Outpacing Omicron

The emergence and quick global spread of the Omicron variant of concern – alongside the ongoing threat of future variants – means the UK must move quickly to ramp up its response.

In this paper, we offer tactical recommendations that the government can implement now to shore up the country’s defences and help the population to live safely and freely alongside Covid-19 while also protecting the most vulnerable. At their core, these recommendations are grounded in building widespread immunity to Covid-19 through vaccination rather than infection.

Ultimately, we show how the government can scale up to administer more than 500,000 boosters per day by adding more vaccine settings, and expanding the ranks of staff who can administer doses to include students and retired medical professionals. This will mean all adults could be offered a third dose by 31 January 2022, extending vital protection not only to the most at-risk people who have yet to receive a booster jab, but to everyone aged over 18. Hitting this target would also mean that the 6 million people who are eligible but have yet to receive any vaccine could receive their first dose and, as set out below, all children aged 5 and older could be vaccinated too. It is vital that we move at this speed; recent modelling suggests that the peak of Omicron will arrive early in 2022, and we must do as much as we can to protect those at risk of hospitalisation and stem the rising tide of infections among young people.

The case for vaccinating the majority of adolescents aged between 12 and 15 in the first month of the first school term of 2022 is compelling. This age group is currently among the most likely to be infected, yet almost half have yet to receive a first dose to date. It is a vital strand of the country’s Covid-19 response, not least because we have seen numbers of infections stabilise as vaccines – even if only few in number – reach this group.

But we also believe the country should go further: the UK should join the US, Germany, Israel, the UAE and a number of other countries in offering vaccines to children aged between 5 and 12. We know that the vaccine is safe and effective among this age group, substantially reducing the risk of symptomatic infection. We also know that cases are accelerating in this group compared to any other, and with a more transmissible variant like Omicron, this will only get faster. The ultimate decision should fall to parents, but it is vital that they are at least given the choice.

Finally, the government should prepare businesses and venues to be able to deploy a Covid Pass that restricts access to certain settings based on vaccination status, a recent negative test result or proof of recovery from Covid-19 in the past six months. While it may not be necessary to enact this measure, preparing a Covid Pass now could be a crucial tool in helping to avoid an economy- and spirit-crushing lockdown in early 2022 when Omicron cases are expected to peak. Doing so will require clear guidance on the rollout of Covid Pass technology, which we set out in detail later in this paper, to allow businesses and venues to ready themselves.

We offer recommendations constructively and with the ultimate objective of ensuring that we can live safely and freely alongside the virus – regardless of variant.

Recommendations

Vaccinating Children Aged Between 5 and 11

1. Approve vaccinations for children aged 5 and older as soon as possible.

2. Continue to offer Covid-19 jabs in schools.

3. Offer Covid-19 vaccines to children and adolescents at the same time as their flu vaccination.

4. Explore including younger age groups in the use of any future Covid Pass system.

5. Continue research into safety and efficacy of vaccinations for children aged under 5 and prepare for rollout subject to approval.

Vaccinating the Unvaccinated

1. Actively encourage those who are unvaccinated or have only had one dose to come forward through targeted communications campaigns.

2. Apply a carrot-and-stick approach to tackling vaccine hesitancy, improving access to information and incentives while exploring potential restrictions based on vaccination status.

Topping Up Immunity and Protecting the Most Vulnerable Through Boosters

1. Ensure that health services are equipped to deliver an ambitious booster campaign that can keep pace with the growing numbers of eligible people.

2. Think creatively about the who and where of vaccination by recruiting from non-traditional backgrounds and using diverse venues.

3. Tailor vaccination strategies to meet the needs of the most vulnerable, particularly people who are housebound.

4. Ensure clear and consistent public messaging to prevent “vaccine complacency”.

5. Continue to explore whether the time between boosters and second jabs can be shortened without compromising effectiveness, using the latest available data.

