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expert reaction to comments from Jeremy Hunt about the COVID-19 booster schedule, including his thoughts that “we should just get on, not wait for that advice” in reference to the JCVI advice on boosters

The former Health Secretary Jeremy Hunt suggested the government should “get on with the booster programme” in an interview on the Today programme this morning.

 

Prof Sir Andrew Pollard, Chair of JCVI & Professor of Paediatric Infection and Immunity, University of Oxford, said:

“The World Health Organisation recommends that all countries have a national immunisation technical advisory committee that is independent of political influence. This expert advice is provided in the UK by the JCVI, a committee of unpaid independent experts and members of the public, providing scientific advice on vaccines to Her Majesty’s Government. The availability of independent scientific advice is important  as it is not bound by short term political expediency but can take a long term view of safely protecting the health of our population that extends beyond a single parliament. And that advice can be modified at any time when new scientific advice emerges – such a change is not bound by political ideology or opinion, but an appropriate response to the science. Taking this approach, the UK has been a world leader in innovation in vaccine policy over almost 60 years as successive Governments have followed the best advice from JCVI, protecting the UK population from life-threatening infections with one of the most comprehensive and cost-effective programmes in the world.

“Although I do chair JCVI, I am not involved in the JCVI Covid19 committee and so cannot comment on their deliberations, but I have no doubt that they will be following the normal careful processes in coming to conclusions and will not be taking account of external commentary, but driving their decision-making on the evidence. JCVI is in the exceptional position in 2021 in having access to world-leading data on COVID19 vaccines, since many of the key studies are being conducted in the UK that drive national and even global policy. It is right that JCVI fully assess this scientific evidence to provide the best advice on vaccine policy when they have the necessary information to make these profound decisions for our health.”

 

Dr Peter English, Retired Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice, Immediate past Chair of the BMA Public Health Medicine Committee, said:

“Hunt made comments suggesting that JCVI is being tardy in recommending booster Covid-19 jabs for the general population, and universal vaccination of 12-15 year olds.

“The JCVI is a committee of experts set up to advise the government on immunisation and vaccination.1 In a way comparable to NICE, with other drugs and treatments, it makes recommendations on vaccination. Where they have been requested by ministers to answer a particular question (‘should we use this vaccine?’), the government is then legally obliged to follow their recommendations; but the committee also undertakes ‘horizon-scanning’ and can make other recommendations, which will not have the force of law.

“In some ways their role is more complex than that of NICE, because JCVI will consider the whole of the vaccination programme. A decision to recommend a vaccine will often impact on other aspects of the programme – if you recommend too many injections, people might decide (for themselves or their children) not to have them all, for example.

What will JCVI take into account when making this decision? What is the evidence for and against widely delivered booster jabs and vaccination of 12-15 year olds in the UK?

“When SARS-CoV-2 was first identified as the cause of Covid-19 we were concerned that long-term immunity to the virus might not arise from natural infection; and we have never had a programme in humans to vaccinate against any coronavirus, so it was not immediately clear if we would be able to develop an effective vaccine at all.

“From the start there were concerns that immunity – following infection and/or vaccination – might ‘wane’ – becoming less effective over time.

“Since then, however, some of our fears were found to be unsubstantiated: we were able to develop vaccines which provide excellent protection against severe disease (bad enough to require admission to hospital or to critical care (ICU), or to cause death); and the vaccine also stimulate cellular immunity and immune memory. They do also prevent infection and thus onward transmission, but less effectively than they do serious disease. They also provide excellent cross-protection against the variants that have arisen to date (and are likely to continue to do so against newer variants).

“The main form of immunity to the infection appears to be circulating antibodies (and possibly also IgA antibodies at mucosal surfaces). These can neutralise the virus before it can cause infection. Prior exposure to the virus or to a vaccine can provide immunity which will kick in quickly after infection, thereby preventing serious illness.

“There has been some evidence that antibody levels have fallen in some of the people vaccinated several months previously, and that this may result in more infections; however – almost certainly as a result of immune memory – this does not translate into serious illness. It is also the case that often even fairly low levels of antibodies can provide more-than-adequate protection; we do not yet have fully

“In the UK we have excellent systems to monitor the number of cases and the burden of disease from Covid-19; and these be able to detect and quantify real-world illness (as opposed to laboratory measurements in vitro of declining antibody levels.

