Boosting the UK’s Covid Measures: How to Go Further, Faster and Protect the NHS

Covid-19

Boosting the UK’s Covid Measures: How to Go Further, Faster and Protect the NHS

Paper
Posted on: 21st October 2021
By Multiple Authors
James Browne
Head of Work, Income and Inequality Analysis
Jacob Delorme
Researcher, Political Team
Brianna Miller
Researcher
Ruby Osman
Geopolitical Researcher
Ryan Wain
Executive Director, Politics
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    Overview

    Overview

    As we near the end of 2021, the dark days of lockdowns and restrictions are small specks in the rearview mirror. Thanks to the remarkable work of scientists, regulators, the NHS, government and the public, we have been able to sever much of the link between cases, hospitalisations and deaths, in turn successfully reopening our economy. But now, as case numbers rise, immunity wanes and infections break through the vaccine barrier, this link is threatening to return. We cannot become complacent, and while the government has set out many of the right measures, we must move faster in implementing them and use every tool at our disposal. Covid remains a priority issue and one that requires action now.

    In this paper, we offer a series of recommendations that, if actioned now, will ensure that murmurs of a fourth wave are curbed well before they end up overwhelming the NHS this winter. We draw on the success of the initial vaccine rollout to set out a booster campaign that will further protect the elderly and most vulnerable from Covid-related hospitalisation. This means going much faster in administering boosters, at least doubling the rate we have today – a target that can be achieved by bringing certain vaccine infrastructure from early 2021 back online.

    Protecting the most vulnerable must be our priority, and it is why we encourage a concerted effort to vaccinate pregnant women, a group that now makes up 20 per cent of female Covid-19 patients in intensive-care (ICU) wards. It also means we must do all we can to keep cases to a manageable number and prevent transmission. As the UK sees daily case rates up to 20 times higher than some of its European neighbours, we propose measures that are proven to reduce the risk of infection. This includes going further on vaccinating those aged 12 to 15 – now the main carriers of the virus – and urgently considering the approval of vaccines for younger children. Another transmission-reducing measure – the effective, low-cost solution of face coverings – should be a key pillar of the government’s winter Covid strategy, with masks mandated in indoor public spaces and on public transport. Not only do face coverings provide protection against transmission, but they also have the helpful dual purpose of signifying that vigilance is still important: that while progress has been made, we are not out of the woods.

    These measures, combined, will save lives, reduce cases and ensure that a lockdown to preserve hospital capacity is not needed. Our proposals will mean a more bearable winter than what we experienced last year and ensure the year’s end isn’t one of cancelled plans, but instead an opportunity for families and friends to connect, to celebrate and to begin to move forward from two challenging years. It’s this goal that makes action now both politically necessary and bearable.

    Key Recommendations

    Go Faster on Boosters

    1. Adopt a target of administering 500,000 boosters a day.

    2. Reactivate the vaccine infrastructure used in mid-2021, including staff and settings.

    3. Use AstraZeneca as a booster.

    Go Further on Vaccinating Children

    4. Make vaccinating 50 per cent of 12- to 15-year-olds by 1 December a government priority.

    5. Roll out a clear, clarifying government communications campaign that shows the safety and efficacy of vaccines for children.

    6. Make approving vaccination for under-12s a priority.

    Go Further on Vaccinating Pregnant Women

    7. Provide clear guidance on vaccines for pregnant women.

    8. Provide much-needed reassurance for pregnant women through safe-space vaccination venues and a 24/7 helpline run by midwives.

    9. Offer priority bookings for pregnant women.

    Go Further on Reducing Risk at Mass Gatherings

    10. Urgently explore the option of introducing a Covid Pass, drawing on best practice from countries currently using one, to ensure everyone attending a mass event has been fully vaccinated or at least received a recent negative test.

    11. Keep free, NHS-supplied lateral-flow tests readily available for the duration of the global pandemic, given their proven effectiveness.

    Go Further in Encouraging Mask-Wearing

    12. Reinstate mandatory face coverings for crowded indoor public spaces.

    State of Play: Rising Cases, Hospitalisations and Deaths

    State of Play

    With winter and the flu season fast approaching, our objective when it comes to handling the Covid-19 pandemic should be to prevent the NHS from being overwhelmed and avoid unnecessary loss of life. If the UK continues on its current trajectory and no changes are made to address the recent rise in cases, this objective is at risk.

    Since 19 July, when most Covid-related restrictions were dropped, the UK’s main line of defence against Covid-19 has been vaccination. However, going into this winter, relying solely on vaccinations will not be enough. The recent rise in cases has had a knock-on effect on the number of hospitalisations and deaths, once again edging the NHS closer to capacity.

