Implementing Plan B (and C?)
First, a little chronological review. On 8 December,
Boris Johnson, the UK Prime Minister, confirmed that,
because of the rapid spread of Omicron, Plan B, first set
out in September, would be implemented. He said that
moving to the tougher measures was the ‘proportionate and
responsible’ thing to do. So from 10 December, face
coverings became compulsory in most public places, such as
shops and public transport, as well as in cinemas,
theatres and places of worship, though with exemptions in
hospitality settings. On 12 December, following
advice from the four UK Chief Medical Officers, the UK
raised the Covid-19 alert level from Level 3 to Level
4. The latter is defined by the government as ‘a
Covid-19 epidemic is in general circulation; transmission
is high and direct Covid-19 pressure on healthcare
services is widespread and substantial or rising.’
From 13 December, people were again asked to work from
home if possible. From 14 December, double-jabbed
people who have been in close contact with Covid-19
patients could take lateral flow tests (LFTs) for seven
days rather than self-isolate for 10 days. Close
contact adults, who are unvaccinated, would still have to
self-isolate for 10 days. From 15 December, the NHS
Covid Pass on the NHS App became mandatory for entry into
nightclubs and other settings where large crowds
gather. In other words, the UK had entered into a
very, very serious situation.
No-one believes that Plan B alone will stop Omicron
spreading but hopefully it will slow its transmission to
allow more time to understand the variant and to expand
the vaccine roll-out, including booster jabs, and so
reduce likely threats to the NHS. Instead of the
predicted infection peaks occurring in early January, they
might now be stretched out over January and into February.
Plan B was outlined under four headings:
1] Expanding mandatory mask requirements to more
venues.
2] Changing isolation rules to allow contacts of
suspect Omicron cases to take daily tests.
3] Introducing Covid-19 passports for certain
venues.
4] Making it mandatory for NHS staff to get a
vaccine.
Plan B needed Parliamentary approval. On 14
December, having previously debated these four measures,
Parliament finally endorsed them with the closest vote
concerning so-called Covid passports – some MPs argued
this was ‘lockdown by stealth’. The Plan B
regulations are set to expire six weeks from their
implementation, with a review after three weeks. Two
questions arise – what is Plan C and when will it come
into force? It could include, for instance, reducing
people’s social contacts, which can be effective, but
disruptive. It could also require Covid-19 contacts
to isolate, extend Covid-19 passports to hospitality and
entertainment venues, require a wider use of lateral flow
tests (LFTs) and make facemasks mandatory in secondary
schools, all of which would likely be unpopular, but
probably effective.
Sensibly, neither politicians nor the medical community
ruled out the imposition of further restrictions.
And they came. From Boxing Day, 26 December, the
three nations, Scotland, Wales and Northern Ireland,
introduced various extra curbs on the hospitality and
leisure industries, resumed social distancing rules and
put limits on the size of gatherings. No further
measures were announced for England, but Boris Johnson
said he would not hesitate to act if necessary.
Where are we now? Plan B has been implemented.
In reality, it is more like an enhanced scheme, a sort of
Plan B+. What is in Plan C and when will it be
revealed? Will there even be a Plan D?
Throughout December, the citizens of the UK uttered two
cries, ‘Save our Christmas’ – accomplished. And
‘Please, anything other than another full-scale lockdown’
– accomplished, so far.
The Omicron variant
On 25 November 2021, almost 2 years since the first case
of Covid-19 was announced, a new variant of concern (VoC),
named Omicron, was reported in South Africa. Though
an anticipated event, the arrival of this particular viral
configuration was unusual because it is such a
highly-mutated coronavirus variant and therefore it posed
an unknown threat to the efficacy of Covid-19 vaccines and
antibody therapies. It brought with it two key
questions. How fast will it spread? How sick
will it make people? While data are still scarce and
inchoate, Omicron appears to be more highly transmissible
but of milder severity than other variants.
Omicron began to spread rapidly around the world with the
first UK case of hospitalisation reported on 11
December. On 13 December, it was confirmed that the
first UK patient had died with Omicron. Overall, it
has created general unease and uncertainty in this
viral-weary world. By mid-December it was becoming
clear that the UK was facing a substantial wave of Omicron
infections – case numbers were doubling every two to three
days. By the end of December, Omicron had overtaken
Delta as the dominant variant in the UK. According
to modelling data from the UK Health Security Agency, an
estimated 200,000 people might become infected with
Omicron each day. That proved to be a pretty
accurate guesstimate. Moreover, some scientists
reckoned that, without further restrictions, the total
number of deaths from Omicron could possibly reach between
25,000 and 75,000 by the end of April. Others
predicted more than 2,000 daily hospitalisations, with a
total of 175,000 hospital admissions and 24,700 deaths
between 1 December and 30 April. We must wait to see
if these doomsters were correct.