Preparing for a Covid Pass

1. Consider requiring visitors to large indoor settings in England to show a Covid Pass for entry.

2. Upgrade the NHS app's COVID Pass function.

3. Publish analysis on the costs and benefits of using a Covid Pass.

In light of the Omicron variant, we believe it is essential that we give everyone the opportunity to receive the doses that will give them the most protection as quickly as possible. For the UK, this includes:

• One dose for about 5.7 million children aged between 5 and 11.^[_]

• Two doses for about 6.4 million unvaccinated individuals (who have not received a single dose).^[_]

• One dose for about 4.5 million partially vaccinated individuals (who have not received a second dose).^[_]

• Boosters for 22 million people, based on the most up-to-date, publicly available figures.

Our modelling indicates we can achieve this goal and provide vaccine-induced immunity to all those individuals by 31 January 2022.

However, our modelling also indicates that the government is not on track to meet this goal, especially when it comes to boosters. Currently, the UK is administering about 425,000 doses per day as the first week of December. We need to increase this rate to at least 700,000 doses per day in order to ensure we give everyone the opportunity to receive the doses that will give them the most protection as quickly as possible. In England, we need to increase the daily vaccination rate from 375,000 to 650,000, and the boosters vaccination rate from 300,000 to 500,000, as the charts below show.

Figure 1

Scale-up in boosters vaccination needed in England to vaccinate all eligible adults by 31 January 2022

Source: UK Coronavirus Dashboard, Office of National Statistics

Note: Figure 1 compares the total adult population eligible for boosters and the cumulative boosters vaccination rate, projected forwards from December onwards. The dotted line indicates the change in government policy in late-November to bring forward the boosters eligibility threshold from six months post second-dose to three months.

Figure 2

Source: UK Coronavirus Dashboard, Office of National Statistics

Note: Figure 2 shows the total outstanding adult population still requiring boosters, in addition to those aged 12+ currently between first and second doses, and those aged 5+ who may require a first dose in the coming months. Current and projected scale-up vaccination rates are projected forwards from December onwards.

Modelling from Public Health Wales indicates that Omicron cases are likely to peak towards the end of January 2022.^[_] If this turns out to be the case, we need to get ahead of the virus and start ramping up vaccination and booster campaigns now, in order to have the most protection when the Omicron variant is at its most prevalent in the community.

This paper sets out why people in the groups listed above should be vaccinated and offers practical recommendations for how to do so in the quickest, most effective way possible. We have the opportunity now, through vaccination, to get ahead of the virus and we must not hesitate to do so.

The UK has been slower than many other middle- and high-income countries to vaccinate children and adolescents. The US, for example, made the decision to vaccinate its 12- to 15-year-olds in May 2021, but it took the UK four months to follow suit.^[_] During that time, case rates among children and adolescents in the UK have continued to grow.

The UK now risks falling behind in vaccinating another crucial age group responsible for higher levels of transmission: children aged between 5 and 11.

According to ONS data, there are about 5.7 million children aged between 5 and 11 in the UK.^[_] Not extending vaccinations to this age group means that there are millions of potential carriers of the virus across the UK, without any vaccine-induced immunity.

In light of the Omicron variant, and its potential for increased transmissibility, vaccinating children and providing vaccine-induced immunity to as many people as possible is more important than ever. Otherwise, we risk having Covid-19 spread among the unvaccinated younger age groups, leaving a trail of ill and contagious children, higher case rates and missed school days in its wake.

The urgent need for the UK to vaccinate children aged between 5 and 11 is twofold. First, recent trends have shown that children make up a larger proportion of those testing positive for Covid-19 than older age groups. Even though children are less likely to become severely ill from the virus, some still do. Vaccination provides direct protection to those who receive a jab.

The potential impact of vaccination on case rates among younger children is becoming increasingly clear. As shown in Figure 3, the number of infections in those aged between 12 and 16 fell dramatically in the weeks after vaccines were approved and made available to this age group. However, it is also worth noting that as infection rates were quite high in the weeks leading up to the approval of vaccines for the 12- to 15-year-old age group, many children will have also developed natural immunity from previous infections.