    Cases are rising; hospitalisations and deaths tend to follow suit.

    The recent rise in cases in the UK means we are rapidly approaching the high rates seen in mid-July after the Euro 2020 Final. Unfortunately, the rise in cases has also meant a rise in the number of people being admitted to hospital as well as the number of people dying from Covid-19. While the corresponding link between a rise in cases and a rise in hospitalisations and deaths is nowhere near as strong as we saw during the first wave of the pandemic (when the population had no protection from vaccination), the UK’s case, hospitalisation and death rates are now much higher than many other countries around the world.

    The UK is seeing a greater increase in cases compared to its European neighbours and other OECD countries.

    As the table below illustrates, the UK has higher case, hospitalisation and death rates than other countries with similarly high levels of vaccination.

    Figure 1 – Average case and hospitalisations rates per 100,000

    Country

    Case rate per 100k (rolling 7-day)

    Hospitalisation rate per 100k

    UK

    63.9

     8

    Israel

    16

     5.8

    Germany

    11.1

     1.5

    France

    7.1

     2

    Italy

    4.2

     1.1

    Spain

    3.5

     0.5

    Source: https://ourworldindata.org/grapher/weekly-hospital-admissions-covid-per-million?tab=table&country=GBR~ISR~DEU~FRA~ITA~ESP (new daily hospitalisations, data as of 10-10-21); https://ourworldindata.org/covid-cases (new confirmed case rate, data as of 18-10-21)

    The disparity in numbers is likely due in part to the decision taken by the UK to remove all Covid-related restrictions from 19 July. This decision emanated from a constant theme throughout this crisis: the need to balance reopening the economy with saving lives. Given the hugely successful vaccine rollout, the government got this balance largely right and has helped the UK economy recover. From May 2021 to July 2021, when most restrictions began to lift and people were able to return to shops, restaurants, hotels and pubs, GDP grew by 3.6 per cent.1 https://www.theguardian.com/business/2021/sep/10/uk-economic-recovery-stalled-july-worker-shortages-gdp-covid-supply-chain-crisis However, as winter draws in and the NHS risks being overwhelmed, it is important that the decision remains under constant review and that early action is taken to prevent a return to the most disruptive of Covid restrictions.

    An international comparison shows that fewer measures means higher cases.

    As can be seen from the below data, the UK has fallen behind other OECD countries – notably France, Spain and Italy – when it comes to the measures in place and has seen a concurrent rise in cases. There are several areas of concern that need to be addressed by going further and faster on certain measures, such as vaccinations and boosters, and by introducing new mandatory measures that are already in place elsewhere.

    1) Mask-wearing is lower in UK than in other countries.

    In England, the legal requirement to wear a face covering ended on 19 July, except in health-care settings and care homes. Instead of a legal mandate, the government relied on a message of “personal responsibility”, leaving the decision to wear a mask up to individuals.

    According to YouGov polling from mid-October, around 15 per cent of UK adults said they never wear a mask in public spaces, compared to below 2 per cent in Spain and Italy, and about 4 per cent in France.2 https://www.ft.com/content/34582534-4510-4d45-bcba-2f9e04005309 As the data below shows, mask wearing has declined significantly across the UK but has remained an effective tool to reduce transmission in EU countries that have retained relatively high levels of mask wearing.

    Figure 2 – Percentage of adults no longer wearing masks in public spaces, by country

    chart showing that people in the UK have stopped wearing masks at higher rates than people in Germany, France  and Italy

    Source: Imperial College London YouGov Covid-19 Behaviour Tracker Data Hub, via https://www.ft.com/content/34582534-4510-4d45-bcba-2f9e04005309

    2) There are more large-scale gatherings in UK than in other countries.

    In addition to fewer people wearing masks, individuals in the UK have been less hesitant to attend large-scale or close-contact events. Central to this is the fact that nightclubs in England have been open since mid-July with no mandatory Covid precautions in place, whereas clubs in Italy only reopened in mid-October with strict capacity limits and vaccine certification required for entry; club-goers in Madrid must wear masks.3 https://www.ft.com/content/34582534-4510-4d45-bcba-2f9e04005309

    3) Boosters are rolling out at a slower pace in the UK than in other countries.

    England was slow to make the decision to administer booster jabs and, unfortunately, rollout has yet to catch up to the speed of booster campaigns in other countries that began earlier.

    4) The UK is vaccinating 12- to 15-year-olds at a slower pace that other countries.