A high degree of uncertainty about Omicron exists.
More real-world, hard figures are awaited. More
transmissible? Yes. Less severe?
Probably. By late December, additional, yet still
preliminary, data were emerging from the UK Health
Security Agency. They indicated that people catching
Omicron are 50% to 70% less likely to require admission to
hospital compared with previous variants. That was
good news. NHS staff were cautiously delighted.
Though encouraging, consider this. The fact that
Omicron appears more transmissible but less severe, means
that it could infect more people though less
seriously. However, some, perhaps many, from that
numerically greater infected cohort, could still become
severely ill and require hospitalisation. In other
words, Omicron could still lead to increasing numbers in
hospitals and therefore still put unsustainable pressure
on the NHS. That was bad news. NHS staff were
cautiously disappointed.
Booster doses
So, the question of the month – how effective will current
vaccines be against the Omicron variant? Preliminary
data were not encouraging. Two doses of the
Oxford-AstraZeneca vaccine alone, that is, without a
booster, gave less than 10% protection against Omicron,
whereas the figure for two jabs of Pfizer-BioNTech alone
was less than 40%. However, when the Pfizer-BioNTech
vaccine was given as a booster dose those protection
figures rose to 71% and 76% respectively. These were
early days with limited numbers, but, long live
boosters! However, additional research has shown
that vaccine efficacy against Omicron starts to wane 10
weeks after the booster dose.
So, what to do? Obviously, ramp up the booster
programme. And so, starting from Monday 13 December,
everyone over the age of 18 in Britain was offered a
Covid-19 booster jab by the end of December. Ts
& Cs apply, such as a second vaccine dose must have
been administered at least three months before the
booster.
Logistically, this is an immense undertaking. It was
estimated that 15 million vaccinations must be
administered within three weeks, equivalent to about 1
million doses per day. On 13 December, the first day
of the ramped-up roll-out, the target was hindered because
the NHS booster booking website crashed and the demand for
lateral flow tests (LFTs) overtook supply. The
latter problem was exacerbated by new advice that
fully-vaccinated people should take daily tests for seven
days after coming into contact with a Covid-19
patient. Nevertheless, the scheme soon
stabilised. Healthcare workers were seconded,
walk-in clinics were constructed, opening hours were
extended and the military were redeployed to speed up the
campaign. There has been jabbing around the clock
and, in some places, even on Christmas Day.
Hooray for boosters! They are probably here to
stay. Maybe we will need extra jabbing every few
months or every year. So, is a fourth vaccine on the
cards? Israel has already started testing such a
scheme targeted at the vulnerable over-60s and healthcare
workers. We already have the essential vaccine
technologies, so why not improve them and use them?
Above all, the Omicron saga has shown that two jabs are
not enough – a third booster dose is needed to improve
immunity. The full-page newspaper advertisements
scream ‘GET BOOSTED NOW.’ It has become the UK’s
pandemic war cry.
New vaccine and new treatment
news
Vaccine makers are already busy – yes, even this very
day. Not only are they actively manufacturing their
already-approved products, but many are planning ahead and
tweaking their vaccines, especially against Omicron.
Some of these updated versions should be ready by early
2022, say, around March. In addition, new vaccines
and treatments are in the news, in trials and in cold
storage. It is estimated that researchers are
currently developing more than 300 novel products.
Of these, nearly 200 are being tested in Phase 1 and Phase
2 laboratory and animal studies while 40 are in large
international Phase 3 human clinical trials and a few are
actively seeking regulatory approval. Here is a
selection of the most ready so far – the news is not all
good.
On 4 November, the Medicines and Healthcare products
Regulatory Agency (MHRA) authorised the UK to become the
first country to approve the use of molnupiravir,
an oral antiviral drug, marketed as Lagevrio.
Interim data from clinical trials showed it could halve
the risk of hospitalisation for Covid-19 patients.
On 19 November, the European Medicines Agency (EMA)
informed EU member states that they too could use
molnupiravir to treat Covid-19 cases.
Strangely, this US product had not yet been approved for
use in the US. On 30 November, an advisory committee
of the US Food and Drug Administration (FDA) voted to
recommend its approval, but by only 13 to 10. Why
the delay and lack of accord? Simple. Full
trial data submitted to the FDA showed molnupiravir to be
less effective than originally thought. That
luminous 50% reduction in the risk of hospitalisation was
now reported to be a lacklustre 30%. Moreover, there
are now concerns about research suggesting that
molnupiravir can cause mutations in human DNA. Last
October, Britain bought almost 500,000 courses and in
December procured another 1.75 million. Were these
good buys?
