IF 2020 felt hellish, be warned that we aren’t out of the fire yet, even if we are moving in the right direction. Welcome to 2021, aka purgatory.
There is little doubt that vaccines hold the key to ending the pandemic. A recent predicted that vaccinating just 40 per cent of US adults over the course of 2021 would reduce the coronavirus infection rate by around 75 per cent and cut hospitalisations and deaths from covid-19 by more than 80 per cent.
But all this is still some way off. In the meantime, we will have to adapt to a middle ground where some people are protected but not others. As Adam Kleczkowski, a mathematical biologist at the University of Strathclyde, UK, points out, supplies of the various vaccines are limited, distributing them is challenging, immunity takes a few weeks to develop and the protection they offer isn’t 100 per cent.
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In the northern hemisphere, he says, the most likely scenario is a third wave of covid-19 in the new year, requiring further lockdowns and restrictions for up to five months. “Realistically, we’re in for a longer ride than we hope for,” he says.
Tim Spector at King’s College London, who leads the , also predicts a third wave. But if lots of healthcare workers and vulnerable people have been vaccinated, the mortality rate will be lower and the pressure on the healthcare system lessened, he said at a recent
The upsides of ever-widening vaccination will kick in around April, he said: “I’m optimistic that if we can just get our mental state together until Easter, we can hang on in there.”
There are still many things we don’t understand about this virus, however, and we may well be in for some surprises in the coming year that throw that trajectory off course. At the time of writing, for example, there was widespread speculation about the impact of a new variant of the SARS-CoV-2 coronavirus circulating in the UK that may be more highly transmissible.
In Australia, the goal will be to keep the virus from resurging as the summer fades into autumn, says epidemiologist Catherine Bennett at Deakin University in Melbourne. A recent outbreak in Sydney has led to new restrictions.
Nobody says purgatory is fun, but it does end. In the meantime, these are some of the big issues we face in the months ahead.
Vaccine roll-out
Now we have covid-19 vaccines that seem to work, the conversation has turned to who will get a vaccine, and when. A huge challenge will be ensuring that poorer countries can access doses.
In 67 low and lower-middle income countries, nine out of 10 people are set to miss out on a vaccine this year, according to an , a coalition spearheaded by Oxfam.
High-income countries have already snapped up more than half of the total of around of vaccines that have been allotted to date. If these were evenly distributed, it would be enough to immunise more than half the world’s population, given that most of the vaccines in development require two doses.
The UK has pre-ordered from seven developers, all at various stages of development. If they were all green-lit, and all needed two doses, this would be more than enough to immunise its residents twice. It also has options to buy 152 million more doses. The European Union has secured 1.3 billion doses, while Canada has bought enough doses to vaccinate five times its population.
COVAX, a vaccine allocation coalition co-led by the World Health Organization (WHO), is aiming to distribute 2 billion doses to 92 low and middle-income countries by the end of 2021 at a maximum price of $3 per dose. by the middle of 2021 in participating countries that have asked for doses in that time frame, and would cover 20 per cent of people in the other countries – those most vulnerable. To achieve this, COVAX still needs a by the end of 2021. It has no supplies of the vaccine made by Pfizer and BioNTech that is already being rolled out in some countries, including the UK and US.
The US has ordered enough doses of the vaccines created by Pfizer/BioNTech and Moderna to immunise 150 million people – less than half the population – by the end of June. It recently asked Pfizer for doses to immunise an additional 50 million people, but the firm has already promised all of the doses it can feasibly produce by mid-2021 toother countries.
Even in wealthy countries with adequate doses of covid-19 vaccines, immunising the entire population will take time. In the UK, it will take nearly a year, according to Jeremy Farrar, director of Wellcome and a member of the UK government’s SAGE advisory committee. “1000 vaccination centres each vaccinating 500 people a day for 5 days a week, without interruptions of supply or delivery, would take almost a year to provide two doses to the UK population,” he
The Pfizer/BioNTech vaccine doses bought by the UK are produced in Belgium and a no-deal Brexit could result in import delays at Channel crossings. The UK government has a contingency plan to airlift vaccines into the country if necessary.
“Canada has bought enough coronavirus vaccine doses to vaccinate its population five times over”
Restrictions and measures
Places that have effectively eliminated the virus, such as New Zealand and some parts of Australia, have already been able to end almost all restrictions within their borders for long periods of time. They may decide to aim for herd immunity before relaxing all coronavirus-related border controls. “We won’t be out of this until we have a nation which has had a full vaccination programme,” Australian health minister Greg Hunt .
Protecting an entire population – achieving herd immunity – might require vaccinating anywhere from depending on how effective the vaccines are at preventing severe disease and transmission. In countries that failed to contain the virus, the aim is to vaccinate the most vulnerable before easing restrictions. In the UK, , are at risk for other health reasons or work in healthcare or care homes. The hope is this could be done by spring.
In practice, many countries may decide to ease restrictions as soon as the number of people dying or in hospital with severe covid-19 begins to fall, even if case numbers remain high. This could start to happen once a significant proportion of older and vulnerable people have been vaccinated.
In the meantime, lockdowns are likely to continue to be part of life. And measures with minimal economic impact could continue well into 2021. Lynne Williams, a psychologist at the University of Strathclyde, says that vaccination should bethought of as just one of many layers of defence that we will need to use for at least the next six months. The others include hand washing, mask wearing and social distancing. This is becoming known as the model of pandemic defence: each layer has holes, but stack them up and it is much harder for a virus to sneak through.
How long immunity lasts
As vaccine trials only began a few months ago and this coronavirus is new to humankind, we don’t know how long immunity lasts, whether from infection or from a vaccine. But it is a good sign that the number of people who have been infected twice seems to be small so far. “Immunity works most of the time,” says Tim Cook at the University of Bristol, UK.
