What an incredible achievement by covid-19 vaccine researchers and manufacturers. By January 2021, several covid-19 vaccines are now approved under EUA and their rollouts have started across several countries. [1] These candidates were designed using different technologies, but were approved having one constant: they should be administered using two jabs. Reasonable assumptions include that those two jabs are the same vaccine and the timing between jabs correlate to clinical trial protocols.
Communicating vaccine rollout and schedules could be a straightforward affair, to reassure the public that—as we are following the science—when offered, one may receive the same vaccine over two appointments scheduled according to the clinically ordained timeline. Remarkably, on New Year’s Day, the New York Times reported that the UK is allowing the mixing of vaccines—for example, the article alleges that a person in the UK could receive the Pfizer vaccine and then the AZ vaccine as a booster (should the Pfizer vaccine not be available upon the 2nd appointment), though no clinical trials involving mixing covid-19 vaccine candidates are completed, and the UK’s Joint Committee on Vaccination and Immunisation (JCVI) advised against mixing candidates. [2,3] However, on that same day, it was reported that the JCVI supported scheduling up to 12 weeks between jabs of AZ or Pfizer, defended by the rationale that more people can receive their first jab within a shorter period. Clinical data do exist for a 12 week AZ regimen: clinical data for anything other than a 3 week regimen do not yet exist for the Pfizer vaccine. [4-6]
We now have confounding issues, mostly involving communication. On 3 January 2021, the editor in chief of The BMJ, Fiona Godlee, called for a correction to the New York Times article, as the JCVI gave no such endorsement of vaccine mixing. [7] I immediately contacted Godlee to defend the New York Times article, because the source referenced in the article is not from the JCVI, but rather the Green Book manual published by Public Health England, which states: “For individuals who started the schedule and who attend for vaccination at a site where the same vaccine is not available, or if the first product received is unknown, it is reasonable to offer one dose of the locally available product to complete the schedule. This option is preferred if the individual is likely to be at immediate high risk or is considered unlikely to attend again. In these circumstances, as both the vaccines are based on the spike protein, it is likely the second dose will help to boost the response to the first dose.” [8,9]
Supporting a one-vaccine-two-dose schedule, Mary Ramsey, Public Health England’s head of immunisations, said: “We do not recommend mixing the covid-19 vaccines—if your first dose is the Pfizer vaccine you should not be given the AstraZeneca vaccine for your second dose and vice versa.”…and that another vaccine should be offered under “extremely rare occasions.” But such language or inclusion criteria are not included in the Green Book, and recent reports from the NHS show that different covid-19 vaccines may be administered for the second jab, apparently with little concern for “rare occasions.” [10] Quite simply, the New York Times piece found an inconsistency in communications as a Public Health England document misrepresents the position of the JCVI on this issue, and both conflicting statements may be found on the same website host (gov.uk). I agree with the stances of Fiona Godlee and Mary Ramsey, but the Green Book needs correcting or updating if it does not align with the official policy on covid-19 vaccine two-dose regimens.
A communication management plan that supports streamlined, clarified, and consistent messaging for national vaccine rollouts would help. In the UK, the public would be served with a simple explanation of the roles of the JCVI (versus the Vaccine Task Force) and Public Health England, their relationship and dependencies, as well as relevant officials, such as MP Nadhim Zahawi. Technically, the JCVI’s input is independent advice, rather than governmental policy. Therefore, who owns the policy, which body has executive or communications authority, and where can such information be found? Keep messaging simple and explain any known unknowns, and log versions of instructions to best instruct health professionals of any administrative changes. Explain benefits, such as explaining the number of individuals that may receive their first jab under a 12-week compared with a 4-week regimen, as well as risks, such as uncertainty regarding one-jab-only Pfizer immunity up to 12-weeks. Unless communications are aligned, given the numerous and complex parties involved, it is likely that miscommunications will emerge again.
Corners were not cut during the vaccine research and manufacturing stages: why should there be pitfalls in communications during rollout? Clear and simple upfront messaging could positively re-enforce the perception of these vaccines. In addition to falling trust, another potential risk of inefficient communication is that nominally brief first jab appointments can be prolonged by there being (too many) people asking questions about their second jab: which vaccine, when, and how efficacy may be affected? We need a centralised, efficient, and encompassing communications hub.
Benjamin F Pierce is currently Operations Manager for the Future Vaccine Manufacturing Research Hub, within the Department of Infectious Disease at Imperial College London.
Competing Interest: The Future Vaccine Manufacturing Research Hub is funded by the Department of Health and Social Care using UK Aid funding and is managed by the Engineering and Physical Sciences Research Council (EPSRC, grant number: EP/R013764/1). The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health and Social Care. Pierce is on the Imperial College London COVID-19 vaccine team and has seconded to VacEquity Global Health, the social enterprise spin-out behind the vaccine candidate, since June 2020.
References:
1. As of 03 January 2021, the Pfizer/BioNTech (“Pfizer”, RNA), Moderna (RNA), Astrazeneca/Oxford (“AZ”, ChAdOx viral vector), and Sinopharm (“Sino”, inactivated) COVID-19 vaccine candidates were given EUA by the MHRA (UK, Pfizer and AZ), EMA (European Commission, Pfizer), CDSCO (India, AZ), FDA (USA, Pfizer and Moderna), or China’s National Health Commission (China, Sino). Each of these are based on 2-dose clinical regimen data and were approved following review of efficacy data.
2. Britain Opens Door to Mix-and-Match Vaccinations, Worrying Experts – The New York Times (nytimes.com) (last accessed on 03 January 2021)
3. Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination, 30 December 2020 – GOV.UK (www.gov.uk) (last accessed 03 January 2021)
4. https://www.bbc.co.uk/news/uk-55503739 (last accessed on 03 January 2021)
5. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32661-1/fulltext (last accessed 03 January 2021)
6. https://www.nejm.org/doi/full/10.1056/NEJMoa2034577 (last accessed 03 January 2021)
7. https://www.bbc.co.uk/news/uk-55519042 (last accessed 03 January 2021)
8. https://www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a (last accessed 03 January 2021)
9. Bold emphasis is my own.
10. https://www.glasgowtimes.co.uk/news/18983295.nhs-greater-glasgow-may-need-adminster-different-covid-19-vaccine-second-doses/ (last accessed 03 January 2021)