A balanced vaccination strategy to save lives and livelihoods

The accelerating rollout of vaccines in many countries marks the latest sign of hope in the fight to bring COVID-19 under control. Multiple vaccines have now been approved, and they are all remarkably successful by the most important clinical measure: preventing hospitalizations and deaths resulting from COVID-19.

Now, three months into a global vaccination effort, it is time to ask: “What has worked, and what has not?”, “Where do we need to set our sights?”, “What lessons can be passed along to nations whose vaccination efforts are just beginning?”

The latest data on the vaccines and variants suggest it is likely that COVID-19 will become endemic like the flu. While the leading vaccines have all been highly effective at preventing hospitalizations and deaths, people who have been vaccinated are still slightly susceptible to the disease and may still be able transmit the virus to others, especially amidst the rise of new variants.

Given the virus will likely continue circulating and mutating, we should seek to keep people alive and out of the hospital by vaccinating the health vulnerable – those most at risk of developing serious disease or dying if infected – as swiftly as possible. COVID-19 is especially deadly to people over the age of 65 and those with underlying health conditions.

Once the health vulnerable are vaccinated, governments can offer vaccines to the rest of the population and start to reopen their communities. During the reopening, they should retain low-cost public health measures, such as mask wearing and surveillance testing. Even if the virus causes new outbreaks, governments can be confident that their healthcare systems will not be overrun.

As vaccinations ramp-up and cases decline, governments may be tempted to remove restrictions too quickly. Leaders should resist this approach. We have modeled several scenarios showing the effect of relaxing restrictions on intensive care unit occupancy. In the US, delaying the removal of restrictions by just four to six weeks will significantly reduce hospitalizations.

The relaxation of restrictions should occur in phases. Those with the highest cost, such as business closures or capacity restrictions, should be removed before those without economic consequence, such as mask mandates. The virus recedes because of the combination of immunity and restrictions. What we have seen and modeled is that if we simply lift the restrictions as soon as the virus starts to recede, the immunity will not have built up enough to prevent another, unnecessary outbreak.

Governments can execute a strategy built around reducing the risk of serious disease in three phases: rollout, ramp-up, and end game.

The goal is to get needles into the arms of those who are most health vulnerable. Operational simplicity and clear communications should govern the rollout. Practically, this means governments should create high-volume vaccination sites, easy-to-understand prioritization groups, and easy-to-use centralized registration systems. As much as possible, all levels of government and all providers should be echoing the same messages. By excelling at both simplicity and communication, countries such as Israel and UAE, have been leaders in vaccinating sizable shares of the population and have built trust among their citizens.

Nations without adequate immediate supply of vaccines should consider a “first doses first” strategy of vaccinating as many people as possible, especially those most at risk, with their initial dose to stretch supply and reduce hospitalization risks. The data suggests that boosters (second shots) can be delayed by up to 12 weeks.

During this phase, governments must expand throughput to accommodate a greater supply of vaccines and ongoing unmet demand. Their focus should be on volume and outreach to the health vulnerable. Once that segment – about 100 million adults in the US – is vaccinated, the focus should shift to equitable distribution and administration across population groups. In the US, for example, the early vaccination rates of Black and low-income people are lower than their shares of the population. Governments should ensure equitable access to vaccines by simplifying scheduling, expanding location hours, reducing barriers to get to vaccine sites, and addressing whatever concerns arise in these communities.

One looming concern for the ramp-up phase is the emergence of individual preferences for one vaccine over another. Several nations recently paused their use of the AstraZeneca vaccine out of concern that there may be blood clotting issues, despite the lack of evidence tying these issues to the vaccine. On 18 March the European Medicines Agency safety committee concluded that the benefits of the vaccine in combating COVID-19 outweigh the risk of potential side effects.

Governments can address this challenge of preference by promoting all vaccines that have been proven to be safe and effective, especially on the most important outcomes of hospitalization and death. Governments should reinforce that the best vaccine is the one you can get first – and create equitable access across them. Ongoing monitoring of safety and efficacy, uptake of specific vaccines across population segments, and transparent communication, are the best ways to both demonstrate and operationalize equitable distribution.

In this final stage, the centralization strategy that was so necessary to vaccinate the willing during ramp-up becomes a hindrance in reaching the hesitant. Vaccine hesitancy may be the greatest challenge to ending the pandemic; a BCG survey conducted in late February in the US suggests about 45% of the adult population who had not yet been vaccinated were hesitant to get the vaccine.

Much of that hesitancy is driven by fears around safety and efficacy. While the rapidly growing body of reassuring evidence can help address those concerns, research also suggests that people are more persuaded by those they trust, such as their primary physicians and local community leaders.

As execution moves from bringing arms to vaccines to bringing vaccines to arms, centralized access gives way to community access. Receiving a vaccine should be as simple as visiting a local pharmacy, church, community health organization, or physician’s office.

In addition to this boots-on-the-ground approach, addressing vaccine hesitancy requires a societal response, involving all levels of government and unified and targeted messaging from public officials and scientists. England has seen success in driving hesitancy down by connecting local community and faith leaders with doctors in the NHS to address questions and concerns in virtual town halls aimed at ethnic minority communities. As a result, MPs estimate that adult hesitancy for taking the vaccine may be less than 10% across the country.

Unless variants are able to mutate and get around vaccine-induced immunity, some nations are only months away from a return to a “new normal.” Low and middle-income countries are further behind. But they will have the benefit of best practices developed by the other nations.

The desire to return to normal is understandable – COVID-19 fatigue is widespread. But if we act collectively and with caution, COVID-19 need not define us much longer.