This article is a personal view. Although I work for a health charity, this is just my opinion.
At the end of October, I wrote an article attempting to answer the question: when will we get back to normal? My answer was, in short: well into the second half of 2021, at the earliest — and even an attempted move back to ‘normal’ then might be premature. But I added the following caveat: “if the first vaccine to become available proves a super-effective blockbuster that stops COVID-19 dead in its tracks (ie provides reliable and total protection against infection if you are exposed to the coronavirus), you can largely forget the above.”
I’ve been meaning to do a follow-up article for most of December, as the news about vaccines put a potentially very different complexion on things, and seemed for a time to come close to meeting my caveat exactly. But it’s perhaps as well that I didn’t: the unwelcome and still imperfectly understood emergence of a significant new mutation of the virus in the UK (and another in South Africa that may be even more troubling), and the emergence of greater clarity around the likely path of vaccination plans, have made the outlook for 2021 look less sunny than it briefly appeared.
To recap, my definition of ‘back to normal’ centres on requirements for social distancing. That is what makes things like using public transport or attending events with any sort of crowd a dicey proposition at present. These rules will remain in place (and many people will moderate their behaviour as if they were in place anyway) until we can be confident that dispensing with them will not lead to a high level of COVID-19 infections. The ‘normal’ we return to won’t be exactly the same as it was in terms of patterns of living and working, but for the purposes of this article that’s a matter of detail and not something we need to get bogged down in.
The main reason for the updated article is that we have discovered something very welcome: vaccinating against this disease now looks very doable. Indeed, while we don’t quite know yet how the vaccination programme will land, the fact that so much progress has been made so quickly is a strikingly impressive human achievement, and something to remember in gloomy moments when our civilisation appears to be making the wrong choices.
The really significant thing about the vaccines is that they are much more effective than it had been thought they might be: at 90–95% effectiveness, depending on the vaccine and the exact figure you’re looking at, they offer much more protection than vaccines against flu, for instance, and are therefore much better than informed commentators had been expecting.
Before we go any further, let’s be clear about what vaccines can do. There are two things: they can stop you getting ill if you’re exposed to a virus; and they can stop you carrying a virus and transmitting it to other people. The vaccines so far do the first of these; we don’t know if they do the second, but as the Pfizer vaccine is rolled out, monitoring is underway to assess this.
This article won’t get into a ton of detail about the vaccines, but it will be useful to outline a few key facts. The Pfizer / BioNTech and Oxford / AstraZeneca vaccines are the two main vaccines relevant to the UK’s vaccination programme. We have 40 million and 100 million doses of them on order respectively. The Moderna vaccine will be in the mix, but only to the tune of 5 million doses. All of them require two injections, with a gap in between, so for the numbers of people who can be given each, halve those figures (possibly bar the Oxford / AstraZeneca one, which involves a dose and a half-dose). The Oxford / AstraZeneca one is crucial for the UK, partly because of the number of doses on order, but also because it does not require the strict refrigeration of the Pfizer vaccine, and therefore does not pose the same logistical challenges for getting it out to people in care homes, for instance. It is not a given that the Oxford / AstraZenca vaccine will be approved for use by the MHRA, but it will be a shock if it isn’t. Numerous other vaccines are undergoing clinical trials, and the Government has placed orders for some of those as well.
Of those facts, let’s home in on the fact that each vaccine requires two injections. Rather obviously, this halves the number of people who can be vaccinated for a given quantity of injection-giving resource, compared to a single-injection vaccine. The question of how many people can be vaccinated in a given amount of time will prove to be key. The vaccination programme will be run by the NHS (no new Test and Trace-style body is being launched), which has plans to roll out vaccines through a range of channels: currently, people are being vaccinated in hospitals; selected GP surgeries will set up as vaccination centres; there will be ‘roving units’ to take the vaccine to locations such as care homes; and temporary sites will be set up, at locations apparently ranging from sports stadiums to polling station-type venues. However, with all this effort, the NHS’s plans are currently that it will be able to vaccinate 25 million people in England during 2021 — and that’s assuming enough vaccine is available, which in practice means the Oxford / AstraZeneca vaccine being approved. (For most of these figures, I’m relying on this National Audit Office report (PDF); I’m also going to assume that the devolved nations won’t be able to muster resource to vaccinate a greater proportion of their populations, but will welcome correction on this.) This assumes a 75% take-up rate, meaning 25 million people vaccinated ‘covers’ 33.3 million of the adult population.
Now, this will make a big difference. It should (I think) enable the vaccination programme to work down the full list of priority groups, or very close to the full list, developed by the Joint Committee on Vaccination and Immunisation (JCVI). The current list of priority groups is now prioritised as follows:
1. Residents in a care home for older adults and their carers
2. All those 80 years of age and over, and frontline health and social care workers
3. All those 75 years of age and over
4. All those 70 years of age and over, and clinically extremely vulnerable individuals
5. All those 65 years of age and over
6. All individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
7. All those 60 years of age and over
8. All those 55 years of age and over
9. All those 50 years of age and over.
Indeed, as the top priority groups are vaccinated in the early months of 2021, we can expect COVID-19 to lose its status as a massive killer. Even compared to other diseases, the outcome of COVID-19 is massively correlated with age: three quarters of those who have died from it have been aged over 75. The pressure on the NHS should also ease, as fewer older people will become seriously ill and require hospitalisation, and this effect will increase as the vaccination programme works down through the age bands.