In early December, the global healthcare giant,
GlaxoSmithKline (GSK) together with Medicago,
a Canadian biopharma company, announced preliminary
results from a Phase 3 trial of their plant-based Covid-19
vaccine. It is the first vaccine of its kind to
reach the stage ready to seek approval from regulatory
agencies. In the trial, with over 24,000 adult
participants and against various Covid-19 variants
including Delta, efficacy was recorded as 75.3%. The
vaccine was well-tolerated with no serious adverse effects
in the vaccine group.
What is the basis of this somewhat usual, and as yet
unnamed, vaccine? Medicago uses Nicotiana
benthamiana plants as bioreactors
to produce non-infectious, so-called Virus-Like Particles
(VLPs). VLPs are designed to mimic the physical
structure of the Covid-19 viruses so they can trick the
body’s immune system into recognising them as
hostile. But VLPs lack the core genetic material so
they are unable to replicate. Hence, any viral
attack is halted. Fascinating!
The Big Three vaccines approved for use in Britain are
owned by Oxford-AstraZeneca, Pfizer-BioNTech and
Moderna. What has happened to the Novavax vaccine
(officially known as NVX-CoV2373 or Nuvaxovid), that
fourth vaccine with such big promise? Indeed, the UK
government was so impressed by its interim trial results
of February 2021, which reported a 95.6% efficacy against
the original virus, that it ordered 60 million
doses. However, subsequent studies reported reduced
efficacies of 90.4% in a Phase 3 trial and 51.0% in a
Phase 2 trial against Beta. Further difficulties and
delays with manufacturers, scientists and regulators,
especially the FDA, seem to have scuppered Novavax’s early
promise.
Have these delays disqualified Novavax from joining the
Big Three? In late November, Novavax submitted its
final trial data to the UK Medicines and Healthcare
products Regulatory Agency (MHRA) and the European
Medicines Agency (EMA). Approval by the latter was
granted on 20 December – the European Union (EU) has
already signed a deal to buy up to 200 million
doses. Novavax remains hopeful that, by the end of
2021, it will be able to manufacture 150 million doses a
month and that the pending authorisation problems will be
solved. In the meantime, Novavax has reported
commencement of human trials of its new Omicron-specific
vaccine in early 2022.
And where is that one-shot Janssen vaccine
manufactured by Johnson & Johnson? It was
approved for use in the UK in May 2021 with doses due to
be delivered by the end of this year. The UK ordered
20 million doses, but, somewhat oddly, these are now
destined to be donated to developing countries, via the
COVAX initiative, as soon as they come off the production
line in 2022. Is this a case of ‘vaccine
dumping’? The Janssen vaccine has been associated
with rare but serious blood clots and some deaths and
subsequently downgraded for use in the USA.
The Covid-19 vaccine produced by the French biotechnology
company Valneva (officially
known as VLA2001) looked set to be another effective
weapon in the armamentarium. Functionally, unlike
most other Covid-19 vaccines, it targets not just the
spike protein of the virus but rather the whole virus.
In February 2021, the UK government increased its order of
60 million Valneva jabs by securing an extra 40 million
doses of this ‘promising vaccine candidate’ for delivery
in 2021 and 2022. However, in September, before the
Phase 3 trial’s data had been reviewed, the UK Health
Secretary, Sajid Javid, announced that the Valneva vaccine
would not be approved by the UK Medicines and Healthcare
products Regulatory Agency (MHRA). At the same time,
the UK announced it was cancelling its 100 million dose
contract with Valneva, a deal worth £1.2bn. What,
why? Apparently, Javid had ‘misspoke’ and meant to
say that the vaccine had ‘not yet’ been approved.
A month later, in October, Valneva reported efficacy data
similar to those for the Oxford-AstraZeneca vaccine
suggesting that UK authorisation could be imminent.
The decision from the MRHA is expected by the end of 2021
with initial approval probably for use in 18 to
55-year-olds. Meanwhile, on 10 November, an
agreement for supplying up to 60 million doses was reached
with the European Commission (EC) for delivery starting in
2022. With considerable foresight the EC president,
Ursula von der Leyen, stated that, ‘The contract allows
for the vaccine to be adapted to new variants.’ Or
was that transaction simply an advertisement designed to
instil confidence in other potential buyers?
