Why a COVID-19 Vaccine Might Not Be the Answer We’re Hoping For

As the coronavirus disease 2019 (COVID-19) pandemic has disrupted and derailed 2020, many see the promise of a vaccine as the pathway back to “normal.” As of this August writing, there are 26 vaccines in various stages of clinical trials and 139 vaccines in preclinical trials across the globe.1 Vaccine development typically takes years from design to US Food and Drug Administration (FDA) approval and readiness for mass market. Even with the increased funding and drive to create and distribute a vaccine that protects against COVID-19, it may be well into 2021 before one is available for the public. And even when it is available, the efficacy of the vaccine will be unknown until large populations have received it.2 Given this timeframe, and other factors associated with vaccination as a tool in pandemic response, the road to normalcy may not be as smooth as many hope.

Infection preventionists (IPs) are collaborators with other departments, such as occupational health, human resources, and clinical leadership, to promote and implement vaccination programs for healthcare providers (HCPs). Typically, staff vaccination programs are owned by occupational health departments and IPs work closely to monitor trends and help remove barriers and provide recommendations on special cases or accommodations. When the vaccine for COVID-19 is available, this again will be a collaborative moment to develop the plan for vaccination, tracking, and promoting.

Infection prevention will likely need to be a resource for education about the vaccine, including concerns over side effects or any booster or follow-up needed based on how the vaccine is designed.

Another role for IPs in this pandemic will be to work with local public health programs to promote vaccination of the public, including patients and residents of congregate settings, such as nursing homes, acute rehab facilities, and inpatient mental health centers.

One example of a way that IPs can collaborate with other departments to implement a vaccination program is to work with occupational health and emergency response departments to have a mass vaccination drill.

This is a way for many programs to meet requirements and also provide a vaccine to staff in a rapid and coordinated process. When having these types of drills, it’s important that the vaccine be brought to where the staff is located, so having roving carts or teams is important. Also having stations at staff entrances that are manned during shift change can capture staff members as they come into the facility.

There are many examples of vaccination programs and lessons-learned about ways to increase staff compliance; however, even with a vaccine in development, the role of infection prevention will need to be strong for COVID-19 response for the foreseeable future.

Vaccines are one weapon that is often used in outbreak response for vaccine-preventable diseases (VPD). Countries with strong emergency response and public health programs have vaccination plans in place for such diseases as cholera, polio, and Hepatitis A.3

Disaster preparedness teams in hospitals need to have plans in place for potential increases in VPD and recognize that the typical vaccine administration will be interrupted by that disaster, whether it is a natural disaster, conflict and warfare, or a pandemic.

In this case, given the lag time we have until the vaccine is developed, planning can be done to address the other issues of regulatory barriers, looking at how to store and stockpile vaccine doses and administration supplies, roles of local, national and international partners in the distribution, communication and marketing, enhanced surveillance for adverse response and for effectiveness and the general mobilization and operationalization of the vaccine to the populations of need.3

These are huge undertakings, especially within a global pandemic. However, looking at historical mass-vaccination efforts can provide some guidelines on best practices and lessons learned and can be a resource to help guide the COVID-19 vaccine response plan.In order for the vaccine response to be successful, these areas of operation need to be addressed. Also, the social aspects of vaccine administration are equally important to understand and develop plans for before the vaccine is ready. These areas include vaccine hesitancy, access to healthcare, health equity, and mistrust of government institutions.4

Many of these barriers can be addressed with similar tactics, including assessing areas of vulnerable populations where these social constructs exist and working with local community leaders to build relationships and establish trust. Build capacity in healthcare organizations to address these concerns and to engage the community to provide accurate information. Healthcare providers are the most trusted source on vaccine acceptance.4 If providers have a clear understanding of the benefits of vaccination and have the communication skills to educate their patients, then the likelihood of vaccine uptake may increase. Similarly, HCPs are a high-risk group and their opinions on the COVID-19 vaccine can sway others.

When looking at influenza vaccine compliance, in recent years the percentage of HCPs taking the vaccine has increased, with a reported 81.1% overall compliance in 2019.5 One reason this has increased is because of many organizations making a flu vaccine a requirement for employment. In HCPs who did not have a work requirement or any work-related promotion, the compliance rate was just 42.1%. If we extrapolate this data to a COVID-19 vaccine, likely without work requirements, we would see low levels of uptake within HCPs as well. Not only does this increase potential for transmission in this high-risk population, but it also sends the message to their patients and community that the vaccine is not important.

