Sir Patrick Vallance, Professor Chris Whitty and Dr Jenny Harries appeared before the Health & Social Care Committee and Science and Technology Committee as part of their joint Coronavirus: lessons learnt inquiry.
Watch Parliament TV: Coronavirus: lessons learnt
Inquiry: Coronavirus: lessons learnt
Health and Social Care Committee
Science and Technology Committee
Wednesday 9th December 2020:
Sir Patrick Vallance, Government Chief Scientific Adviser
Professor Chris Whitty, Chief Medical Officer for England
Dr Jenny Harries, Deputy Chief Medical Officer for England
This session covered science advice to Government, data and modelling, public messaging, vaccination, focussing on the lessons that can be learned from the handling of COVID-19 in the UK.
Dean Russell Q1: May I say how fantastic the news about the vaccine is? Thank you for all the work you have both been doing to drive that forward. I have a few questions around the preparations, moving forward. First, could I get an outline and a clear summary of what the next year looks like in terms of the roll-out?
Sir Patrick Vallance: Roll-out of vaccines?
Dean Russell: How are we going to get them to the right people at the right time? There is roll-out in terms of vulnerability. Who is going to be doing the vaccinating? Several million people are going to have to have vaccines. Is it going to be by GPs or hospitals? Who is going to be administering them? I would like to get an overview of what that will look like.
Chair: Sir Patrick is going to tell me that this is an NHS matter, and therefore the chief medical officer is probably best placed to answer it.
Sir Patrick Vallance: Yes.
Professor Whitty: It is an NHS matter. Although the NHS obviously has independence, I am going to speak in broad terms about the kind of approach it is likely to take. The first thing is that the only current vaccine for which we have emergency authorisation for use—the Pfizer one—has a very complicated cold-chain system, having to be maintained at minus 70 or below, with relatively small numbers of changes of hands. That makes it rather harder operationally than some of the potential subsequent vaccines that might come through. We have talked about the AZ one already, but there are several others that will come through from a variety of sources later in the year. It is much easier to operate through hubs, but the aim would be to take it out through the system as far as we can. That is true in all four nations of the UK. Of course, we talk to one another the whole time and try to coordinate our activities as much as we can. When we start off with vaccines, as with any drug, we want to take things a little bit more carefully to begin with, so that we get to know how things work. For example, Dr Raine talked about the fact that we were discussing those two early cases. She and I were discussing that at 11.30 last night. You start off doing it in centres where you have all the equipment, and then, as you are comfortable and understand them, you move them out. That is the standard way you would think about the safety of things. The aim would be to roll out this vaccine, and then any others that get a licence and are effective and safe. We expect by the middle of the year to have a portfolio of probably three or four vaccines that we can use. Provided that all is going fine and there are no late tumbles, in terms of side effects that the regulators find, or anything of that sort, the first question will be, who has it? The Joint Committee on Vaccination and Immunisation—JCVI—has done a prioritisation list, starting with the most vulnerable and those who look after the most vulnerable, as a way of protecting them: care homes; then people over 80; then people over 70 plus care workers and healthcare workers; and so on. The list goes all the way down to people over 50. We go down in stages because this disease is one that, very predictably, is much more dangerous for older people and people with pre-existing health conditions than for others. Once we have gone through the first list, which takes us to roughly 20 million people, there are some wider choices to make about how we go on from there. Those will be important ethical and political choices, as well as clinical choices. The first choices, in a sense, make themselves because they are the people who are the most at risk. The final question—I am happy to expand on any of these—is whether we need to revaccinate people and, if so, when. We know that these are very good vaccines to provide short to medium-term protection. We do not know how long that lasts. It might last for a very long time; it might last for nine months. It is more likely to be somewhere between the two. In that case, we may have a situation where we need to be in a position to revaccinate, particularly people who are the most vulnerable. We will have to think about all of those things as information comes out on length of effect, efficacy, safety and so on, and which vaccines best suit which people.
Dean Russell Q2: Are we going to look at an annual vaccination programme? By the sound of it, that is potentially the case. On the rate of vaccination, if we have the same Select Committee in a year’s time, what would be a good result for you as a percentage of the population being vaccinated?