    England has also fallen significantly behind the EU and even UK counterparts on the task of vaccinating children aged 12 to 15. As of early October, Scotland had vaccinated more than a quarter of all 12- to 15-year-olds, while several European countries had vaccinated nearly all children in that age group. During that same time period, England had administered first jabs to only 10 per cent of the age group, nearly a month after vaccinations for this cohort had begun.4 https://www.telegraph.co.uk/global-health/science-and-disease/englands-slow-vaccine-rollout-children-risks-new-covid-spike/

    5) The UK is falling behind when it comes to vaccinating pregnant women.

    Data from NHS England revealed that one in six Covid-19 patients requiring intensive care are unvaccinated pregnant women.5 https://www.theguardian.com/lifeandstyle/2021/oct/11/one-in-six-most-critically-ill-patients-are-unvaccinated-pregnant-women-with-covid As of mid-October, in England, just 81,000 pregnant women have received a first dose of a Covid vaccine, and around 65,000 have received their second dose.6 https://www.england.nhs.uk/2021/10/nhs-encourages-pregnant-women-to-get-covid-19-vaccine/ This is out of an estimated 606,500 pregnant women in England in 2020-2021, based on estimates from GP records.7 https://www.bbc.co.uk/news/health-58014779

    The UK took longer to approve a Covid-19 vaccine for pregnant women than other countries, including the US, which made the decision weeks earlier. This hesitation in decision-making was compounded by misinformation around the vaccine’s safety profile and its effect on fertility.8 https://www.imperial.ac.uk/news/231196/qa-covid-19-vaccines-pregnancy/ The risks to pregnant women from contracting Covid-19 are far greater than any risks associated with vaccination, and this must be made clear.

    Go Faster: Boosters

    Go Faster: Boosters

    The science is clear that boosters are needed as vaccine immunity wanes, and data show that when the aim is to reduce death and hospitalisation, boosters are especially important for those over the age of 65 or with underlying health conditions. In Israel, boosters have played a significant role in crushing a fourth wave – not too dissimilar to the UK’s – by reducing the likelihood that those who have been fully vaccinated will contract Covid-19 and require hospitalisation.

    The government’s decision on 14 September to allow anyone over the age of 50 or with underlying conditions to receive a booster six months after they received their second jab is to be welcomed. However, there is a gap between the intention of this decision and reality. Every day that passes sees more people become eligible for their third dose, but take-up is dangerously slow and each day also represents more people at risk from hospitalisation.

    The chart below (Figure 3) shows the widening gap and the need to dramatically increase the numbers of boosters being given on a daily basis. It is possible, evidenced by the vaccine rollout in March, and a doubling would see the gap close quickly.

    Figure 3 – The gap between booster eligibility and take-up in England

    chart showing that cumulative booster eligibility dramatically exceeds the number of boosters being administered in England

    Source: TBI calculations using NHS England data

    Set a target of 500,000 boosters a day.

    On 20 March, the UK administered 844,285 vaccine doses in a single day.9 https://coronavirus.data.gov.uk/details/vaccinations This was at the height of the campaign, during a lockdown, when the entire country was mobilised behind the vaccination effort. We need to once again channel this spirit and sense of purpose. This will come from political leadership and a clear, galvanising target. We know that supply is no longer an issue and that infrastructure has been built to get vaccines to people who need them.

    The current rate of booster rollout means the most vulnerable won’t be fully protected until Spring 2022.

    If the booster rollout continues at its current average rate of 165,000 boosters administered each day, the programme will not be able to vaccinate the 27 million eligible people until March 2022. However, if the number of people receiving booster jabs doubles to 300,000 per day, this end date could be brought forward to early January 2022.

    And if we aim for a more ambitious target of 500,000 doses per day, a booster could be offered to every eligible adult before Christmas. Additionally, administering boosters at a rate of 500,000 per day will allow for a catch-up period, meaning all those who are eligible for a booster already but have yet to come forward can receive theirs alongside, on average, the 250,000 to 300,000 people who become eligible for a booster each day.

    Bolstering vaccine infrastructure will help to administer more boosters faster.

