By: David Sinclair

The Australian Prime Minister this week attracted global media attention with an ambition of a 95% uptake target for a new COVID-19 vaccine. Alongside his statement he appeared to advocate for compulsory adult vaccinations.  

Following a backlash, he quickly retracted his idea to mandate uptake but his comments have highlighted two major questions for policymakers across the world:   

• Who should be at the front of a queue for a COVID vaccine? 
• How do we ensure high enough uptake to build herd immunity?  

In an ageing world, where older people seem much more likely to die of the coronavirus than younger people, the question of who gets a future vaccine and when, is going to be at the front of policymakers minds over the next year. The answer may not be as obvious as it seems. 

Who should be at the front of the queue? 

It looks like many countries will attempt to vaccinate as many people as possible. But even if a vaccine is produced over the next six months or year, it will take time to deliver enough supply for all. So decisions will need to be made as to how to prioritise. 

This raises huge ethical and indeed political questions. For example:

• Should the vaccine go to the oldest who may be more likely to die, and/or should they go to people in “at risk groups”? If BAME communities are at particular risk, should this group be a priority? 
• Should key workers also be vaccinated first? And which professions ought to be included in this group?  
• Should pharmacies be able to sell a vaccine as soon as it is on the market? 
• Should employers be able to buy or supply vaccines for their staff ahead of people in “at risk” groups? 

The answers to these questions are not as obvious as they seem. A successful vaccine could turn out to be more effective in younger or healthier people than in older people. Policymakers might then make a seemingly counterintuitive decision to focus vaccination in those groups of the population where efficacy is strongest. Similarly, policymakers might decide to focus vaccine uptake on the groups of the population who are more likely to be “spreaders”.  

In terms of who is a key worker, yes, health and care workers will certainly be up there, but should taxi drivers, retail workers and other public servants? If these and others are to be included, how do policymakers decide on the priority order? And how do we get the vaccine to, for example, taxi drivers in a country where they may not have access to good primary care? 

Some employers and private healthcare providers are likely to want to be able to sell a vaccination privately to get ahead of the queue. Does this matter? If they are limiting supply to those most “at risk” or undermining a national vaccination strategy, then probably. But if doing so provides another route to get as many people vaccinated as quickly as possible, then some policymakers may welcome this intervention.  

The answer is that we need to be led by the science in terms of where the vaccination offers the greatest and quickest return in terms of reducing the number of cases and deaths. But it is likely, as we have seen through the pandemic, that politicians find “following the science” isn’t as easy as it sounds.  

So how do we ensure maximum uptake? 

Once we have decided on the priority groups, we are going to need to work out how to ensure as many people as possible are vaccinated. 

Whereas some countries mandate some childhood vaccinations, there have been few attempts to mandate adult vaccines. There are of course some countries you can’t enter without having been vaccinated (for example, against yellow fever).  

In most places it won’t be necessary and might even be counter-productive to force people to be vaccinated. It isn’t inconceivable though, that in the longer run, certain services or employers might make vaccination compulsory for staff or users (e.g. airlines, care homes, universities etc). 

It seems likely that policymakers will choose to prioritise vaccination uptake in older adults and people in “at risk” groups (unless efficacy in these groups turns out to be poor). And if this decision is made, there is growing evidence about how to ensure those entitled to the vaccine get it.  

Our research over the past decade highlights the key drivers to ensure high uptake. 

• Reimbursement needs to be available (i.e. in this case, the vaccination needs to be free to the end user) 
• The relevant NITAG (National Immunisation Technical Advisory Group) needs to make a strong recommendation 
• The person delivering the vaccination needs to have their costs adequately covered. 
• Recommendations need to be consistent across regions within a country. Different regions with different recommendations risk undermining confidence in a vaccine.  
• Governments need to make the most of big and small data (like the UK’s use of real-time data to maximise uptake of influenza vaccination) and technological innovation. 
• Vaccination needs to be accessible. There will undoubtedly be a role for community pharmacy in delivering a COVID vaccine, as many places are unlikely to have the staff or space to immunise everyone in GP surgeries. Vaccinators will need to go to where people are. For healthcare workers, that means, for example, physically taking the vaccination around wards rather than expecting busy staff to come to a central point in their short breaks. The same applies for people in care homes or retirement villages. We shouldn’t expect everyone to be able to leave their home to get their vaccine.
• Make every contact matter. When individuals come into healthcare settings for other purposes, we need to offer them the COVID-19 vaccine. 
• Infrastructure should be adapted and invested in. We may need to recruit and train additional staff for example. In some cases, we may need to mobilise community centres to ensure we can vaccinate people in a socially distanced way. Some people in “at risk” groups may not want to go to be vaccinated due to a fear of leaving home. Our infrastructure and communications plans need to minimise the risk of this happening. 

And finally... don’t forget 

Alongside a potential COVID-19 vaccine, the pandemic must be a catalyst for taking other vaccine–preventable diseases seriously. There are vaccinations against pneumococcal disease and influenza, yet uptake in older people (and those in “at risk” categories) in most places is pretty poor.  

While there is a WHO target of 75% uptake for older people to receive the influenza vaccine, very few countries meet this target and most are miles behind. We could even question why the older person target is only 75% and not higher. 

So 

 Delivering a new vaccine to millions (billions across the world) of people is not going to be easy or quick. As a vaccination is developed, we need to ensure our infrastructure is better prepared. We need to decide which groups are going to be at the front of the queue. Unless efficacy in these groups is poor, this is almost certainly going to older people and people in “at risk” groups. 

There is some pretty strong evidence of what works in terms of improving uptake. We (just) need to make sure our policymakers utilise this evidence.