Vaccinating children will also provide indirect protection to the wider population. Infected children could go on to transmit the virus to elderly relatives, especially over the fast-approaching Christmas period.^[_] So while the direct physical health burden to children is generally considered to be relatively low, they can contribute to the overall Covid-19 burden in the whole population.^[_]

Modelling from the European Centre for Disease Prevention and Control (ECDC) indicated that vaccinating children aged between 5 and 11 could reduce transmission in the whole population, although research into the extent and duration of this protection is currently ongoing. The study estimated that the impact on the effective reproduction number (R) in the population as a whole would be a decrease of 11 per cent (or slightly more or less, depending on vaccine uptake in the general population) for an average country in the EU/EEA.^[_]

There are also considerations beyond case rates. As a direct result of contracting the virus, children will be forced to miss additional school days, regardless of the severity of their infection. Children have already lost a significant amount of in-person learning during the pandemic at a cost both to their wellbeing and education.

Vaccinating children offers us a path out of both these problems, allowing us to protect children from infection and any further disruptions to their education, while taking us one step closer to herd immunity, even as vaccination uptake levels off among older age groups.

International Comparisons

The UK has already given the green light for 12- to 15-year-olds to receive a vaccination but has not done the same for children aged between 5 and 11, even though this has been safely happening around the world. For example:

• On 2 November 2021, the US approved a smaller dose of the Pfizer vaccine for children aged between 5 and 11. As of 17 November, just over two weeks after the vaccine had been approved for this age group, more than 10 per cent of 5- to 11-year-olds (about 2.6 million children) in the US had received a first dose.^[_]

• Israel began vaccinating children aged between 5 and 11 on 22 November. Health ministers reported that 24,000 appointments – accounting for some 2.5 per cent of eligible children – were booked on the very first day.^[_] The inclusion of young children in the country’s Green Pass, which is needed for access to restaurants and public events, is thought to be partially responsible for high uptake.

Figure 4 sets out a more comprehensive list of Covid-19 vaccination rollouts to 5- to 11-year-olds around the world.

Children Who Have Previously Tested Positive

Vaccines are safe for children in the youngest age groups and it is only right that parents at least have the choice to give their approval for their children to have one, given the significant protection they provide from infection. However, natural immunity from previous infection also provides lasting protection. Parents who have a child that has recently been infected may not feel the need to vaccinate their child immediately, given the likely antibodies that have developed through infection. This would mirror Israeli policy where 18 per cent of the 5- to 11-year-olds age group are considered “recovered Covid patients” and are therefore not eligible for a vaccine, but deemed to have sufficient protection.

Vaccinating Young Children: Best Practice

Family Vaccination Centres

The US government recently announced plans to open family vaccination clinics as part of its winter Covid strategy. Set up across the country, the clinics will provide locations where families can get initial vaccines and booster doses all in one place. The clinics are being located in community health centres and other trusted settings. There will also be mobile units in order to take vaccines direct to hard-to-reach communities.^[_]

Israel’s Green Pass

Israel’s population of approximately 9.4 million people is relatively young, with around 1.2 million children in the 5- to 11-year-old age group. Although Israel has comparatively high levels of adult vaccination, health officials have been doubtful the country will be able to reach herd immunity unless children in that age group are vaccinated.^[_]

In order to incentivise parents to get their younger children vaccinated, children aged 5 and older are now included in the country’s Green Pass. Parents who choose not to vaccinate their children will have to pay for them to have tests before taking them anywhere that requires a Green Pass, such as cinemas and restaurants.^[_]

Tower Hamlets Council

The London Borough of Tower Hamlets has sought to boost uptake of vaccinations among children and adults by coordinating with the local Somali community to produce videos of a Somali GP explaining the importance of getting vaccinated in Somali, with English subtitles. The council has also produced and distributed children’s storybooks (with the plot involving a germ invasion from another planet) to local primary schools and children’s centres. The books incorporate Tower Hamlets’ landmarks and seek to include characters who are reflective of the diverse population.