    With the exception of GP surgeries, which are now once again seeing patients in person, the vaccine infrastructure from the earlier vaccination campaign should be resurrected, and every community pharmacy should be encouraged to administer boosters alongside flu jabs. There are around 11,500 community-pharmacy premises in England alone.10 https://commonslibrary.parliament.uk/research-briefings/cdp-2021-0028/

    Furthermore, there are thousands of sufficiently trained individuals able to administer vaccines; many of these people participated in the vaccination rollout campaign earlier in the year when the law was amended to allow registered health-care professionals who do not normally vaccinate to safely administer a licensed or temporarily authorised Covid-19 or flu vaccine. This includes retired NHS staff, paramedics, student doctors and nurses, doctors and nurses working outside the NHS, occupational therapists and others in the medical field.11 https://www.bma.org.uk/advice-and-support/covid-19/vaccines/covid-19-vaccination-programme-extra-workforce These individuals would be able to staff GP surgeries at weekends (when they would otherwise be closed) and support community pharmacies, mobile vaccination centres and care homes.

    Even if the 500,000 boosters-per-day target isn’t reached, it will still catch the attention of those who are eligible and, ideally, result in a surge of uptake of boosters. By our calculations, we will see the most vulnerable receive enhanced protection against Covid-19 by Christmas if we hit 500,000 booster a day. This is a realistic target given the remarkable achievement of the UK vaccination rollout over the past year.

    Figure 4 – Impact of accelerating the rollout of boosters

    chart showing that increasing the number of boosters administered each day can accelerate the date the current booster campaign will be completed by. For example, the booster campaign will be completed by: •	22 December 2021 if the rate is accelerated to 500,000/day •	3 January 2022 if the rate is accelerated to 300,000/day •	7 March 2022 if the current rate of 165,000/day continues

    Source: TBI calculations using NHS England data

    As the chart above shows, increasing the number of boosters administered each day can accelerate the date the current booster campaign will be completed by. For example, the booster campaign will be completed by:

    • 22 December 2021 if the rate is accelerated to 500,000/day
    • 3 January 2022 if the rate is accelerated to 300,000/day
    • 7 March 2022 if the current rate of 165,000/day continues

    Include AstraZeneca in the booster campaign to use all available supply.

    In the UK, the Medicines & Healthcare products Regulatory Agency (MHRA) has approved the AstraZeneca vaccine to be included in the booster campaign,12 https://www.gov.uk/government/news/mhra-statement-on-booster-doses-of-pfizer-and-astrazeneca-covid-19-vaccines but the Joint Committee on Vaccination and Immunisation (JCVI) has stated a preference for Pfizer to be used and a half-dose of Moderna to be used as an alternative.13 https://www.theguardian.com/world/2021/sep/14/covid-boosters-offered-to-all-uk-over-50s-jcvi-watchdog-confirms By not recommending AstraZeneca as a preferred option for booster jabs, especially for people who received AstraZeneca originally, the UK government could inadvertently be furthering the narrative – both in the UK population and in the rest of the world – that AstraZeneca is not on a par with the other vaccines available. The UK should be championing this UK-made, not-for-profit vaccine that has and will continue to play a leading role in the effort to vaccinate the world.

    Recommendation 1: The government should adopt a target of administering 500,000 boosters a day.

    An ambitious target of 500,000 jabs a day would see the UK provide a booster jab to every vulnerable, eligible adult before Christmas and close the growing gap between provision and eligibility. Even if the target is not met, any and all progress towards greater booster uptake should be welcomed.

    Recommendation 2: Reactivate the vaccine infrastructure used in mid-2021, including staff and settings.

    To avoid disrupting progress on the NHS backlog, retired medical professionals, students and others in the field should be brought in to administer jabs as they were earlier this year. Booster jabs should be provided in a range of venues from pharmacies and weekend GP services to mobile units and care-home visits.

    Recommendation 3: Use AstraZeneca as a booster

    The UK has ample supply of AstraZeneca and approval from the MHRA to use it as a booster. Offering it as an option could speed up booster jab roll-out and restore confidence in a highly effective, UK-developed vaccine.

    Go Further: Vaccinating Children

    Go Further: Vaccinating Children

    Children are currently key carriers of Covid-19, and the latest data from the ONS show that an estimated 8 per cent of children in years 7 to 11 tested positive for Covid in the week ending on the 9 October – the highest rate of any age group. (Among younger children, that number is closer to 5 per cent.) But considering the removal of all Covid-related restrictions this past summer – meaning that masks are no longer mandatory in schools – and the slow progress on vaccinating children, the surge in Covid cases among children of school age was entirely predictable.

    It is now well established that vaccination reduces the likelihood of infection, so it’s no surprise that this largely unvaccinated group is spreading the virus at higher rates than the general population. Despite vaccination being extended to 12- to 15- year olds at the end of September, uptake among this age group is still low.

    While children are at a lower risk of severe illness from Covid-19, there is still a risk of it occurring. More importantly, there is also the potential for children to develop Long Covid. Studies have shown that between 4 and 5 per cent of children under 12 experience symptoms for longer than 28 days. Although the risk is low, it is important to vaccinate children in order to prevent these rare cases.