But if the 25 million figure holds good (and it’s not set in stone — estimating resources needed and logistics involved in a vaccination programme in a fast-changing situation means aiming at a moving target) it means that a substantial portion of the adult population will not get vaccinated in 2021, and particularly that healthy younger adults will not get a jab. It’s also unknown what this might mean for 2022: if vaccinations need to be repeated after, say, 12 months (and we don’t know this one way or the other), how will we re-vaccinate all the previously vaccinated people and also get round to the unvaccinated group? It might be doable of course — but that’s a possible problem for the future.
In practice, I wonder if that 25 million figure might come under a lot of scrutiny and pressure quite soon. With so much else going on — the new strains, Christmas, Brexit, severe weather — it has not become well recognised publicly that the vaccination programme will not cover the whole of the population over the next 12 months. If and when this does become clear (and I wonder who will expose it — the government will obfuscate for as long as possible, and our non-specialist media are often unequal to the task of stating the facts plainly) there may be a good deal of unhappiness among the general public. The European Medicines Agency is pushing to have the whole adult population of the EU vaccinated by the end of the year, a much more ambitious aim than we have — though I’m unsure if this is just aspiration. The UK government’s policy objective is to vaccinate the whole adult population — there just isn’t a timescale on it (that I could find).
The problem appears to be one of human resources. For context, the NHS vaccinated 15.4 million people in England against flu in 2019–20. For 2020–21 it is increasing this to 29.5 million; add on the 50 million planned COVID injections, and that’s an increase of 64.1 million vaccination injections in England alone in a 12 month period. It will constitute a major achievement if realised, but still not return the country to normal. Our long-term failures in NHS workforce planning will bite us hard here: we’re starting from a position of simply not having enough nurses and other healthcare professionals in the NHS. An obvious solution will be to increase the number of professionals who are allowed to give injections — but that lever has already been pulled, and is priced into the figures above. So, injections will be given by healthcare professionals who previously would not have been trained and allowed to do so, and people from related backgrounds like occupational health professionals. One wonders if it would be feasible or advisable to recruit people ‘off the street’ and just train them in the one task of giving injections; but no regulatory change to allow this has been made, as far as I can see it’s not being considered, and quite possibly it would be a really bad idea. Then again, pressure for an even bigger mobilisation of resources may grow through 2021, as people become impatient to be vaccinated and get back to normal.
So, will we get back to normal in 2021? Right now, it doesn’t look like it. In the absence of a vaccine for much of the population, social distancing regulations will have to be maintained, so things like sporting events, live performances and mass commuting by public transport won’t return in their regular forms. Social distancing, face masks and perhaps even quite tough intermittent lockdown-type measures can be expected to persist to the end of 2021 and into 2022, although by the time 25 million people have been vaccinated, and particularly if the vaccines interrupt transmission as well as protecting against illness, the spread of COVID-19 could be markedly reduced by the time we reach Christmas again, meaning that a repeat of the urgent measures taken this year might not be necessary.
Three points to conclude with. Firstly, it’s still very positive that we can look forward to greatly reduced numbers of people dying from COVID-19. It will always be with us, even after population-wide vaccination, but it will become something you can count yourself unlucky to get, very unlucky to get and then experience long-term consequences of, and exceptionally unlucky to get and then die of. But it will persist as an un-startling cause of death, particularly among older people. And although we will get there eventually, we can expect January and February 2021 to be appalling months for COVID-19 deaths and pressures on the NHS generally, before things start looking up in the spring.
Secondly, the new strain means there’s a big question mark over the summer months of 2021. We know that the virus is highly seasonal, and that some socially distanced and/or outdoor activities proved viable (though by no means entirely risk-free) in the warmer portion of 2020. Indeed, lots of businesses and event organisers had got very good at these by late summer this year, so in principle we should expect more and better in 2021. But the more transmissible new strains might be a major snag: if holding down case numbers in the winter months can only be achieved through close-to-full lockdown measures (as is looking likely at the moment, but not yet certain), then maybe even in the summer the baseline level of social distancing might have to be kept higher than it was in 2020. That’s speculation at this stage, but we should probably approach the summer with modest expectations, and hope that they will be exceeded.
And thirdly, remember this is a changing picture, and events could render this article out of date almost as quickly as they did the last one. If single-shot vaccines become available, the NHS’s resources for deploying vaccines will, in principle, go twice as far. Equally, while there’s fair cause for optimism that the vaccines will work against the new strain (and that new ones can be developed quickly if they’re needed), an unwelcome shock is always possible.