Politics and medicine can be strange bedfellows.
And there is Sotrovimab.
Who names these medicines? At the beginning of
December, sotrovimab, commercially known as Xevudy, was
approved by the UK Medicines and Healthcare products
Regulatory Agency (MHRA). It is another monoclonal
antibody (like AstraZeneca’s Evusheld). Developed by
GlaxoSmithKline (GSK) and Vir Biotechnology, based in San
Francisco, sotrovimab works by binding to the spike
protein on the Covid-19 virus. This in turn prevents the
virus from attaching to and entering human cells, so that
it cannot replicate in the body.
In clinical trials, a single dose of Xevudy was found to
reduce the risk of hospitalisation and death by 79% in
high-risk adults with symptomatic Covid-19
infections. It was found to be most effective when
taken during the early stages of infection and so the MHRA
recommends its use as soon as possible and within five
days of symptom onset. Sotrovimab is administered by
intravenous infusion over 30 minutes. It is approved
for individuals aged 12 and above who weigh more than
40kg.
Dr June Raine, MHRA Chief Executive, commenting on
Xevudy’s approval said, ‘This is yet another therapeutic
that has been shown to be effective at protecting those
most vulnerable to Covid-19, and signals another
significant step forward in our fight against this
devastating disease.’
On 22 December, Paxlovid, the
take-at-home, twice-a-day, oral antiviral drug from
Pfizer, became the first such pill to be authorised by the
US Food and Drug Administration (FDA) to treat
Covid-19. In trials it achieved a nearly 90%
reduction in hospitalisations and deaths among those
patients most likely to get severe Covid-19. In
October, the UK government purchased 250,000 courses of
Paxlovid and in December signed a contract for 2.5 million
additional courses. The drug finally received
approval from the UK’s Medicines and Healthcare products
Regulatory Agency (MHRA) on 31 December.
Vaccine mandates, or mandatory or
compulsory vaccinations
Fact 1: vaccination is the principal tool that every
country, every jurisdiction, is currently using to fight
the Covid-19 pandemic. Fact 2: already Covid-19
vaccinations have undeniably saved millions from death and
serious illness. Fact 3: some people struggle with
vaccination hesitancy or vaccination refusal. Fact
4: mandatory or compulsory vaccination is a thorny
issue. But it is not a new issue. Way back in
1853, the UK’s Vaccination Act made jabs against smallpox
compulsory for infants under 3 months old. Parents
who failed to comply were liable to a fine. It was
in the name of public health that governmental authority
was challenging traditional civil liberties. Yet
this strategy of a vaccine mandate caught on and as a
result the often-deadly disease of smallpox was
essentially eradicated worldwide.
The UK and most other countries in the developed world
have made vaccination their primary medical response to
control and escape the Covid-19 pandemic. Two simple
statistics tell the story. In mid-September,
according to England's Deputy Chief Medical Officer,
Jonathan Van-Tam, ‘Our latest estimates are that since we
began deploying these vaccines, they've probably averted
in the region of 24 million cases of COVID in the UK and
112,000 deaths.’ However, this issue of compulsory
vaccination remains contentious and complex.
Where to start? Back in October 2020, Coronavirus
– Part 1, which can be accessed at http://www.johnling.co.uk/Covid1.html,
discussed something of the basic ethics of
vaccination. Four major points arose. First,
some are troubled by the vaccines themselves, including
their development from cellular material historically
derived from aborted human foetuses. Others cite
their alleged hasty production and abridged testing of the
vaccines. Second, there is the ethical force of the
Golden Rule, expounding an obligation to our neighbours –
vaccination benefits both us and them. Third, the
unvaccinated can expect prohibitions, such as exclusion
from public spaces, entertainment venues and community
services. Fourth, the notion and role of
conscientious objection is moot.
The discussion context here is a binary model – there are
two camps, two factions. First, there are the
healthcare workers and second, there are the general
public. In the grand scheme of the pandemic, they
are the care givers and the care receivers.
And so first to the frontline of healthcare workers – NHS
staff and care home staff. These are the people most
frequently in contact with the most vulnerable – the
elderly, the chronically ill, the disabled, and, of
course, Covid-19 patients. On 9 November, the UK
government announced that all ‘health and social care
workers, including volunteers who have face-to-face
contact with service users, will need to provide evidence
they have been fully vaccinated against Covid-19 in order
to be deployed.’ There was a 12-week grace period
between the regulations being made and coming into force
to allow those who have not yet been vaccinated to have
the required doses. Enforcement would begin from 1
April 2022. In other words, the UK Health Secretary,
Sajid Javid, mandated that care home workers who are not
prepared to get the Covid vaccine should get another job.