A recent survey found that less than half of Americans would get a COVID-19 vaccine right away.6 Nearly 25% of respondents would “not get the vaccine anytime soon” or “never” get the vaccine.6 African-American respondents were the least likely to want to receive a COVID-19 vaccine right away compared with other races and ethnicities. These data show that there is much pre-work to be done, in particular with minority groups who have been disproportionately impacted by the disease, to increase vaccine acceptance and address underlying issues that are influencing these responses. Interestingly, respondents who reported receiving the annual flu vaccine were nearly twice as likely to report willingness to get the COVID-19 vaccine.6 Understanding what influences people to get the annual flu vaccine may help guide programs to use similar tactics to influence COVID-19 vaccine uptake.

Even if the vaccine is widely accepted and trusted, how long will it take to establish the level of population immunity necessary to prevent transmission? It’s estimated that, for COVID-19, with the reproduction number (R0) of around 1, about 50% of the population needs to have immunity.7 This is ideally achieved through vaccination, but can also include natural disease acquisition. With COVID-19, most speculate that the vaccine will not provide 100% immunity, and liken it more so to the influenza vaccine, with 40-60% efficacy depending on the annual strains.

Certainly, in the early days of a COVID-19 vaccine roll-out, high-risk groups and vulnerable populations should be targeted first, with prioritization then expanding to general population over time. Given the complexities of such an effort, the timing to reach the 50% threshold could be months to years. Confounding this work is the concept that we may need to have annual boosters or vaccine modifications if the predominant viral strains mutate.

Based on all these challenges with vaccine development, acceptance, and administration, there will need to be a continued emphasis on the basic infection control practices we are currently employing to mitigate risks: wearing masks, social distancing, updating personal protective equipment guidelines in healthcare facilities for universal masking/eye protection, and developing surveillance programs tracking coronavirus activity to be able to adjust the vaccine to fit predominant strains.

These basic tenants are what will provide the most protection against transmission until such a time as we have an effective and widely accepted vaccine. And even after that time, as emerging infectious diseases continue to impact global health, these practices should become part of our culture and part of our national response to outbreaks of respiratory disease.

In disease prevention, it is important to remember that the science exists on a continuum and having all-or-none thinking only impedes progress and understanding. When dealing with a pandemic, multiple approaches are necessary to reach full effect. In infection prevention, we are used to working with bundles for prevention of central line infections, surgical site infections, and other hospital-associated infections. The same approach needs to be taken with COVID-19. We must not dilute the response to relying on a vaccine to “cure” the pandemic. Disease prevention requires a broad range of interventions, including vaccines, in order to be effective and truly address the risks of transmission.

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

References

1. World Health Organization. Draft landscape of COVID-19 candidate vaccines. World Health Organization website. Accessed August 9, 2020. https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines​
2. Wilson J. Experts predict what life will be like after a COVID-19 vaccine arrives. Huffpost. Updated August 6, 2020. Accessed August 9, 2020. https://www.huffpost.com/entry/life-after-covid-19-vaccine_l_5f2ad9c6c5b64d7a55ed7b2c?ncid=APPLENEWS00001​
3. Walldorf JA, Date KA, Sreenivasan N, et al. Lessons Learned from Emergency Response Vaccination Efforts for Cholera, Typhoid, Yellow Fever, and Ebola. Emerging Infectious Diseases. 2017;23(13). doi:10.3201/eid2313.170550.
4. World Health Organization. Improving vaccination demand and addressing hesitancy. World Health Organization website. Updated June 17, 2020. Accessed August 7, 2020. https://www.who.int/immunization/programmes_systems/vaccine_hesitancy/en/​
5. Centers for Disease Control and Prevention. Influenza vaccination information for health care workers. Centers for Disease Control and Prevention website. Updated December 18, 2019. Accessed August 8, 2020. https://www.cdc.gov/flu/professionals/healthcareworkers.htm
6. Bean M. 48% of Americans would get COVID-19 vaccine right away, survey finds. Becker’s Hospital Review. Published August 5, 2020. Accessed August 9, 20202. https://www.beckershospitalreview.com/public-health/48-of-americans-would-get-covid-19-vaccine-right-away-survey-finds.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_source=BHRE&utm_medium=email&oly_enc_id=7243F3869212B6R​
7. Fine P, Eames K, Heymann DL. “Herd immunity”: A rough guide. Clinical Infectious Diseases. 2011; 52(7); 911-916. Accessed August 9, 2020. https://academic.oup.com/cid/article/52/7/911/299077​