“It has been suggested that booster doses of vaccine might provide better cross-protection against new variants of the virus, and top up antibody levels to prevent infections, and thereby reduce spread (you can’t infect others if you don’t get infected yourself). It is not clear, even just within the UK’s perspective, whether the increase in disease as immunity wanes is sufficient (if it is real) to justify booster doses at this time.

“These benefits may exist; but JCVI will have to balance them against other factors such as vaccine scarcity. More manufacturing plant has been coming on stream; but there is still an insufficient supply of affordable vaccine for all countries to vaccinate all their at-risk populations. While the virus is being transmitted at extremely high risk in lower-income countries, the pandemic cannot be controlled. Newer – possibly more transmissible, maybe even vaccine-escape variants will continue to evolve. Quite apart from the humanitarian need to provide vaccines for the world, richer countries have a self-interest in controlling the pandemic worldwide.

“So the question is not just – ‘is there a benefit to booster doses?’. It is ‘is there sufficient benefit to recommend booster doses at this time? Or at a particular interval after the completing dose of the primary vaccinations?’

“I am not at all clear that we have yet reached the point where booster are indicated, and agree with the position taken by JCVI on this (and note that others, such as the European Centre for Disease Prevention and Control (ECDC), have made similar statements).2 3

Do JCVI consider societal advantages/disadvantages or just the individual?

“While relatively few children suffer serious acute (short-term) illness as a result of Covid-19, a higher proportion (including of children who did not have serious primary disease) suffer long-term sequelae; and there is evidence that such sequelae can be prevented by vaccination.7 10-15

“As I said in my previous comment:4

Children also stand to benefit directly from:

– Ending the pandemic and inevitable restrictions sooner;

– Avoiding the harms relating to the secondary cases (people infected by the children), especially if teachers, parents or carers are infected;

– Reducing the effects of Covid-19 (directly or through self-isolation etc) on loss of school;

– And, crucially, given the growing evidence of its severity and frequency, by preventing the long term consequences on the children and adolescents of “Long Covid”.  As Dr Tom Frieden in the USA tweeted: “The most certain way not to get long Covid is not to get Covid. The most certain way to not get Covid is to get vaccinated.”16

Is this a difficult decision?

“This is a difficult decision because it balancing issues which may be fairly clear-cut issues, such as ‘what is the evidence for increasing break-through infections?’, against others which are dissimilar (‘what is the vaccination production capacity?’; ‘how do we balance the UK’s needs against global needs?’).

How does scientific advice feed into government policy decisions? Could government make a different decision to what JCVI advise?

“As discussed above, if the JCVI is tasked by ministers with answering a specific question, then the government is obliged to implement that decision; but other than in these circumstances, the JCVI’s role is advisory, and ministers can make decisions taking into consideration the views of JCVI, other government advisory committees, and financial and political considerations.”