    Unvaccinated children also transmit the virus to others, even when displaying no or minor symptoms. The fact that the age groups with the highest numbers of new cases are among school-age children (and, recently, the age groups of their parents) demonstrates this. Furthermore, the inability of many school-age children to receive a Covid vaccine (either because the rollout is taking too long or because they are under 12) makes outbreaks among young people frequent and difficult to prevent. There is also evidence that children are now becoming the index cases in households, reversing the trend from the start of the pandemic where children were catching the virus from their parents.

    Currently, children aged between 12 and 15 are eligible for one dose of the Pfizer vaccine. In England, the vaccine is currently administered in schools, although vaccine clinics for 12- to 15-year-olds will be opened within weeks. Children between the ages of 5 and 11 are currently not eligible for the vaccine. Initial trials by Pfizer have shown vaccine efficacy, as well as minimal side effects. Pfizer has signalled its intention to seek approval by relevant medical bodies as soon as possible.

    Figure 5 – Vaccination rates of 12- to 17-year-olds, by country

    Country

    Per cent of 12- to 17-year olds vaccinated with at least one dose

    England

    30

    Italy

    62.3

    France

    75

    Spain

    79.2

    Only 15 per cent of children in England aged 11 to 15 are vaccinated.

    The data are damning. Sustained hesitancy and confused messaging around approval have meant that uptake is much lower than it could otherwise be. This can be addressed through a concerted effort by the government.

    Although the vast majority of children are eager to receive the Covid vaccine, some parents are still reluctant. A recent poll by YouGov showed that around 18 per cent of parents with underage children have said that they would not have them vaccinated against Covid-19. Among parents who are themselves unvaccinated, this figure rises to 74 per cent. The government has urged parents to let their children receive the vaccine, with Secretary of State for Health and Social Care Sajid Javid writing directly to parents in secondary schools to encourage them to do so.

    As well as hesitancy, the fact that children are currently only able to receive their vaccine in schools has considerably slowed efforts. Some schools have had vaccination dates delayed at late notice, while other students have been absent on the days where they should have been vaccinated, often for Covid-related reasons. More than 200,000 pupils in England were estimated to have been absent from school for Covid-related reasons in the first week of October, either because they have been in close contact with people who have tested positive for the virus, or because they have tested positive themselves.

    The UK is falling behind when it comes to vaccinating children.

    Around the world, uptake of the vaccine among children is much higher and there is best practice to be heeded: in France, 3.5 million children between the ages of 12 and 17 are fully vaccinated, which equates to over 68 per cent of the number of children in that age group. In the UK, 57 per cent of 16- to 17-year-olds are fully vaccinated, a number which falls to less than 15 per cent for 12- to 15-year-olds, for whom only one dose is required.

    Approval of vaccinating those 11 and under should be a priority.

    Studies in the US and Australia show that once a child tests positive for Covid-19, there is an approximately 2 per cent chance of them being admitted to hospital. Considering that fewer children than adults tested positive for the virus during the first 18 months of the pandemic, and that most children do not experience severe symptoms, the absolute numbers are low. But with a rapid increase in cases among children since schools reopened this September, we should look out for an increase in hospitalisations for children who have tested positive. The fact that they are unable to receive the vaccine makes them dependent on adults being fully vaccinated to limit their risk in public settings, and it also means they are vulnerable to infection in school. For all of these reasons, approving the vaccine for children aged 5 to 11, now that scientific evidence shows that it is safe, is a priority.

    Additionally, studies have shown that younger children are more likely to transmit the virus to other members of their household than older children. This is because younger children need more assistance from parents and adults, and therefore come into closer contact more frequently. Children are increasingly becoming the index case in households, so it is vital that they be vaccinated in order to prevent transmission.

    One compelling reason to vaccinate 12- to 15-year-olds is to avoid repeated absence from school, both to reduce short-term impact on students’ mental health and also to avoid constant disruption to education that is likely to deepen social inequalities over the long term. Likewise, children aged 5 to 11 risk falling behind in their education due to repeated absence, alongside the mental-health toll of a stop-start year. This would be solved by approving the administration of the vaccine to 5- to 11-year-olds.

    Trials by Pfizer in children 5 to 11, containing a dose a third of the size of the dose used in adults and older children, have shown that this dosing in children is helpful in reducing the risk of catching Covid-19 while also presenting no evidence of side effects. The smaller dose used means that children are less likely to experience side effects compared to those aged 12 to 17.

