Dr Tedros Ghebreyesus, called for booster doses to be delayed “until at least the end of September, to enable at least 10 percent of the population of every country to be vaccinated.”

Booster doses means that low-middle income countries will have reduced access to vaccine supply, allowing COVID-19 to spread in these countries, resulting in many more people becoming ill or dying, and new variants emerging.

Dr Ellie Murray said, “From a public health perspective, it’s way, way more impactful to get more people vaccinated than it is to boost the vaccine effectiveness by a few percentage points in those who have already gotten the vaccine.”

Many people have still not received one dose of COVID-19 vaccine. Only two percent of people in Papua New Guinea, Australia’s closest international neighbours, have received one dose of a vaccine.

This map highlights the disproportionate distribution of vaccines across the globe, where less than 10 percent of people living in African countries have still not received one dose.

While distribution of booster doses will likely widen the vaccine gap, an editorial in Nature Journal on 17 August made the case for booster doses for some groups of people, including transplant organ recipients who are immunocompromised.

In short, it appears that while boosters of Pfizer-Comirnaty appear effective in reducing COVID-19 infections and severe COVID-19, and may be beneficial for some groups of people, it is crucial to act on equitable distribution of vaccines.

Australia’s booster dose regime will begin next week; however, as Associate Professor Lesley Russell outlined in her recent Health Wrap, Australia has a role in improving vaccine supply for low-middle income countries.


From the UK: lessons learned to date

A report by the United Kingdom’s ‘Health and Social Care’ and ‘Science and Technology’ committees was published on 12 October 2021 outlining their joint findings from inquiries examining the British Government’s response to COVID-19.

Their findings are divided into six key areas of the response and recommendations for improvements. Some key points from the report are summarised below.

1) The country’s preparedness for a pandemic

Prior to the COVID-19 pandemic, the Global Health Security Index had found that the UK were the second most prepared country for a future pandemic.

However, the new report found that the UK’s pandemic response was predominantly based on influenza, not considering lessons learned from SARS, MERS and Ebola pandemics, and asymptomatic transmission.

The National Risk Register is the UK Government’s evaluation of the potential impact of a range of public emergency risks, including natural hazards, diseases, major accidents, societal risks, and malicious attacks.

The last version of the National Risk Register prior to the pandemic was published in 2017 (it has since been updated in December 2020), in which the register greatly underestimated the risk of a non-influenza infectious disease outbreak, stating: “the likelihood of an emerging infectious disease spreading within the UK is assessed to be lower than that of a pandemic flu.”

The inquiry found that the UK implemented its Influenza Preparedness Strategy 2011 as the basis of its early response to COVID-19.

As such, they were greatly unprepared for a coronavirus pandemic.

However, the authors wrote: “it is the nature of preparing to face future risks that there will be much that must be unknown about them. Perfect foresight, and therefore a perfect response, is not available.”

Some positive responses were highlighted in the inquiry:

  • The Armed Forces played an important role delivering a mass testing program and in the vaccine roll-out.
  • The National Health Service (NHS) and NHS volunteers played a vital role in distributing vaccines, but it is acknowledged that it was an administrative burden to manage.
  • Nightingale hospitals helped increase capacity of acute hospital beds during the first wave of the pandemic.

Recommendations from the inquiry

  • Include greater diversity of expertise in the framing of future National Risk Register and plans; learn from international practice.
  • Establishing a volunteer reserve in the NHS may be beneficial if human resources are required rapidly in future.
  • The NHS should develop and publish new protocols for infection prevention and control in pandemics that cover staffing, bed capacity and physical infrastructure.

2) Use of non-pharmaceutical interventions such as border controls, social distancing and lockdowns

The inquiry found that advice from scientific experts in early stages did not include enough learnings from international responses to COVID-19. Members of parliament found it difficult to challenge scientific experts, when their own perceptions of response management were based on instinct.

The authors reported: “The UK, along with many other countries in Europe and North America made a serious early error in adopting {a} fatalistic approach” that “the public would not accept a lockdown for a significant period”.

As a result, the Government chose to slow down the speed of the virus’ spread in the early stages (February through to early March).

Rather than do everything possible to prevent the spread, as Singapore, Taiwan and South Korea were doing, with strong physical distancing and isolating requirements, the Government decided to take a gradual approach to introducing non-pharmaceutical interventions.

“As a result, decisions on lockdowns and social distancing during the early weeks of the pandemic—and the advice that led to them—rank as one of the most important public health failures the United Kingdom has ever experienced,“ the authors wrote.

By mid-March, UK government officials realised that a stronger approach was required and a major lockdown was ordered from 23 March 2020.

The inquiry highlighted that the lockdown was accompanied by clear public health messaging, “stay home, protect the NHS, save lives”, which was acknowledged as being successful in raising public awareness and understanding of the importance of the lockdown.

However, when divergent approaches began across the UK and across different jurisdictions in England in May 2020, the message became confusing.

For example, England started a gradual lifting of lockdown, with the message, “stay alert,” whereas Scotland remained in lockdown with the clear message, “stay at home.”

Recommendations from the inquiry

  • Due to scientific uncertainty in early stages, it may be appropriate to act quickly but cautiously, rather than wait for scientific certainty.
  • Greater questio