Health visitors and clinics have also been placed in children’s centres, which is useful because these centres are trusted venues, while pamphlets, leaflets and crib sheets are also available to signpost families to their nearest vaccination centres and provide them with useful information.^[_]

Recommendations

1. Approve vaccinations for children aged 5 and older as soon as possible.

2. Continue to offer Covid-19 jabs in schools.

3. Offer Covid-19 vaccines to children and adolescents at the same time as their flu vaccination.

4. Explore including younger age groups in the use of any future Covid Pass system.

5. Continue research into safety and efficacy of vaccinations for children aged under 5.

Vaccinating children is essential. However, it is not a substitute for vaccine uptake among the general population. In the European Centre for Disease Prevention and Control (ECDC) modelling mentioned above, the data indicated that vaccinating children reduces the R by about 11 per cent (within a likely range of 3 to 26 per cent), with the greatest proportional impact if high adult-vaccination coverage has already been achieved.^[_]

Therefore, it is crucial that all eligible adults get vaccinated and when the time comes, take up the boosters. In addition to the 4.5 million partially vaccinated people who still need to receive a second dose as of 6 December^[_], there remains a substantial number of people across all age groups who have yet to get a single dose of a Covid-19 vaccine.

Here, good data will matter. The UK government does not regularly release clear data on vaccination rates and data reporting is often inconsistent between the four nations. The table below provides an estimate of current vaccination rates per age group in England, but going forward clear, regular and consistent data would help ensure that efforts to combat vaccine hesitancy and reach the most vulnerable can be directed where they’re needed most.

Figure 5 – Estimated total number of unvaccinated people in England by age group, as of 7 December

Vaccination Rates Have Plateaued

The data indicates that there are more than 6 million unvaccinated individuals in England, more than half a million of who are within the Joint Committee on Vaccination and Immunisation’s (JCVI) priority groups. With Scotland, Wales and Northern Ireland taken into account, the figure for the whole of the UK is even larger. Data also indicate that vaccination rates have levelled off in every age group over 18.

With vaccines now readily available and future proofed following the recent purchase of an additional 114 million doses^[_], the UK is now experiencing a demand – not supply – problem in vaccinating these remaining groups. In recent weeks, we have seen first-dose appointments level off.

This means that while boosting vaccination rates among newly eligible children should be a priority, we cannot afford to lose sight of the millions of adults who have yet to come forward for one or both of their doses.

Similarly, while we shift focus to extending eligibility to 5- to 11-year-olds, we must ensure that uptake continues among those in the 12- to 15-year-olds age group, who only became eligible recently. There are about 1.4 million unvaccinated 12- to 15-year-olds in England alone who have not yet had their first dose because of delays and disruption to the rollout to this age group, according to a report in the i newspaper.^[_]

Tackling Hesitancy Among the Unvaccinated

With vaccination rates levelling off in all but the youngest age brackets, the UK is leaving itself dangerously exposed to infection – especially from any new variants of concern.

Hesitancy rates are higher in young adults, who are less likely to experience severe disease, but it remains a problem in all but the highest age brackets. As many as 24 per cent of 18- to 24-year-olds remain unvaccinated, despite them having been eligible since June. And even among older adults, the number of unvaccinated remains worryingly high, with more than half a million in the JCVI’s most vulnerable groups yet to receive a single dose.

As the UK looks to ramp up its booster rollout, those left completely unprotected cannot be forgotten. Ensuring these groups are vaccinated as soon as possible must be a priority, both to protect the hundreds of thousands of vulnerable, unvaccinated people who remain at heightened risk of severe infection, as well as to curb infections in young people – often a key driver of transmission.

Recommendations

1. Actively encourage those who are unvaccinated, or have only had one dose, to come forward through targeted communications campaigns.