    Recommendation 1: Make vaccinating 50 per cent of 12-15 year olds by 1st December a government priority.

    Although the objective set by the government to have offered all eligible children a vaccine by half-term will not be met, it is now vital to ensure that a substantial proportion of school children are vaccinated by the start of the winter.

    Recommendation 2: Roll out a clear, clarifying government communications campaign that shows the safety and efficacy of vaccines for children.

    The evidence of vaccine efficacy and safety exists, but there needs to be a clear campaign by the government to ensure that parents understand this. Otherwise, vaccine hesitancy will continue to result in low vaccination rates and high case numbers among children.

    Recommendation 3: Make approving vaccination for under-12s a priority.

    Although the chances of developing severe Covid-19 is low among children, the number of cases among children aged between 5 and 11 is the highest it has been since the start of the pandemic. In order to reduce the number of symptomatic cases among children and limit the transmission of Covid to vulnerable populations, the approval of the vaccine for under-12s should be a priority.

    Go Further: Protect Pregnant Women

    Go Further: Protect Pregnant Women

    Record numbers of pregnant women are being admitted to hospital with Covid-19. In Scotland, pregnant women and new mothers have made up more than 20 per cent of all women admitted to intensive care since May 2021. Not only does Covid infection during pregnancy present additional risks, but vaccination rates among pregnant women are also lower; more than 99 per cent of pregnant women admitted to hospital with Covid-19 are unvaccinated.

    It is no surprise that there has been greater vaccine hesitancy among pregnant women. There has been mixed messaging from the outset, with pregnant women initially barred from vaccination until scientists could gather enough real-world data to prove its safety. This may have been a scientific necessity, but it sparked understandable concern and confusion.

    In July, a survey of 9,000 expectant mothers found that just 21 per cent had received two jabs, with 40 per cent completely unvaccinated. But pregnant women were also well aware of the increased risks they faced from Covid-19, with three-quarters expressing anxiety about the UK’s easing of restrictions.

    This means the priority is clear: health authorities must act quickly to rectify their earlier mixed messaging and put measures in place to make sure women feel as safe as possible when receiving their vaccines.

    The risk from Covid-19 is greater than the risk from the vaccine for pregnant women.

    Pregnant women must be a key target for boosting vaccination take-up. While pregnant women are no more likely to catch Covid than other groups, they are at higher risk of developing severe illness, with one in ten pregnant women admitted to hospital for Covid requiring intensive care.

    Covid presents a risk to both mother and baby. According to the JCVI, pregnant women with symptomatic Covid-19 are two to three times more likely to give birth prematurely. A US study also found that women who contracted Covid around the time of birth were twice as likely to have a stillbirth.

    This means that clarifying the safety and efficacy of vaccination for expectant mothers is vital. Initial messaging may have been confusing, but the data are now clear. More than 80,000 pregnant women have received at least one vaccine dose in the UK and the data have not raised any safety concerns. The same is true in the US, where the Centres for Disease Control and Prevention have not found “any safety problem” with administering vaccines to pregnant women. In other words, this isn’t a problem with the science – it's a problem with the communication.

    Recommendation 1: Provide clear guidance on vaccines for pregnant women.

    Ensure that the data on vaccine safety and enhanced risk of Covid are communicated clearly and sensitively to pregnant women. Look to develop resources for midwives, GPs and expectant mothers that help to combat vaccine hesitancy.

    Recommendation 2: Provide much-needed reassurance for pregnant women through safe-space vaccination venues and an expert-run helpline.

    Make the vaccination process as smooth and fear-free as possible by providing venues that cater specifically to pregnant women – as well as free transport to get there. A 24/7 post-vaccine helpline, staffed by midwives and medical professionals, could ease fears in case of side effects.

    Recommendation 3: Offer priority bookings for pregnant women.

    Partially vaccinated or unvaccinated pregnant women should be offered priority bookings, with greater clarity given on when fully vaccinated women are eligible for booster shots.

    Go Further: Reduce Risk at Mass Gatherings

    Go Further: Reduce Risk at Mass Gatherings

    Mass gatherings can spur transmission. We saw this during Euro 2020, where celebrations, matches and private gatherings sparked a rise in Covid-19 cases as England advanced through the tournament.

    This winter, as the days get shorter and colder, it is likely that people will be convening more indoors where the virus spreads more easily. At the same time, a fully reopened economy means that large-scale events in stadiums and music venues nationwide are happening on a near-daily basis.