Studies of people infected with the virus suggest that while antibodies produced in response wane relatively quickly, measures of longer lasting immunity, such as levels of memory B-cells and T-cells, do persist for more than six months.
The initial protection from vaccination is likely to taper off over time, says Al Edwards at the University of Reading, UK. “The trouble is, we need to know how long that curve is,” he says. As larger numbers of people are vaccinated, it is also possible that the virus will evolve and regular vaccinations will be required, like with seasonal flu.
Immunity passports
The question of immunity is intricately tied to the idea of vaccination certificates. Organisers of entertainment events, for instance, might enforce proof of vaccination to make sure the virus isn’t spreading through the crowd. Airlines could do the same to try to prevent spread into countries that have infection under control. Indeed, the , Alan Joyce, has said he envisages this becoming necessary for all passengers on the airline’s long haul flights.
The main problem with the idea is that we don’t yet know how long a vaccine confers immunity for, nor whether it stops people from incubating the virus and passing it on.
Assuming that answers begin to emerge, it could be helpful for people to have certificates showing they have been vaccinated and when, as well as which product they received, as different vaccines may give different lengths of protection.
This wouldn’t be unprecedented. Some countries require visitors to show evidence of vaccination against yellow fever on entry. And some hospitals require healthcare workers to have been vaccinated against hepatitis B, a blood-borne virus that causes liver disease.
Vaccines against those viruses aren’t in short supply, however. So until everyone who wants a coronavirus vaccine has had one – which could take many years– placing restrictions on people who lack such a certificate would be impractical.
“I don’t think [vaccination certificates] are as much of a new concept as they might appear,” says Edwards. “But depending on what you want to do, it’s greyer than it seems.”
Mandatory vaccination
Many of us are eager to get vaccinated against covid-19. But what if you aren’t? Will governments force you to do so?
“I think all of us who work in public health would rather avoid that as a means of getting people vaccinated,” Michael Ryan of the WHO
Policies worldwide are already diverging. For instance, President-elect Joe Biden has said to have the vaccine. The UK has no plans to make it mandatory but hasn’t ruled it out, while the state of São Paulo in Brazil has said by law. Australia already withholds some benefits from parents whose children don’t receive vaccines for other illnesses.
Even where vaccination isn’t required by governments, people might still end up feeling obliged to get vaccinated. For example, in some countries, workplaces, schools, sports arenas or entertainment venues might demand proof of vaccination. Care homes, in particular, might insist that workers and visitors have had a shot, as even if all residents have been vaccinated there is still a risk a few of them could get covid-19 because the vaccines are not 100 per cent effective.
Could health insurers refuse to pay for treatment if people who refuse vaccination develop covid-19? Lawrence Gostin at Georgetown University in Washington DC doesn’t think so. “The fact that an individual refused a vaccine does not affect the legal obligations of the health insurer to pay covid-related treatment bills,” he says. “I also think this is the ethically right decision.”
“In some countries, workplaces, schools, sports arenas or entertainment venues might demand proof of vaccination”
Vaccine hesitancy
About a quarter of the UK population is hesitant about getting a covid-19 vaccine. A recent paper by Daniel Freeman at the University of Oxford and his colleagues shows that , 6.1 per cent said they definitely wouldn’t take a covid-19 vaccine, 5.7 per cent that they probably wouldn’t, 12.7 per cent may or may not take it and 1.6 per cent don’t know.
“What I find concerning is there’s a substantial minority of people where there seems to be a divide with mainstream medical scientific opinion,” says Freeman. For example, 1 in 5 people think safety and efficacy data has been made up. The two drivers for hesitancy seem be the misplaced ideas that covid-19 is no worse than the flu, and that vaccine safety isn’t established.
In the US, . Another quarter are unsure and the remaining quarter say they won’t take it, according to a recent survey.
Patrick Vallance, the UK’s chief scientific adviser, says hesitancy falls into several groups. “The vast majority of people want to get vaccination. There’s then a group with a legitimate set of questions: how do I know it’s safe, is it right for me? Many of the people labelled as vaccine hesitant actually just have a series of questions that need to be addressed,” he says. “Then there’s a third group, of anti-vaxxers, and you’re never going to persuade them come what may, but they are a very, very small group.”
Return to normality
After the first results showing the Pfizer/ BioNTech vaccine to be effective, John Bell at the University of Oxford that life in the UK would return to normal by the spring. His view is a very optimistic one. Most think something resembling normality, with widespread social mixing in public places, homes and workplaces, will come later. Depending on vaccine supply, that will come later still in other parts of the world.
Even these forecasts may yet change. As Farrar tweeted on 19 December in response to the news of the new SARS-CoV-2 variant in the UK: “Since Jan 2020 much of this pandemic has been very predictable…
Unanswered questions
Back in March 2020, the World Health Organization (WHO) published a document setting out the known unknowns about the SARS-CoV-2 coronavirus and covid-19, which also served as a global road map for research. A spokesperson for the WHO told żěè¶ĚĘÓƵ that while good progress has been made so far, “urgent questions remain”.
These include:
• The origin of the virus, and exactly how it spreads
• The strength and duration of naturally acquired immunity
• How best to treat people, and the development of highly effective treatments
• How to win public acceptance for restrictive control measures
• Development of low-cost, high-volume, rapid diagnostics for infection and immunity
• Making absolutely certain the vaccines really are as effective in the real world as they have been in trials
New questions have also arisen since March, especially around the long-term effects of the virus, and the evolution of new strains. żěè¶ĚĘÓƵs will urgently seek to answer all these in 2021.