2. Apply a carrot-and-stick approach to tackling vaccine hesitancy, improving access to information and incentives, while exploring potential restrictions based on vaccination status.

On 29 November, the JCVI advised that all adults were eligible for a booster, and that the waiting time between second and third doses could be reduced from 6 to 3 months. The advice came as the Omicron variant had started to circulate, with early data suggesting that Omicron is more transmissible than the previously dominant Delta variant – and therefore potentially more resistant to vaccines.

Boosters Are Effective

A recent study in The Lancet has shown that many vaccines make effective boosters when administered between 10 and 12 weeks after the second dose of either AstraZeneca or Pfizer. Six vaccines all resulted in enhanced immunity when used as a booster after an initial two doses of Pfizer or AstraZeneca, with Moderna and Pfizer providing the best results.^[_]

For those who had received two doses of Pfizer, the study participants’ day-28, anti-spike protein antibody levels – the level of immunity reached four weeks after receiving a booster shot – rose by anywhere from between 1.3 times to 11.5 times, depending on the booster used. For those who had received two doses of AstraZeneca, antibody levels rose from between 1.8 times to 32.3 times. While antibody levels are not always directly correlated to long-term protection, the fact that a third dose is proven to boost immunity, with no safety concerns, is still very welcome news.

A separate study has confirmed that booster vaccines should continue to provide protection against the Omicron variant. The trial, using the body’s T-cell response, showed that several vaccines (Pfizer, Moderna, AstraZeneca, Johnson & Johnson and Novavax) provided strong antibodies when used as a booster.

Are Vaccines and Boosters Still Effective Against Omicron?

The emergence and rapid spread of the Omicron variant, which first caught the attention of scientists in November 2021, have raised questions as to whether vaccines can still protect us against this new strain. Given that there are over 30 mutations to the spike protein, the SARS-CoV-2 protein that recognises host cells and is the main target of the body’s immune responses^[_], many feared that this could result in the virus having considerable escape from vaccine-induced immunity.^[_]

However, one of the earliest studies on the Omicron variant and vaccinations (the study used by Pfizer) has found that Omicron still reacts in the same way as previous variants (i.e., it still binds to the ACE2 receptor, which is the receptor through which the virus gains entry to our bodies^[_]), so it will not escape vaccine-induced immunity entirely. This is promising news.

Despite this, it is the case that the Omicron variant is capable of much higher levels of immune escape than previous variants of concern. So, while immune protection holds up well for individuals that have protection from a previous infection and double vaccination, this is less so the case for those who are only double vaccinated.^[_]

Another study, this time conducted by Pfizer, found that a third vaccine dose increased antibodies 25-fold compared with two doses, against the Omicron variant. While researchers suggested that two doses may still provide protection against severe illness, it is clear that a third dose delivers a substantial amount of additional protection.^[_]

This means that for now, at least until we know more, we do not need to change our strategy. But it does mean that boosters and providing individuals with protection from three doses as soon as possible, is more important than ever.

Ultimately, we need more real-world evidence to make informed decisions. The arrival of this should be imminent, but that shouldn’t stop us from taking action now.

Explore the Possibility of Administering Boosters Eight Weeks After the Second Dose

In September, the JCVI advised that immunosuppressed people should be given a third dose at least eight weeks after their second dose. These doses are given as part of a primary vaccine course, as opposed to counting as a booster. However, the vaccines given as third doses are the same as those administered as part of a booster campaign so it makes sense that, where required, boosters be administered 8 weeks after a second dose.

Additionally, reports in July found that the sweet spot between first and second doses was 8 weeks. It would therefore be worth exploring whether the time between the second dose and the booster can be further shortened from 12 to 8 weeks. Although this will not matter for most people – many will be invited for a dose more than three months after receiving their second dose – it would accelerate the process for those who were hesitant about getting the first two doses, but now want a booster.

How Is the UK Performing on Boosters?