    These freedoms should be celebrated and protected at all costs: it is important culturally, socially and economically. But if we want to prevent a return to restrictions and lockdowns, then we must act decisively now.

    Figure 6 – In the UK, people are less likely to avoid crowded spaces compared to other countries

    four charts showing that people in the UK less likely to wear masks in public, avoid public transport, avoid large gatherings and avoid crowded spaces than people in Germany, France and Italy

     Source: Imperial College London YouGov Covid-19 Behaviour Tracker Data Hub, via https://www.ft.com/content/34582534-4510-4d45-bcba-2f9e04005309 

    Our aim is to keep crowded spaces as safe as possible.

    As winter approaches, we need to ensure the UK is doing everything it can to keep hospitalisations at a manageable level – without returning to an economically costly lockdown. This will mean working to find smarter ways to make sure large gatherings don't turn into super-spreader events.

    Exploring the viability of some form of UK-wide Covid Pass should be a matter of priority. The practicalities may be complex, but the government should work to assemble evidence from international best practice and develop a model that could best protect the UK and the NHS.

    Covid Passes, in whatever form they take, have three core benefits that could help see the UK through winter:

    1. Increasing confidence: Covid Passes provide peace of mind for people visiting large venues, a vital step in helping economies to reach pre-pandemic levels.
    2. Boosting vaccine uptake: Covid Passes spur uptake of vaccines and booster doses among those reluctant – but not entirely opposed – to being vaccinated. In France, more than a million people booked a vaccine appointment in the 24 hours after President Emmanuel Macron announced the implementation of a Pass Sanitaire, while Israel's Green Pass has been central to high booster-jab uptake.
    3. Preventing lockdowns: By ensuring that anyone attending large indoor events is fully vaccinated or has recently tested negative, transmission rates can be kept at a manageable level without the need to return to lockdowns.

    A Covid Pass system would not make the UK an outlier. In fact, it's an area in which we – especially England – are already lagging behind. At the moment, the use of NHS Covid Pass is optional for events and venues in England. Plans for a mandatory system of “Covid passports” for large indoor events were scrapped in September (although they might be brought back as part of the government’s autumn and winter Plan B).

    Scotland and Wales have gone a step further, requiring a Covid Pass for large indoor gatherings, such as nightclubs, as well as unseated outdoor events with more than 4,000 people. In Scotland, attendees must be fully vaccinated, while in Wales proof of a negative test in the past 48 hours can be used as alternative proof of Covid status.

    While a welcome step in the right direction, the UK’s measures are still a way off those used elsewhere. We may understandably be wary of an overly stringent or restrictive approach, but other countries have nonetheless proved that Covid Pass systems can be workable at scale and keep case numbers at a fraction of our own.

    Figure 7 – Covid Pass rules by country

    Country

    Pass system

    Key rules

    Israel

    Green Pass

    Access to shops, restaurants, gyms and large events is restricted to those who have received their booster jab or have recently recovered from Covid-19.

    France

    Pass Sanitaire

    People must scan a digital QR code to access key venues and services, including restaurants, museums, hospitals and long-distance travel.

    Italy

    Green Pass

    The EU’s most stringent Covid Pass system. All workers are obliged to present a coronavirus health pass before entering their workplaces, as well as to access indoor public spaces and long-distance travel.

    As we gear up for a difficult winter, therefore, we need to ensure the UK remains open to new ways of improving our response to the virus.

    Show proof of being fully vaccinated or at least a negative test.

    There is mounting evidence that people who are fully vaccinated are both less likely to be infected and less likely to transmit the virus. A study conducted in Sweden, where households of between two and five people contained at least one unvaccinated person, highlights this fact: in a household containing five people, where four are fully vaccinated, the chances of the fifth person testing positive for Covid-19 was reduced by 97 per cent. Extrapolating this out to large-scale events, it’s easy to see the value in ensuring that the majority of people at such events are fully vaccinated, in order to reduce the risk of transmission.

    For those still unwilling or unable to receive their vaccination, lateral-flow tests (LFTs) remain a reliable and simple way to prove that individuals are not carrying the virus. Although they have often attracted criticism for being less reliable than PCR tests, recent data show that these tests are more effective than first thought. LFTs are more than 80 per cent effective in detecting any level of Covid-19, and 90 per cent effective when it comes to determining those who are most infectious. The renewed confidence in the reliability of LFTs means that they should be used at scale, in order to ensure that people are not unknowingly spreading the virus in situations where many people could catch it.

    Recommendation 1: Urgently explore the option of introducing a Covid Pass, drawing on best practice from countries currently using one, to ensure everyone attending a mass event has been fully vaccinated or at least received a recent negative test.