  1. Joint Committee on Vaccination and Immunisation (JCVI). Joint Committee on Vaccination and Immunisation (JCVI) landing page. Joint Committee on Vaccination and Immunisation (JCVI) 2021; Updated Undated; Accessed: 2021 (27 Jan): (https://www.gov.uk/government/groups/joint-committee-on-vaccination-and-immunisation).
  2. Public Health England. JCVI issues advice on third dose vaccination for severely immunosuppressed. Press release 2021; Updated 01 Sep 2021; Accessed: 2021 (03 Sep): (https://www.gov.uk/government/news/jcvi-issues-advice-on-third-dose-vaccination-for-severely-immunosuppressed).
  3. European Centre for Disease Prevention and Control (ECDC). ECDC and EMA highlight considerations for additional and booster doses of COVID-19 vaccines. Stockholm: ECDC, 2021 (14 June);  (https://www.ecdc.europa.eu/en/publications-data/covid-19-public-health-considerations-additional-vaccine-doses or via https://www.ecdc.europa.eu/en/news-events/ecdc-and-ema-considerations-additional-and-booster-doses-covid-19-vaccines).
  4. English PMB, Royal College of Paediatrics and Child Health, Brown D, Ghani A, Ferguson B, Ward P, et al. Expert reaction to JCVI interim advice on whether children and young people aged 12-17 years should be offered the COVID-19 vaccine. Science Media Centre 2021; Updated 21 Jul 2012 (Originally published 19 Jul 2021); Accessed: 2021 (21 Jul): (https://www.sciencemediacentre.org/expert-reaction-to-jcvi-interim-advice-on-whether-children-and-young-people-aged-12-17-years-should-be-offered-the-covid-19-vaccine/).
  5. Covid Action Group, Gurdasani D, McKee M, Michie S, Pagel C, Reicher S, et al. Open letter to Secretary of State for Education (UK) May 4, 2021. 2021; Updated 04 May 2021; Accessed: 2021 (04 May): (https://covidactiongroup.net/open-letter-to-secretary-of-state-for-education-uk-may-4-2021/).
  6. Gurdasani D, Bar-Yam Y, Denaxas S, Greenhalgh T, Griffin S, Haque Z, et al. England’s schools must be made safe: An open letter to the education secretary. thebmjopinion 2021; Updated 03 Sep 2021; Accessed: 2021 (03 Sep): (https://blogs.bmj.com/bmj/2021/09/03/englands-schools-must-be-made-safe-an-open-letter-to-the-education-secretary/).
  7. Strain D, MacDermott N, Altmann D, Absoud M, Bishop N. Expert reaction to preprint from the CLoCk study looking at long COVID in children. Science Media Centre 2021; Updated 01 Sep 2012; Accessed: 2021 (02 Sep): (https://www.sciencemediacentre.org/expert-reaction-to-preprint-from-the-clock-study-looking-at-long-covid-in-children/).
  8. Alwan N. @Dr2NisreenAlwan: The updated headline: “Long Covid in children ‘nowhere near scale feared’”. What was the scale feared then? The study shows that symptoms are more common in those who tested positive. 30% in test positive vs 16% in test negative had 3+ symptoms at 3 months. Twitter thread 2021; Updated 02 Sep 2021; Accessed: 2021 (03 Sep): (https://twitter.com/Dr2NisreenAlwan/status/1433318405164126208 or https://threadreaderapp.com/thread/1433318405164126208.html).
  9. Independent SAGE. The Independent SAGE Schools redux: September 2021: An Urgent Plan for Safer Schools. Education, Short statements 2020; Updated 03 Sep 2021; Accessed: 2021 (03 Sep): (https://www.independentsage.org/wp-content/uploads/2021/09/Schools-redux-Sept-2021.pdf or via https://www.independentsage.org/september-2021-an-urgent-plan-for-safer-schools/).
  10. Strain D, Openshaw P, Head M, Maxwell E. Expert reaction to study looking at long COVID, including in those who weren’t hospitalised with the disease. Science Media Centre 2021; Updated 23 Jun 2012; Accessed: 2021 (24 Jun): (https://www.sciencemediacentre.org/expert-reaction-to-study-looking-at-long-covid-including-in-those-who-werent-hospitalised-with-the-disease/).
  11. Terence S, Terence S, Snehal Pinto P, Roz S, Bianca De S, Natalia R, et al. Long COVID – the physical and mental health of children and non-hospitalised young people 3 months after SARS-CoV-2 infection; a national matched cohort study (The CLoCk) Study [preprint]. Nature Portfolio 2021. (https://www.researchsquare.com/article/rs-798316/v1).
  12. Molteni E, Sudre CH, Canas LS, Bhopal SS, Hughes RC, Antonelli M, et al. Illness duration and symptom profile in symptomatic UK school-aged children tested for SARS-CoV-2. The Lancet Child & Adolescent Health 2021. (https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(21)00198-X/fulltext).
  13. Huang L, Yao Q, Gu X, Wang Q, Ren L, Wang Y, et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet 2021;398(10302):747-758. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01755-4/fulltext).
  14. The L. Understanding long COVID: a modern medical challenge. Lancet 2021;398(10302):725. (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01900-0/fulltext).
  15. Antonelli M, Penfold RS, Merino J, Sudre CH, Molteni E, Berry S, et al. Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: a prospective, community-based, nested, case-control study. The Lancet Infectious Diseases 2021. (https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00460-6/fulltext).
  16. Frieden T. @DrTomFrieden: The most certain way not to get long Covid is not to get Covid. The most certain way to not get Covid is to get vaccinated. Tweet 2021; Updated 19 Jul 2021; Accessed: 2021 (19 Jul): (https://twitter.com/DrTomFrieden/status/1417183808114282499).