Compared to other countries, the UK’s booster rollout is progressing well. As of 6 December, more than 20 million booster doses have been administered, covering 36 per cent of all individuals aged over 16 (30 per cent of the entire UK population). The current 7-day average for daily booster administration is 378,126, with a total of 2.6 million boosters administered over the past 7 days.

Figure 6 shows how, compared to countries such as the US and France, the UK’s booster campaign is successfully reaching a higher proportion of the population. The UK has currently administered more than twice as many booster doses as France, and the proportion of population covered by boosters is almost three times higher than in the US. As to be expected, the UK’s booster coverage still lags behind Israel, the first country in the world to offer boosters to all its adult population.

We Still Need to Speed Up Booster Rollout

Progress has been good to date, but the speed and success of the UK’s booster rollout is far from secure. In fact, despite the JCVI recommending last week that all adults be made eligible for a booster three months after their second dose, booster numbers on the weekend of 4 and 5 December were actually down on the weekend before.

The government has shown a clear commitment to accelerating the rollout in recent weeks, but it is still in the planning stage when it comes to effectively scaling up its booster strategy, and better leadership will be needed to ensure that it can avoid mixed messaging. The JCVI’s recommendation on expanding eligibility, for example, led to much confusion among people who believed they were now eligible, but found themselves unable to book an appointment. Effective communications and leadership will be key to a smooth transition back to the rapid rollout that we achieved in the spring.

This time, strategy – not supply – will be the main challenge. The Department of Health and Social Care has announced that there is enough vaccine supply for the expanded booster-rollout programme, while the government has purchased an additional 54 million doses of Pfizer and 60 million doses of Moderna for 2022 and 2023 – to guarantee supply for any potential additional booster campaigns.^[_] Securing doses on this scale should not only be more than enough to cover future booster campaigns for the UK’s domestic population, it will also put the UK in a stronger position to contribute to essential vaccination efforts across the world.

This means that the main obstacle to a faster booster rollout in the UK is now infrastructure, in particular securing the right staff and venues for vaccination. As we set out in our recent report on levelling up health care in the UK, it is essential that, wherever possible, we draw on non-traditional recruitment sources to ensure that NHS staff are not prevented from working through the growing backlog of non-Covid work caused by the pandemic.

To efficiently administer vaccines, and avoid wasting both time and supply, we should also explore the possibility of a registration system for people who are enthusiastic about receiving a booster, but have not yet received an invitation. In France, waiting lists such as Vite Ma Dose and Covidliste enable people who are keen to receive a vaccine to be contacted when a dose becomes available at short notice. This is a relatively efficient way to avoid wastage and increase the speed of the rollout.

Thinking Creatively About Recruitment

The NHS is currently recruiting both paid and voluntary positions for the Covid vaccine rollout. Paid positions are for health professionals and individuals with relevant first-aid training who can be trained in how to deliver vaccines. Volunteer positions are also open for people looking to help with the smooth running of vaccination services.

But in order to administer boosters at the speed at which the government is hoping, without preventing the NHS from working through the backlog, additional workers will still need to be drafted in. Here, it is worth thinking creatively about recruitment, whether that’s retirees, medical students or medical practitioners from the private sector.

Retirees, with or without health-care backgrounds, could help either to administer vaccines or assist with the logistics of the rollout. The same applies for students – medical students could be trained to administer vaccines, while other student volunteers could help with administration and other coordinating tasks. Private health workers could be drafted in to deliver specific services, such as administering vaccines to those who are housebound in areas where this is not being done already.

Ensuring Coverage: Expanding Vaccination Venues and Reaching the Housebound

As the booster campaign picks up pace, accessibility is key. According to the NHS website, there are now hundreds of walk-in sites offering booster vaccines as part of a revamped “Grab-a-jab” campaign. Examples of these sites include pharmacies, sports stadiums and community centres. This is welcome news – the more walk-in centres there are, the more convenient it is for people to receive a booster.