    This would increase vaccine take up, restore confidence in the fact that attending mass events is safe, and crucially, mean that there is no need for any lockdown in the future.

    Recommendation 2: Keep free, NHS-provided lateral-flow tests readily available for the duration of the global pandemic given their proven effectiveness.

    LFTs provide an effective tool for both the vaccinated and unvaccinated and are a simple way of checking whether or not individuals are infectious, thus reducing the spread of Covid-19.

    Go Further: Encourage Face Coverings

    Go Further: Encourage Face Coverings

    As cases and deaths continue to rise, we shouldn't be afraid to revisit our toolbox. Face coverings, which were mandatory in indoor spaces in England until 19 July, are familiar and low-cost – and they’re proven to reduce transmission. As we approach winter, we propose they are made opt-out, not opt-in, in crowded indoor spaces.

    Face Coverings Work

    England has been far quicker to ditch face coverings than many of our European neighbours. As of mid-October, roughly 15 per cent of UK adults say they never wear a mask in public spaces, compared to just 2 per cent in Spain and Italy and around 4 per cent in France.

    A lack of masks is by no means the sole factor behind UK’s soaring case numbers, but reintroducing some form of mask mandate could still help bring cases back down to a manageable level over the winter months.

    There is growing evidence to suggest that masks hinder transmission. A large-scale trial in Bangladesh tracked mask use by 342,000 people across 600 villages for eight weeks. The study found that surgical masks could lead to an 11 per cent drop in symptomatic infections and cloth masks to a drop of 5 per cent.

    Another study looked at the impact of mask mandates across US states in April and May. After controlling for other mitigation measures such as social distancing, researchers estimated that mask mandates reduced the increase of Covid-19 cases by up to 2 percentage points per day.

    While the jury might still be out on the exact efficacy rates of masks and face coverings, they serve a crucial symbolic role too. Masks work as a visible reminder that vigilance is still important – without having to roll back any of our hard-won progress in reopening the economy.

    Recommendation 1: Reinstate mandatory face coverings for crowded indoor public spaces.

    A mask mandate, covering crowded indoor spaces and public transport, should be re-implemented until the threat to NHS capacity has subsided.

    Conclusion

    Conclusion

    A fourth wave of the pandemic is looming, threatening to overwhelm the NHS this winter. However, the extent to which cases and hospitalisations rise is still largely within our control – but we must act now.

    As we set out in this paper, we need to go faster and further in our response to the steady rise in cases. Continuing as we are and relying solely on the vaccination campaign and a mantra of personal responsibility will not be enough.

    An acceleration of the booster programme will ensure the most vulnerable are as protected as possible as quickly as possible. We need to go further to vaccinate children, protect pregnant women, reduce the likelihood that mass events become super-spreader events by using a Covid Pass and ensure that masks are worn in indoor public spaces.

    Some of these measures, including proof of vaccination for certain settings and mandating masks again, are rightly set out in the government’s autumn and winter Plan B. However, it is unclear what it would take for the policies set out in Plan B to be put into action. The recommendations in this paper, listed below, emphasise the need to take these decisions now. This will save lives, reduce case numbers and hospitalisation rates, and ensure that the NHS does not become overwhelmed.

    Key Recommendations

    Go Faster on Boosters

    1. Adopt a target of administering 500,000 boosters a day.

    2. Reactivate the vaccine infrastructure used in mid-2021, including staff and settings.

    3. Use AstraZeneca as a booster.

    Go Further on Vaccinating Children

    4. Make vaccinating 50 per cent of 12- to 15-year olds by 1 December a government priority.

    5. Roll out a clear, clarifying government communications campaign that shows the safety and efficacy of vaccines for children.

    6. Make approving vaccination for under-12s a priority.

    Go Further on Vaccinating Pregnant Women

    7. Provide clear guidance on vaccines for pregnant women.

    8. Provide much-needed reassurance for pregnant women through safe-space vaccination venues and a 24/7 helpline run by midwives.

    9. Offer priority bookings for pregnant women.

    Go Further on Reducing Risk at Mass Gatherings

    10. Urgently explore the option of introducing a Covid Pass, drawing on best practice from countries currently using one, to ensure everyone attending a mass event has been fully vaccinated or at least received a recent negative test.

    11. Keep free, NHS-supplied lateral-flow tests readily available for the duration of the global pandemic, given their proven effectiveness.

    Go Further in Encouraging Mask-Wearing

    12. Reinstate mandatory face coverings for crowded indoor public spaces.

    Lead Image: Getty Images

     

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