More than ever before, we must look behind the reported Covid-19 numbers in hospitals and communities to understand what is happening in the pandemic. We also need to better understand how the pandemic is playing out among unvaccinated people, and those who have been vaccinated.
To the public, the pandemic was and still is a silent pestilence, made visible by the images of patients fighting for their next breath and reporters at intensive care units talking about the fear of patients and the exhaustion of doctors and nurses from behind their fogged visors. This ongoing horror, which is taking place in ICUs across Britain, is now largely restricted to unvaccinated people. Generally, Covid-19 is no longer a disease of the vaccinated; vaccines tend to limit this suffocating affliction, with a few exceptions.
If the protection that vaccines offer against severe Covid-19 began to wane, given that tens of millions of people are now vaccinated in the UK and only a fraction of the population have not received the jab, ICUs would be filled to the brim with vaccinated people. But they are not. Vaccines still seem to give almost complete protection against this form of life-threatening cases of Covid-19. The latest wave of the virus in the UK – with cases rising rapidly in parts of Europe – will directly translate into a stream of mostly unvaccinated patients entering ICU.
In the short term, boosters and social restrictions will help prevent Covid-19 from spreading among people who are unvaccinated this winter. But in the long run, the pressure of Covid-19 on ICUs won’t be solved through these measures. The virus will eventually reach unvaccinated people. To prevent serious illness, these people need first and second doses of the vaccine as soon as possible.
It is therefore obvious that governments with doses to spare should be making every effort to ensure vaccines urgently reach people who are undecided and unvaccinated. Some countries are already hoping to drive uptake among this group by imposing social restrictions or introducing vaccine mandates. But understanding and dealing with people’s underlying objections to vaccinations would be a visionary project to secure the public’s health, during the pandemic and beyond.
In countries with lower vaccination rates, the impact of the current wave on hospital ICUs will be far worse than in Britain. As a proportion of the whole population, vaccination coverage in the UK is 69%, but in Bulgaria it is only 24% and in Slovakia 43%. It is also important to address pockets of unvaccinated people in countries where vaccine uptake is otherwise high. In the US, for example, fewer than 50% of people have received both jabs in certain states. In other states, the rate is 70%.
In this context, it is shameful that in some low-income countries only 5% of the population have received at least one dose, almost a year since the first licensed dose was given in Britain. The director general of the World Health Organization expressed his deep concern last week that there are now six times more booster doses being administered every day than first doses. We are still not doing enough to end the pandemic for the world’s unvaccinated, and governments and manufacturers urgently need to work together to get doses to those in low-income countries, keeping an eye on the long-term gains of global vaccination, despite the challenges posed by the current Covid spike in Europe.
For those of us fortunate enough to have already been vaccinated, the story now seems very different. For the most part, we are protected from very severe cases of Covid-19. But it is now clear that even the fully vaccinated can get mild infection with the virus: the effectiveness of two-dose vaccines against mild symptomatic infection now ranges from 44% to 63%, according to the UK Health Security Agency.
This lower level of protection is partly a feature of waning immunity against mild infection. It’s also a result of the Delta variant, which is better at infecting people than its predecessors, even when they have vaccine immunity. For most vaccinated individuals, these mild infections are little more than an unpleasant inconvenience. But for those who are very frail, immunocompromised or have underlying health conditions, these infections are enough to destabilise them and lead to hospital admissions, which is what happens every winter with other viruses, including flu.
For some, these are serious, life-threatening health problems that add to the pressure on the NHS. But this situation is not the same as the one we faced last year. It’s also worth remembering that while daily hospital admission data includes people with Covid-19, these numbers may also include people admitted for an unrelated illness, an accident or indeed for elective surgery who happened to have tested positive for Covid. It is difficult to know the true burden of disease in hospitals when the background rate of infection in the community continues to be high.
Booster doses drive up the antibody levels that are needed to prevent infection. According to recent figures from the UKHSA, they appear to increase protection against Covid-19 to at least 93%. As a consequence, they will help to drive down the number of Covid-19 cases in the community, and reduce the chance that milder infection will occur among vulnerable people that result in hospital admissions. In highly vaccinated regions where the supply of doses is not limited, this is good news. But we don’t yet know how long this boost to protection will last.
We need better and cleaner clinical data to understand fully which patients are being admitted to hospital, to improve our assessment of how effective vaccines are at preventing hospital and ICU admission, and to assess who would be most likely to benefit from boosters. It is also important to monitor and assess the duration of the top-up protection afforded by boosters to then inform the best long-term strategy for future control beyond this winter.
What this means for people who are vaccinated is that we have our first glimpses of what “living with the virus” might look like, though it will be some time before it is clear where or when this will all level out. There are still questions over whether we will need regular boosters, and who these should target. But the horrors of the pandemic continue unabated for the unvaccinated, who remain at risk wherever in the world they live. We have to do better at delivering first doses to these people by addressing the unequal access to vaccines across the world, and the barriers that exist to vaccine acceptance among some communities.