It has been estimated that 73,000 NHS staff would leave
front-line roles in addition to another 38,000 employees
from care homes. According to Javid, there are
around 100,000 unvaccinated NHS staff. There is
obvious concern about the cumulative effect of staff
departures and insufficient recruitment arising from this
vaccine mandate. A survey conducted during the
autumn of 2021 showed that over 90% of NHS trust leaders
were worried by the projected outcomes, whereas 58% of
them supported mandatory Covid-19 vaccinations for
staff. Of course, temporary and permanent workforce
absentees, including both those infected and contacted,
plus leavers, including both those voluntarily and
obligated, will increase the workload of existing staff,
while infected employees will be potential spreaders also
adding to the overall burden on the NHS.
Arguably, the first and foremost reason to get vaccinated
is to protect oneself. However, the healthcare
profession uniquely functions face-to-face with others,
and often physically closer than that. Does this
occupational uniqueness bring extra obligations?
Yes, because patients are not secondary, nor is this a
case of ‘my body, my choice.’ Consider those two
ethical giants, Scripture and the Hippocratic Oath.
The former expresses the primary public duty in the
so-called Golden Rule of Matthew 7:12, ‘In everything, do
to others what you would have them do to you’ and again in
Matthew 22:39, ‘Love your neighbour as yourself.’
The Hippocratic Oath expresses the primary medical duty
even more succinctly as ‘first, do no harm.’ These
two enduring ethical statements re-emerge, for example, in
the first rule of the General Medical Council’s (GMC),
updated November 2020, publication, ‘The duties of a
doctor’, which states, ‘Make the care of your patient your
first concern.’ Furthermore, the GMC instructs
doctors to be ‘immunised against common serious
communicable diseases.’ Herein, already exists a
robust ethic for medical professionals, so why should
further insisting it is underwritten by a legal mandatory
requirement be anything other than a minor step?
Surely it is a minimal intrusion into personal freedom,
yet justifiable on the grounds of protecting the health
and welfare of both staff and patients.
However, the professionals are not all approving.
For example, the UK’s Royal College of Physicians and the
Royal Pharmaceutical Society have spoken out against
mandatory Covid-19 vaccinations for healthcare
staff. The Royal College of Nursing has ‘significant
concerns’ about it. And the Nuffield Council on
Bioethics has called for more evidence of the need for
mandatory vaccination before resorting to coercion.
Now, what about compulsory vaccination and that second
branch of the binary model, the general public? At a
televised press conference on 8 December, the UK’s Prime
Minister, Boris Johnson, stated that ‘I didn't want us to
have a society and a culture where we force people to get
vaccinated.’ However, he went on to say, ‘I do think
we need to have a national conversation about ways in
which we deal with this pandemic.’ And he declared
that ‘the country can't keep going indefinitely with
non-pharmaceutical interventions’ [NPIs, such as imposed
lockdowns] just because ‘a proportion of the population’
remain unvaccinated – the latter currently extends to some
six million Britons, who are eligible, but have yet to
receive even a first dose. Yes, this issue is
certainly contentious and complex.
Indeed, upholding a bold ethical stance and formulating a
practical response can be a knotty conundrum. And
the UK is not alone. What is happening
worldwide? France has already taken the leap.
Back in July 2021, when a new law on mandatory
vaccinations was announced, the vaccination rates among
healthcare workers was 60%, but by October it had reached
over 99%. Then, at the beginning of December 2021,
Austria and Greece announced that their citizens must be
fully vaccinated against Covid-19 by early 2022.
Austria is requiring all adults to be vaccinated by
February 2022. Greece is targeting the over 60s and
has already started collecting monthly fines from those
who refuse. Meanwhile, in the USA, where the
pandemic has already killed over 800,000 citizens,
mandatory regulations are escalating. For instance,
on 5 November, the Biden administration, under the
auspices of the Occupational Safety and Health
Administration (OSHA), issued a ruling that companies with
100 or more workers must require their employees to be
vaccinated or undergo weekly testing. The decree was
immediately challenged, then suspended and then, on 18
December, reinstated by the courts. This
vaccine-or-test order will effect 84 million US
workers. In the meantime, driven by recent surges of
the Omicron variant, more and more countries around the
world are faced with implementing or, at least, discussing
plans for mandatory vaccinations.
So, what to do? There are three possible
strategies. Strategy 1 is, to do nothing and hope
the pandemic will somehow naturally come to an end – an
unlikely scenario. It consists of neither carrot nor
stick, and is hardly worthy of the title ‘strategy’.