But we should also be on the lookout for more ways to boost convenience. Establishing vaccination centres on university campuses, for example, would ensure that we’re ready for rapid inoculation of 18- to 25-year-olds when they receive their booster invitation in the near future. Equally, offering to administer the Covid booster and flu vaccination at the same time could drive uptake of both vaccines.

But adding more walk-in centres is not a cure-all. Greater attention is needed to ensure people who cannot leave their homes are still able to receive boosters. Of an estimated 470,000 housebound people, many of whom are classed as highly vulnerable, nearly two-thirds are yet to receive a booster. This highlights the need for a versatile and adaptable booster vaccination campaign that is ready not only to meet the sheer scale of demand, but also to meet the specific requirements of those who need it the most.

Current measures don’t go far enough to doing this. While GPs have been offered a £30 incentive for each housebound person they give a booster to, many have opted out of the scheme, citing staff shortages and time pressures. In some places, including London, Devon and Cambridgeshire, responsibility for visiting the housebound has been taken over by NHS clinical commissioning groups, or contracted to pharmacy firms. New avenues, such as using non-GP administrators, should be urgently explored to ensure that the remaining 300,000 housebound people can receive their jab as soon as possible.

Hesitancy Shouldn’t Affect the Booster Rollout, but Complacency Could

Vaccine hesitancy is still preventing millions from coming forward for their first dose. Luckily, it should be smoother sailing for the booster rollout – as long as we can get the messaging right.

According to the ONS, 9 in 10 adults in the UK who have been fully vaccinated said they would be either very likely or fairly likely to get a booster vaccine if offered one. Only 5 per cent reported being very unlikely or fairly unlikely to receive a booster if offered. In other words, booster hesitancy – as opposed to initial vaccine hesitancy – should not be a significant problem.

But we still need to be aware of the risk of vaccine “complacency” among those who have already received two doses. Some improvements have been made in recent weeks, but public messaging around the benefits and logistics of getting a third dose remains inadequate.

This information vacuum may lead to lower-than-expected take-up of the booster, especially among younger age groups. The sheer length of the pandemic may also fuel a feeling of frustration, especially among those who were hesitant to be vaccinated originally, leading to lower take-up.

Therefore, we need to make sure the incentives for getting a booster shot are clear. This means ensuring that information on the importance and efficacy of boosters is accessible and well-publicised, as well as exploring options for a potential Covid Pass that would require a booster jab for an individual to access certain venues and events.

Hopefully, the success of the UK’s vaccine rollout, and the comparatively limited spread of anti-vaccine disinformation, means that the number of individuals who are vaccine “complacent” should be small. But this doesn’t mean we can neglect the problem entirely: every dose will count in the race to protect our population.

Recommendations

1. Ensure that health services are equipped to deliver an ambitious booster campaign that can keep pace with growing numbers of eligible people.

2. Think creatively about the who and where of vaccination by recruiting from non-traditional backgrounds and using diverse venues.

3. Tailor vaccination strategies to meet the needs of the most vulnerable, particularly people who are housebound.

4. Ensure clear and consistent public messaging to prevent “vaccine complacency”.

5. Continue to explore whether the time between boosters and second jabs can be shortened, without compromising effectiveness, using the latest available data.

A Covid Pass could be a valuable part of the approach to managing the spread of Covid-19 during the race to herd immunity. Requiring people to prove their health status using a Covid Pass when they enter certain settings would have a dual benefit: first, protecting more vulnerable members of the population and those waiting to get their booster jab; second, acting as an incentive for people to get vaccinated. (France, Denmark and Italy have all seen significant increases in vaccination rates following the announcement or introduction of Covid Pass requirements.)

The venues most affected are non-essential spaces with large numbers of people in close proximity, such as clubs, theatres and sports venues, but care homes and other spaces used by vulnerable people could also be included. This requirement is already in place in Scotland, Wales and Northern Ireland: bringing England into line with the rest of the UK would be technically straightforward, and help to limit transmission.