 

Dr Doug Brown, Chief Executive of the British Society for Immunology, said:

“The Joint Committee on Vaccination and Immunisation is composed of expert doctors and scientists who carefully review the available evidence to provide recommendations to government around the provision of vaccines to the UK population.

“As with all decisions around vaccine use, it’s critical that the evidence around COVID vaccines, including whether additional doses are needed or not, is robustly scrutinised by the experienced experts from the JCVI. By following this well-established process, the public can have confidence that experts in the field have fully analysed and evaluated the evidence to provide recommendations that maximise the public health benefits that COVID vaccines can have in reducing disease levels and ultimately saving lives.”

 

Prof Saul Faust, Chief Investigator, COV-BOOST Trial & University of Southampton and University Hospital Southampton NHS Foundation Trust, said:

“It is hard to understand the timing of some senior politicians and some news media comments on this topic today.

“The UK is the only country in the world who commissioned urgent research to inform booster decisions and the trial timelines have always been set to report next week for the decision making.  As people in a booster trial had to have had at least the same gap between dose 2 and a 3rd dose as for the initial course in most people, recruitment of nearly 3000 people to the COV-BOOST trial happened in June 2021 and blood tests were taken at the 18 UK sites in July 2021, 28 days after each person’s dose. The laboratories have been working hard on the immune responses including antibodies, T cell memory responses and how people’s blood kills both the original strain and variants of concern. These data will be available to JCVI and the MHRA next week – immediately after the data arrives from the laboratories and has been formally analysed by the trial team.

“The UK population can be reassured that JCVI decisions are the only ones globally being made on hard evidence for a mixed booster schedule. People who received AZ or Pfizer will be able to be confident that their offered booster will be safe and effective even if not the same as the first one – and the combination or recommendation may have been selected because a particular combination has benefit in immune response or longer term memory. COV-BOOST also studied different (fractional) doses of some vaccines, and it could be that a lower dose or one or other vaccine tested provides enough immune response or has better side effect profile with “enough” immune response to provide longer term protection.”

 

Relevant comment sent out from previous roundup: https://www.sciencemediacentre.org/expert-reaction-to-jcvi-advice-on-third-covid-19-vaccine-dose-for-severely-immunosuppressed-people/

Dr David Elliman, Consultant Paediatrician, Great Ormond Street Hospital, said:

“The decision to give a third dose of vaccine to those who are likely to have responded poorly to the first two doses is to be welcomed.  However, I find it very worrying to see reports that pressure is being put on JCVI (Joint Committee on Vaccination and Immunisation) to decide that boosters should be given to a high proportion of adults and to young people aged 12-15 years, even if they have no underlying health problems.  We should be using the vaccine, a precious resource, carefully and any action should be based on the evidence.  The JCVI is the expert body that can weigh all the evidence and come to a considered decision based on the balance of risks and benefits.  It should not, and will not, be forced into an inappropriate decision by pressure from politicians or the media.  The latter would be the first to complain if someone who had little to gain from having the vaccine came to harm.”

 

 

https://www.bbc.co.uk/sounds/play/m000z784 (1:56:02 – 1:57:01)

 

 

All our previous output on this subject can be seen at this weblink:

www.sciencemediacentre.org/tag/covid-19

 

 

Declared interests

Dr Peter English: “Dr English is on the editorial board of Vaccines Today: an unpaid, voluntary, position. While he is also a member of the BMA’s Public Health Medicine Committee, this comment is made in a personal capacity. Dr English sometimes receives honoraria for acting as a consultant to various vaccine manufacturers, most recently to Seqirus.”

Prof Doug Brown: “Doug is a Trustee of the Association of Medical Research Charities.”

Dr David Elliman: “No conflicts.”

None others received.

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