Yet it has its supporters, especially among those who
consider that herd immunity will get us out of this
dilemma. However, for that to work a population must
consist of about 70% of carriers of Covid-19
antibodies. To achieve that high figure will require
not only naturally-infected individuals but also a cohort
who have already submitted to the ‘derided’ vaccines.
Strategy 2 is, to use the current ongoing, gentle, nuanced
persuasion campaign, with a specific focus on the
disinclined, plus a greater provision of easy-access
vaccination facilities in order to achieve a largely,
triple-jabbed populace. A public majority would deem
this as the most sensible approach – indeed, it is
currently being enacted – but is there sufficient time and
means to realise it?
First, who are these disinclined, those who are impeding
Strategy 2? They consist of two rather nebulous
groups. There are the indolent, whose lives are
typically characterised by a measure of disorder and
sloth. Yet given time and encouragement and some
badgering, most will eventually get round to organising
that trip to the vaccination centre. And there are
the vaccine hesitant. They tend to be genuinely
unsure about certain aspects of the whole Covid-19
affair. They come in assorted flavours. For
instance, there are the ethically hesitant, such as those
who fear the vaccines have been specifically derived from
human abortion materials. They have largely
misunderstood the basics of vaccination. And there
are the legally hesitant, those objectors who would cite
Article 7 of the EU Charter of Fundamental Rights, or some
similar statement, ‘Everyone has the right to respect for
his or her private and family life, home and
communications.’ For them a government diktat is a
step too far in curtailing their liberties. However,
time usually erodes their objections. After all,
such citizens of the so-called Free World, frequently
baulk at governmental edicts. For instance, in the
UK, when the wearing of motorbike helmets was made
compulsory in 1973, and car seatbelts a decade later,
there were howls of protest. Nowadays, these
measures are regarded as for the individual and public
good. And there are the scientifically
hesitant. They fear that the vaccines have been too
hastily made and insufficiently tested. Again, they
are unaware of the decades of completed research that
underlies the current vaccines.
It is these vaccine-hesitant folk who are currently
attracting the ire of the general public. One simple
statistic tells the story. Up to 93% of Covid-19
patients, who are hospitalised in the UK and occupying
intensive care beds, are unvaccinated. In other
words, they are denying hospital access to numerous
victims of strokes, heart attacks, elective surgery and so
on.
Caution, caution! Making moral judgements against
the unvaccinated is not without menace – restraint and
benevolence are called for. For example, are the
unvaccinated any worse than those who drink or smoke
excessively, those with a high BMI or those who engage in
dangerous sports? They too are mostly making
deliberate choices that can lead to illness,
hospitalisation and death. Such people are also
costing the NHS dear. After all, their lifestyles
can also place them in competition with the unvaccinated
for those scarce, intensive care unit beds. But are
we less angry with them? And are the advocates of
‘no vax, no bed’ on a slippery slope to denying medical
treatment for all Covid-19 patients? And are
supporters of ‘no jab, no job’ happy to deny employment
opportunities for many? Yes, this issue is certainly
contentious and complex.
Second, quite part from the disinclined, the indolent and
the hesitant, there are the anti-vaxxers, the conspiracy
theorists, various ideologues, Uncle Tom Cobley and all,
who tend to be militantly opposed to all things
vaccination. They tend to dislike legislative
authorities and their rulebooks, so they regard the
government’s Covid-19 responses as government
overreach. Theirs is a continuing campaign of
misinformation, fake news and false claims conducted
mostly via social media. Such widespread
dissemination of falsehoods about the safety, efficacy,
components, adverse effects and purpose of vaccines and
vaccination programmes will have negatively affected
vaccine uptake among some.
Yet, for the vast millions of citizens, this Strategy 2
generally progresses quite nicely without any inducements
– most people accept a Covid-19 vaccine when
offered. But occasionally the roll-out can be helped
along with real-life sticks and carrots. Some
jurisdictions use sticks. For instance, in
Singapore, those who choose not to be vaccinated must,
from 8 December, pay for treatment costs if they contract
Covid-19. A stay in intensive care is reckoned to
cost about £14,000. That stick may well increase the
vaccine take-up rates. Other jurisdictions use both
sticks and carrots. For example, when New York City
insisted that its public employees must get jabbed, the
stick was loss of employment, whereas the carrot was an
extra $500 in their pay packets. What about carrots
alone? Certainly in the USA, gifts of tickets to
entertainment events, free food and even lotteries with
cars as prizes have driven up jab rates.