The NHS app already has a COVID Pass function, available since May, allowing individuals to access a QR code containing their vaccine information. In the summer, NHSX launched a Verifier App, which allows staff at a venue to quickly scan a customer’s Covid certificate and see at a glance that it is valid. The venues listed are generally ticketed or require payment or security checks on entry, so the additional cost in terms of staff time would be limited.

The government could also ask people to show a recent negative test result using the NHS app. This measure could be put in place either for those yet to be offered their booster, or for everyone, as an additional layer of protection to guard against asymptomatic transmission by fully vaccinated individuals. Additionally, it could act as a mechanism to increase the take-up of regular rapid testing, as well as the reporting of results.

As with mask-wearing and other elements of the Covid management response, the requirement to show a pass could be switched on and off depending on the level of Covid-19 cases. To be ready, the government needs to do three things: 1) upgrade the NHS app's COVID Pass function; 2) publish its analysis of the costs and benefits of using a pass in different venues; and 3) publish full and clear guidance for the operators of relevant venues.

Consider an Immediate Covid Pass Requirement for Visitors to Large Indoor Settings in England

The government should explore imposing a requirement for visitors to show a Covid Pass when attending settings, such as clubs and large events. The set of venues should be in line with those in Wales and Scotland at a minimum. It should also monitor the impact of the CovidCertNI rules in place in Northern Ireland since 29 November, which also apply to pubs and other licensed venues regardless of their size, and the government should consider following suit.

Upgrade the NHS App's COVID Pass Function

Currently, all UK nations have access to a Covid Pass in the form of a digital Covid certificate (a QR code) provided via the NHS app (or CovidCertNI App in Northern Ireland). The NHS has also released a Verifier App to allow businesses and other venues to scan users’ QR codes to check that they are valid. However, the Covid certificate does not reflect test results for individuals who have been vaccinated, only those who are unvaccinated. These two functions should be added to provide a quick, more secure and convenient way for people to show their Covid test status.

Publish Analysis on the Costs and Benefits of Using a Covid Pass

In October, a leaked document showed that the Cabinet Office’s Covid-19 taskforce had concluded that health passes would reduce transmission at events by 40 per cent to 45 per cent. However, since only to 2 per cent to 13 per cent of overall community transmission happens in venues, there would only be a moderate impact on reduced community transmission as a whole, so the actual reduction figure would be 1 per cent to 5 per cent.^[_] The government should publish this work, alongside analysis of the costs and benefits of implementing a Covid Pass in a wider set of venues such as pubs, shops and public transport.

Guidance

In preparation for implementing the Covid Pass, the government should publish guidance, including:

1. The set of venues being considered and the circumstances (for instance, new case numbers) under which the requirement would be likely to be switched on and off.

2. Step-by-step instructions for businesses on how to check Covid certificates using the Verifier App.

3. Information on how the requirement to check the Covid Pass will be monitored and enforced.

Recommendations

1. Consider requiring visitors to show a Covid Pass for entry to large indoor settings in England.

2. Upgrade the NHS app's COVID Pass function.

3. Publish analysis on the costs and benefits of using a Covid Pass

The Covid-19 virus has evolved and so must our response. There are still many unknowns about the impact of the new variant, including its transmissibility and how well vaccines will protect against this new strain. Our understanding will increase in the coming weeks as we gather real-world evidence.

This should not stop us from acting now. There is the potential for the Omicron variant to lead to an uptick in cases, potentially peaking in January 2022.^[_] For this reason, we need to give every eligible person the opportunity to get vaccinated by the end of January – when the Omicron cases are likely to hit. This includes those who have yet to be vaccinated, the partially vaccinated, and younger children aged between 5 and 11.

The early data on Omicron suggests that the protection provided from two vaccine doses has decreased, making boosters a critical part of baseline protection from the virus. Every adult that is eligible should be able to get a booster as soon as possible. Our modelling indicates that this can happen, if all of the right steps are taken, and taken quickly.

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