From the beginning of the Covid-19 pandemic, the world waited with bated breath for news of a protective vaccine. In the end, much like the proverbial buses, when one came along, others followed in rapid succession. Vaccines from both Pfizer and Oxford/AstraZeneca have been licensed for use in the UK, and vaccinations are well underway. The Moderna vaccine has also now been given the green light, although it will still be a few months before it’s available for use. The NHS plans to vaccinate a significant part of the population before Easter.
But what are the challenges for the health service as it delivers the biggest mass vaccination project in its history?
The hurdles ahead
First, there is the logistical challenge. It will be no mean feat to get the right staff in the right place at the right time with the supplies they need, while ensuring that the people they need to vaccinate are also in the same place at the same time.
There are three competing demands on NHS staff. The need to respond to the very considerable pressures caused by Covid itself, the need to keep ‘normal’ NHS services operating as much as possible (including treating the backlog of patients that has built up), and now the need to deliver the vaccination programme. NHS England have acknowledged that these demands cannot be met solely by the existing workforce.
It has been the responsibility of NHS organisations and GP practices to identify premises to deliver the vaccinations. They need to be easy to reach by both staff and the public – and not already being used by the Test and Trace service. They also need to be big enough for everyone to maintain social distancing throughout, while providing storage for the vaccines themselves and also the PPE and other consumables required. As of January 22, vaccinations in England were being delivered from almost 240 hospital sites and over 1,100 community locations, from pharmacies to mass vaccination centres.
A national distribution service has been established to ensure that every site delivering vaccinations receives supplies of the necessary vaccines, consumables and PPE, seven days a week.
While it does feel appropriate that such logistics are coordinated centrally, we must hope that lessons have been learned from the challenges of PPE distribution during the first wave. In these first few weeks of the programme, it does appear that supply of the vaccine at a local level is the main limiting factor for local delivery. There is no evidence as yet of any Brexit-related disruption to imports from Europe impacting the vaccine supply chain, although Pfizer has announced a temporary slow-down in production while their factories are reconfigured.
The Pfizer vaccine also needs to be stored at a temperature of at least -70°C until shortly before use, presenting an additional challenge. The Oxford/AstraZeneca vaccine is less problematic from this point of view, but there are other challenges to the supply chain. A worldwide shortage of the glass vials in which the vaccine is delivered to sites is one rate-limiting factor to distribution, and a second is the requirement for each individual batch to be assessed by the Medicines and Healthcare products Regulatory Agency (MHRA). The latter issue is being addressed by the MHRA, but the former is likely to be problematic for some time.
Getting the message right
The speed of the vaccines’ development has been truly impressive – no vaccine has ever before progressed from the starting blocks to licensing for use within a year.
Perhaps unsurprisingly, it appears that throwing vast sums of money and the best expertise in the world at a problem is one way to find a rapid solution. And regulators have worked hard to ensure that they can carry out their safety checks through a ‘rolling review’ process, running in parallel with the clinical trials.
The vaccines’ developers and regulators have given welcome reassurance that no corners were cut around safety in the race to get a vaccine ready. Nonetheless, there is still a significant communications challenge for the NHS to ensure the public are confident to come forward and be vaccinated. Communications leads working at both local and national level have a critical role to play working alongside their clinical colleagues – including in reassuring the public if there is an incident of an adverse reaction to the vaccine.
The MHRA have specific arrangements in place to track any such incidents, with an anticipated incidence of 0.05-0.1%. Because the Covid vaccines will be administered on a large scale, there may well be instances of people who get ill at the same time as having the injection, which may not have a relationship with the actual vaccination.
In fact, within 24 hours of the first Pfizer vaccines being administered, ‘yellow card’ reports were received indicating two serious allergic reactions. Fortunately, communications teams were able to work well with the media to keep these individual incidents in context, and although standard operating procedures were revised, they do not appear to have undermined public confidence in the vaccine programme.
However, there are concerns about the level of uptake of the vaccine among people from ethnic minorities, who appear to be at greater risk of poor outcomes from Covid infections. It is now a requirement to record the ethnicity of those vaccinated, so that any trends and disparities are rapidly identified. Given the concern surrounding the apparent risks for people from BAME communities, it is hard to see why this requirement was not in place from the start of the programme. NHS England is working closely with community leaders to ensure confidence in the vaccination programme, including designating facilities such as mosques as vaccination centres.
A return towards normality?
Many questions have been asked about who will be vaccinated, and when. The Joint Committee on Vaccines and Immunisations published the priority order for receipt of the Pfizer vaccine in early December, and this was reconfirmed on the approval of the Oxford/AstraZeneca vaccine later in the month.
Most invitations to NHS staff and members of the public are being coordinated locally via NHS employers and GP practices, but a national booking system has also been put in place to support the mass vaccination centres. When called for their vaccination, people are able to make an appointment at a GP practice, a community pharmacy or one of the mass vaccination centres. For people unable to travel, ‘roving teams’ bring the vaccine to them. A second national system has also been established to hold data on who has received the vaccine (the Pinnacle system), which crucially will help to ensure that people receive both doses needed to confer the maximum possible immunity.
It will be critical that information flows smoothly between the national system and local services. Any glitches will impact not only on public confidence, but on the confidence of the health care professionals relied upon to reassure the public. Unfortunately in the early stages of the rollout, the Pinnacle system has experienced system problems, and GP practices have been recording data manually. We must hope that these issues can be addressed rapidly.
The last 10 months have been some of the most difficult the NHS has ever experienced, and it’s also been an extraordinarily tough year for the public. The next few months will not be easy either. But a successful vaccination programme will mean we can all look forward to a return to normality during 2021, and to the human contact that so many people have so desperately missed.
Buckingham H (2021) “Safe delivery? The main challenges for the NHS in delivering the Covid-19 vaccine”, Nuffield Trust comment.