Professor Whitty: To answer your first question on whether we need to revaccinate and how often, we do not know. There are broadly two reasons to revaccinate. One is that the immune system wanes, so the same vaccine is used repeatedly but you still have to revaccinate. The other is that the genetic thing you are targeting the vaccine against shifts, and the infection evolves around the vaccine. That is what happens with flu. You then have to reformulate the vaccine and use a slightly different vaccine to deal with the new version. Those are the two situations in which you might need to do it. In terms of what looks like a good response, the first priority is absolutely to provide protection for the people who are most likely to have severe ill-health, potentially die or certainly end up in hospital with severe problems. Those are predictable based on the numbers. Some people who are younger and not predictable will still get severely ill with this infection. We would want to go down further than that, but start off with the most vulnerable. That is all about protecting the individual who has the vaccine. A second question, to which we do not yet know the answer, is whether, if you vaccinate someone, you protect the people they meet. Is it a transmission-preventing vaccine? We do not yet know that. My expectation is that it will be to some extent, but whether it is a small or a large amount is not yet clear. Some vaccines only provide individual protection. The tetanus vaccine, for example, only protects the person who is vaccinated; it protects no one else at all. In that case, you are really trying to make sure that it is for the most vulnerable. If, on the other hand, it is something that protects everyone around you, it is strongly in the interests of everybody that many other people are vaccinated. It then means that people for whom the vaccine is not working, or who cannot take it or have chosen not to take it, are protected by the fact that people around them have immunity and are therefore not going to transmit disease to them. We do not know that yet, and it would be a mistake for us to say that we are going to try to achieve that kind of population immunity. We are not confident yet whether that is biologically possible. I think it is likely, but it is not definite.
Dean Russell Q3: The thing that everybody is looking at for the vaccine is around when we are going to come out of lockdown. That is the light at the end of the tunnel. If it is the case that the vaccine only protects the individual from transmission and not others, at what point does SAGE recommend that lockdowns are no longer needed? Have there been conversations on that point yet?
Professor Whitty: I will give a view, and then Patrick will want to give a view. My view on that is that what the vaccine will do for sure, even if it has no onward protection advantage at all—I think that is unlikely; I think it will reduce transmission, but let’s assume it doesn’t—is that, incrementally, it will first reduce the mortality rate very substantially. Mortality is very heavily skewed towards older people, so once you get through that it will substantially reduce it. Then it will start to reduce very substantially the number of people who go into hospital and have severe disease. At a certain point, society, through political leaders, elected Ministers and Parliament, will say that this level of risk is a level of risk that we think it is appropriate to tolerate, just as we accept that in an average year 7,000 die of flu and in a bad flu year 20,000 people die of flu. We accept that that is what happens biologically. At a certain point, you say that the risk is low enough that we can largely do away with the most onerous things that we have to deal with.
It will happen incrementally. We will not do absolutely everything until one day when we suddenly stop. There will be a gradual retreat, but it is a de-risking process rather than it just going away. We will de-risk, hopefully to a very low level of risk, but it is very unlikely that we will get to a zero level of risk. SAGE can help—this is where I turn to Patrick—in saying what level of risk there is. It is ultimately a societal, and therefore a political, question as to what level of risk the population wishes to tolerate, relative to the damage that is done to other areas of society, the economy and so on. Those are the difficult choices. We are not there yet. For the next three months—I want to be very clear—we will not have sufficient protection. We are going through the most difficult time of year for respiratory infections, and the most difficult time of year for the NHS. The idea that we can suddenly stop now because the vaccine is here would be premature. It is like someone giving up a marathon race at mile 16. It would be absolutely the wrong thing to do, but there will come a point when the choice about exactly when to start to ramp things down, how fast and which things, needs to be made. That is fundamentally a science-informed political decision.
Chair: Sir Patrick, do you have anything to add?
Sir Patrick Vallance: I agree that it is a science-informed political decision. What we are looking at is exactly that sort of question, depending on the effects of the vaccine on transmission. As Chris said, we do not know that yet. You would have different models as to what that would mean for the degree of immunity you end up with across the population that is relevant to keeping suppression of transmission versus protecting those who are most vulnerable. Priority No. 1 has to be to protect those who are most vulnerable. You can see the effects of that. There will still be transmission among others at that point, so we need to be aware of that. Then we will know a bit more, as we learn about transmission across the different vaccines, about their effect. Ultimately, there are decisions to be made about how much risk society wishes to take with that.