The Autumn vaccine offer for COVID is shrinking and this could leave a lot more people at risk

Why the UK could be lagging behind other countries

This summer has seen a large COVID wave- which is on a similar scale to and may potentially be larger than the winter wave. The current wave has been largely driven by the so-called FLiRT variants which have acquired greater immune evasion and ability to enter our cells. The COVID wave has been seen across the globe with it notably having a toll at the Paris Olympics. Although, the infection is not a serious risk to most people the infection remains a significant risk to some - especially for those who are clinically vulnerable and/or older. The rise in cases across the UK is being accompanied by more hospitalisations albeit at a lower rate thus far than last year.

Hospitalisation data shows that certain groups are much more vulnerable to the worst COVID can do and its typically those whose immune system may be compromised whether it is because they are pregnant which can temporarily alter immune function,  very young (2 and under) and their immune system is developing, they are older (Over 65 years) and their immune system is declining or have underlying health conditions that affect immune function. Fortunately, the risk of severe disease is markedly lower after vaccination. Drugs like Paxlovid can also reduce the likelihood of developing severe disease in clinically vulnerable groups. Given the enhanced vulnerability of older people and immunosuppressed or immunocompromised to COVID, it is right that these groups are prioritised for booster COVID vaccines. COVID is not seasonal, as this current wave is stark evidence of, and this means we, like many other countries offer additional boosters in the autumn and spring to the most clinically vulnerable.

Vaccine eligibility is changing

The next roll-out of vaccines will be Autumn and the Joint Committee for vaccination and immunisation (JCVI) have just announced their recommendations. The JCVI use a number of considerations in costing their recommendations for vaccine campaigns and they have not fully released as yet details of their costing model which “will be published by the DHSC in due course”. (As an aside this or similar wording was used last year so it is not clear when the costing model will be public). However, what is clear is that the main onus is on the costs of buying and delivering vaccines verusus prevention of severe disease. Last year (2023), this calculation resulted in a shrinking of the autumn offer for people eligible for free NHS vaccination. This year, the costing tool sees a further diminishing of who can access the vaccine for free as well as some decisions about what to vaccine with (more on that later).

The boosters will be offered those over the age of 65, residents in a care home for older adults and individuals aged 6 months to 64 years in a clinical risk group. The JCVI have not advised offering the vaccine to frontline health and social care workers, staff in care homes and unpaid carers or household contacts of immunosuppressed people.  JCVI have suggested that health and social care providers may wish to set up occupational health vaccine programmes as would be done for flu. Fortunately, the government have agreed to maintain the vaccine this year for frontline workers.

The reduction in vaccine coverage leaves a lot of people with regular, close access to vulnerable people unable to access free vaccines that could reduce their likelihood of catching infection and/or reduce the duration of infection. This will mean they will have less time off and/or would feel conflicted to act as a carer. Although, it is possible to purchase vaccines from many pharmacies, this is not cheap with doses costing as much as £100. I for one fear that many carers will not have the resources to do so.

People who are more vulnerable to the impacts of COVID should also be able to access the anti-viral Paxlovid freely.  Access to Paxlovid was to be expanded to cover many vulnerable groups who may not be eligible for the vaccine including people with a high BMI. However, the reality is there are insufficient supplies and funding to cover the 15 million people that could become eligible so this cannot be fully implemented as yet. As it stands now, people who are clinically vulnerable have described the lottery and difficulty of accessing this valuable treatment.

Long Covid remains excluded from vaccine eligibility criteria

COVID is of course not just linked with severe disease and it can cause long COVID with an estimated 2 million living with this condition in the UK. Recent published data has shown that the risk of Long COVID from infection has not gone as acquiring COVID infection is a risk for developing Long COVID even in the post-Omicron era. This US-based study was echoed in data from the most recent ONS study showing that new cases of Long COVID were still occurring in the UK. Vaccination reduces the risk of Long COVID by up to 52%.  It should be noted that in addition to the toll on their health and wellbeing, people with Long Covid are often unable to work because they are just too unwell and that is both a personal and an economic cost we shouldn’t be ignoring. However, the JCVI position holds from last year and Long- Covid risk is not factored into their cost-benefit analysis.

What vaccines will be offered?

For those who are eligible, what will the autumn vaccine offer be? This is perhaps the most surprising aspect to the statement. Previously there was outcry that excess vaccines left over from the Autumn 23 campaign might be discarded. However, it now seems they are to be used after all for the 2024 vaccine campaign. “The cost effectiveness assessment for the autumn 2024 programme considered the unique situation that COVID-19 vaccines have already been pre-procured as part of the government’s pandemic emergency response.” This is quite surprising as data has shown the vaccines from last year, whilst offering some protection, are less effective against the JN.1 related variants. Indeed, the European Medicines agency EMA, in line with WHO advice, have made the recommendation that the boosters be updated to target the JN.1 variants. Several vaccine manufacturers have begun to prepare this updated formula for mRNA and protein based vaccines. However, the FDA noted the upsurge in FLiRT variants and have requested a modification to target KP.2 – a FliRT variant- if possible. Even that guidance is looking tardy given we are seeing further deviation to the KP3.1.1 descendant that is starting to dominate. Recent data suggests the virus is evolving away from the FLiRT variants with even more evasive features.

The UK could have been ahead of the curve

The fact that we are stuck in a position whereby we are using vaccines that may be less optimal and give us transient protection (necessitating further boosters as the virus keeps mutating) is enormously frustrating. Ideally we would be looking to develop or acquire more long-lasting durable vaccines that either confer longer lasting immunity such as nasal vaccines. Another option are multi-variant Universal vaccines that may be more resilient against the ever evolving virus. So why aren’t we developing thees vaccines?

Whilst individual labs are researching such vaccines we lack wider capacity for manufacture. In 2018, plans to build on the UK’s science excellence led to the development of a UK based vaccine manufacturing and production centre to help us be ready for future epidemics and pandemics. However, this centre was dissolved by the Conservative government of the time. Contrast the picture in the UK with that of the USA which has Project NextGen. Project NextGen is investing over 1.4 billion dollars to support the development of next generation vaccines. India has already launched its own nasal vaccine as has China. As its stands though, we seem to be lagging behind and it is unclear when, or, indeed if, we will change strategy and develop a more long-term view. Two-for one flu and covid vaccines may also be available soon but it’s unclear if this will be a strategy that will be explored.

There are other ways we can protect ourselves

Vaccines, of course, are not the only tool we have. We can look to reduce the impact of infection with widening access to anti-viral drugs like Paxlovid as well as the risk of becoming infected by wearing masks and improving ventilation. Unfortunately, mis- and dis-information discourage mask-wearing. The current financial climate has not encouraged prioritisation of enhancing building ventilation (despite it being found to be very cost effective). We also know that dis-information fuels vaccine hesitancy and notably the spring booster saw a much reduced uptake of the offered vaccines. This reduction in vaccine uptake is echoed for other conditions including pertussis (whooping cough) and measles with devastating consequences. Sadly with more of us having to buy the vaccines, cost will become another barrier to discourage vaccine uptake further.

COVID is not just another cold- it still has the potential to cause serious and life threatening or altering disease and it’s a threat that is not going away anytime soon. Ignoring it is not an option, we must take action to prevent more people suffering.