And when all of the above Strategy 2 arguments and urgings
prove to be insufficiently effective, what? Strategy
3 is, to legally impose mandatory vaccination – by and
large, it would likely succeed, but at a price.
While the majority of people favour Strategy 2, that is, a
policy of multiple and widespread vaccinations, they are
less enamoured about a programme of compulsory
vaccination. After all, the implementation of such
an obligatory scheme would not be simple. For
instance, how are the unwilling to be vaccinated?
Should they be restrained and jabbed by force?
Should they be repeatedly fined until they are
bankrupt? What about those, who, with some ethical
vigour, oppose vaccinations in general and Covid-19
vaccines in particular? Is the legal status and role
of conscience objection moot? Should no-one ever
have their conscience rubbed raw? Should no-one ever
be coerced to participate in an action against their
ethical principles? Healthcare workers are already
excused some procedures on personal medical grounds, but
what about on ethical grounds? Non-involvement in
procedures, such as abortion, are allowed since a
colleague can usually be readily deputed, but a colleague
cannot stand in to receive a proxy Covid-19
vaccination. What about those employees who are
threatened with the loss of their jobs because they refuse
to be jabbed with what some conscientiously regard as
experimental vaccines, which are still only permitted
under so-called Emergency Use Authorisation (EUA) and
which inevitably lack long-term safety data?
Life is often beset with difficult choices.
Formulating personal and community values and then framing
appropriate responses are best achieved by discussion and
argument. Questioning is crucial. For example,
why are NHS workers continually constrained to treat the
unvaccinated? Why are tens of thousands of NHS
workers refusing to be vaccinated? Why not insist
that unvaccinated patients are treated by unvaccinated
staff in isolation hospitals? Why not mandate all
unvaccinated front-line healthcare workers to accept
frequent Covid-19 testing? After all, would not a
recent negative test result provide better patient
protection than a vaccine passport that merely indicates
details of past vaccinations? Yes, this issue is
certainly contentious and complex.
But there comes a time when a decision has to be made,
albeit even with partial information. For the
Covid-19 pandemic that time, at the borders of 2021 and
2022, is imminent. Omicron has forced our hand.
For front-line medical healthcare and care home workers
especially, unless they are medically exempt, they should
be subject to mandatory Covid-19 vaccinations to protect
not only their own lives but also those of the patients
they treat. Caution, caution! The statement of
such a single-minded approach to healthcare can be easily
misunderstood and quickly turned to be perceived as both
coercive and cruel. Granted this approach is radical
and all-inclusive. But cruel? Never.
And for the general public? A more
rigorously-implemented Strategy 2 vaccination programme,
perhaps with additional restrictions, even lockdowns, will
counter much of this anti-vaccination narrative and see us
through. In other words, as yet, keep Strategy 3 in
reserve. In the meantime, follow the mantra, ‘GET
BOOSTED NOW.' And when that fourth jab becomes
available, get that too!
Vaccinating the world
‘No-one is safe until everyone is safe.’ Who coined
this now famous sentence? Certainly it was used at a
media briefing on 18 August 2020 by Dr Tedros Ghebreyesus,
the Director-General of the World Health Organization
(WHO). And it has since become the watchword of
several global organisations like the WHO, UNHCR and
COVAX. Who first said it? Never mind, because
it is ethically, politically, socially and medically true.
At that same meeting, Ghebreyesus called for international
collaboration with regards to research, medicines and
supply of necessary items, including vaccines. He
said, ‘We need to prevent vaccine nationalism. This
is the only way to ensure equitable access and fair
allocation of future vaccines.’
Think about this. The western and developed world
has stockpiled more Covid-19 jabs than it can use.
Demand has dipped below supply. Excess stocks can go
out of date. Poor logistical and health
infrastructures remain key challenges. While vaccine
inequity persists it will prolong the pandemic. If
billions of people are left unvaccinated, the virus is
more likely to mutate and return and render stockpiled
vaccines ineffective.
According to a recent report from the House of Lords, as
of mid-December, only 6% of people in low-income countries
have received at least one vaccine dose compared with 75%
in high-income countries. Similarly, the WHO has
calculated that by mid-2021 more than 5.7 billion vaccines
doses had been administered globally, but only 2% had gone
to Africans. Just 1 in 4 front-line healthcare
workers on the African continent had been fully
vaccinated. Is there a moral imperative to ensure
that Africa receives sufficient vaccines for its 1.2
billion people? Africa is but one example –
other poorly vaccinated areas exist.
