Learning to live with covid-19: testing, vaccination, and mask wearing still play a key part in managing the pandemic

With a fall in covid-19 mortality and hospital admission rates over the past two years,1 public interest in the pandemic has reduced.12 However, SARS-CoV-2 remains in widespread circulation.2 As we approach winter, a period associated with increased strain on our NHS, what can we expect from the covid-19 pandemic, and how can we prepare?

As temperatures in the UK fall, we are seeing a steady increase in SARS-CoV-2 infection rates, in keeping with patterns seen with other respiratory viruses, such as influenza.23 SARS-CoV-2 test positivity was almost five times greater in September 2023, compared with June and July.2 This has coincided with the emergence of new variants, such as BA.2.86, named “Pirola” and JN.1.45 Early data suggest that BA.2.86 has higher angiotensin converting enzyme-2 receptor binding affinity than previous omicron variants, which may be associated with increased transmissibility.4

Accurately predicting future trends in SARS-CoV-2 infection and tracking the emergence of new variants is difficult and made even more challenging by declines in testing in the UK. During January 2022, more than one million SARS-CoV-2 test results were reported daily, but this figure is now less than 5000.2 This scaling back in national testing, in addition to the end of community surveillance studies and waste water monitoring, means increased uncertainty about SARS-CoV-2 activity.6 Encouragingly, the UK Health Security Agency has announced a temporary increase in testing and community surveillance until March 2024. Recent increases in SARS-CoV-2 infections throughout the year, not just during winter, highlight the need for longer term surveillance of the virus.6

With an increase in SARS-CoV-2 infections likely over the coming months, the question of how we tackle this is important. The vaccination programme has played a critical role in reducing severity of infection.7 The government has introduced an “autumn booster” programme targeted at populations most at risk.8 Unlike previous booster campaigns, adults aged 50-64 years, a group comprising roughly one fifth of the UK population, will not be eligible. This represents a drastic scaling back of the booster programme.8 This is the first time a cost-benefit analysis has been used to decide eligibility.9 But numbers needed to vaccinate focus on preventing hospital admissions without reference to other costs associated with SARS-CoV-2 infection—for example, health worker absenteeism and long covid.

Although 77.7% of the UK adult population eligible for a fourth vaccination received a fourth dose, less than half of eligible 18–39 year olds received their fourth dose, with similarly low uptake among certain ethnic and lower socioeconomic groups.1011 Interventions aimed at engaging these groups, with the support of trusted leaders in the community, are needed to tackle concerns around vaccination and emphasise its benefits, to increase uptake.

In addition to groups at increased clinical risk, vaccination of health and social care workers is important. Although uptake of first and second dose covid-19 vaccines among health and social care workers was around 80%, only 42.1% received a booster between September 2022 and February 2023.1213 Influenza vaccination for these workers has also declined from 60.5% in the 2021-22 season, to 49.9% in 2022-23.12 Substantial variation in uptake of covid-19 and influenza vaccination in healthcare workers is seen between NHS trusts.12 Given the extent of variation, it is likely some role in vaccine uptake is played by local trust based vaccination promotion schemes. Therefore, we can look to trusts with the highest uptake to learn lessons about how promotion schemes can be effective.

Although recommendations on NHS covid-19 booster eligibility are guided by cost effectiveness, this does not affect private vaccination. Almost 85 000 private influenza vaccines were administered at one nationwide pharmacy chain in 2012-13.14 This suggests a strong appetite for influenza vaccination in people not eligible through NHS programmes. Given the similarities in eligibility between NHS seasonal influenza and covid-19 booster programmes, a similar demand for private vaccination likely exists for covid-19.815 Government and vaccine manufacturers have discussed private accessibility of covid-19 vaccines, but this dialogue has not progressed.16 And we should be mindful that such private schemes could widen health inequalities in uptake that are already seen with the covid-19 booster offered on the NHS.17

Face masks are effective in reducing transmission of respiratory viruses.18 Previously, use of masks was required in public spaces, but this has now been replaced with guidance outlining when to “consider” use. This guidance places the onus on people and organisations to implement their own policies.19 For example, with the recent spike in cases, some NHS trusts have reintroduced a requirement for mask wearing in clinical areas. But this is not a nationwide policy, which may cause confusion for patients and staff. A nationwide mask wearing policy in certain high risk areas such as healthcare spaces, in response to increases in health and social care worker absenteeism or community prevalence rates, may be more effective.20 This is especially important given our decreased ability to respond to a surge in cases caused by declines in testing.

The repeated emergence of new variants and a recent increase in cases should serve as a reminder that—while we are adapting to live with covid-19—caution is required.2 Surveillance studies, mask wearing, and vaccination, which played critical roles in the initial stages of the pandemic, must continue to be employed effectively to tackle this continuing global health challenge.