What to do? COVAX is the major player in the global
effort to provide fair and equitable access to Covid-19
vaccines for every country in the world. It is
backed by the UN and co-led by the Gavi Vaccine Alliance,
the World Health Organization and the Coalition for
Epidemic Preparedness Innovations. It allocates
vaccine doses proportionally among its 140-plus
beneficiary states according to population size.
COVAX faces a mountainous task.
What has the UK contributed? At the June 2021
meeting of G7 leaders in Carbis Bay, Cornwall, the UK
promised to donate 100 million vaccine doses by June
2022. Of these, 80% would be distributed through
COVAX. Back in October 2021, the UK promised to give
away all of its ordered 20 million Janssen vaccine doses
to COVAX by 2022. After all, the UK had decided to
use mRNA vaccines, such as the Pfizer-BioNTech and
Moderna, for most of its teenage and booster vaccination
programs rather than the adenovirus-based Janssen
vaccine. The UK is also not using the
Oxford-AstraZeneca jab in its current booster program, nor
for those aged under-40 who have been advised to have mRNA
vaccines for their two main doses. As of 6 December
2021, according to a House of Lords research briefing,
26.2 million doses of the Oxford-AstraZeneca vaccine had
been delivered to COVAX, with a further 20 million
expected by the end of 2021 and around another 20 million
in 2022. This brings the UK’s grand total of donated
plus promised doses to a laudable 86 million. But do
these dealings hint at a quiet ditching of our unwanted
vaccines rather than a wholehearted donating?
Elsewhere, COVAX has, for example, set aside 4.73 million
doses of AstraZeneca's vaccine for shipment to North
Korea, one of the very few countries that has not yet
started vaccinating. The reclusive state had earlier
rejected the offer of nearly 2 million doses. This
allocation is part of COVAX’s grand plan to distribute
another 43 million doses of the Oxford-AstraZeneca and
Moderna vaccines by the end of December 2021, bringing to
fruition its aim to ship up to 1 billion doses in total
during 2021.
Of course vaccine donation is not the only way to help
vaccinate the world. Exempting Covid-19 vaccines
from intellectual property (IP) rights would allow greater
production worldwide and so improve access and
equity. Simple cash is also useful to fund not just
vaccine manufacturing facilities but also to initiate test
and trace schemes and other public health measures.
These and other arrangements are currently being addressed
and answered in mostly minor ways. After all, what
is the UK’s promised contribution of 100,000,000 vaccine
doses in a world of 8 billion or 8,000,000,000
people? It’s 1.25%. And that percentage will
be lower when the required multiple doses are taken into
account.
This Covid-19 pandemic has undeniably created a global
rich versus global poor conflict. It is the duty of
the rich to sort it out. As they say, ‘No-one is
safe until everyone is safe.’ We are certainly not
safe yet.
Covid-19 in animals
Human beings are self-evidently prime targets for several
of the variants of the Covid-19 virus. But animals
are sometimes infected too. For example, the famous
Lincoln Children’s Zoo in Nebraska has long enjoyed the
antics of three of its snow leopards – Everest, Makalu and
Ranney. In mid-November, the Zoo announced that
these celebrated cats had died of complications from
Covid-19. Other animals, including hippos and
hyenas, have also been infected at other zoos around the
world. In addition, wild animals, such as the
white-tailed deer in USA, are susceptible to
Covid-19. Could such captive and wildlife animals
become reservoirs of Covid-19 infections, or even
locations for viral mutations, that could be transmitted
to people and other animal populations?
And what about pet animals? What are the threats to
pet owners? It seems that humans can infect cats and
cats can infect other cats. But, so far, there is
little evidence for Covid-19 transmission from either pet
cats or dogs to humans. Nevertheless, the very
origins of the Covid-19 pandemic in Wuhan, China, may have
involved the initial virus jumping from animals to humans,
possibly from bats or pangolins or some other
intermediary. Meanwhile, the US Centers for Disease
and Control Prevention (CDC) warns that the virus could
spread from people to animals during close contact.
Will there be jabs for cats and all those newly-acquired
‘pandemic’ dogs? Could they become cuddly, silent
super-spreaders? Already, Zoetis, a global animal
health company, a spin-off from Pfizer, has developed a
vaccine based on coronavirus spike proteins which could be
adapted for a wide range of animal species. Zoetis
has recently donated 11,000 doses of this experimental
Covid-19 vaccine to nearly 80 zoos across the USA for use
in animals ranging from great apes to mink. However,
Covid-19 vaccines for domestic pets are not generally
available, or needed. Yet. So your Felix and
Rover are currently spared the needle.