Coronavirus (COVID-19) vaccine certification: evidence paper update

1. Executive Summary

This paper provides an update on the latest evidence relating to options for the vaccine certification scheme in Scotland. Evidence is drawn from available literature, from the first four weeks of the operation of the exiting scheme, from attitudinal data and from international experience.

Current state of the epidemic

The COVID-19 epidemic continues to pose considerable challenges, with case rates currently averaging around 3,000 per day, an increase from October. COVID-19 related acute hospital admissions have fluctuated over the past month but have recently started to decrease. Case rates and age standardised hospital admissions are considerably lower in vaccinated vs unvaccinated individuals.

Modelling indicates uncertainty over hospital occupancy and intensive care in the next four weeks. Hospitals are currently at, or very close to, capacity and have been in this position for many weeks now with several Health Boards operating within an environment of unprecedented pressure and heightened risk plus a requirement for military support. This is likely to be driven by COVID-19 cases and delayed discharges but also may reflect that patients with higher acuity are now requiring admission. As we prepare for winter, our primary and secondary health and social care services are facing arguably the most significant and increasing pressures and demands in the history of the NHS.

Vaccine uptake has progressed extremely well in the Scottish adult population with approximately 79% of 18 to 29 year olds and 77% of 16 to 17 year olds having received the first dose of the vaccine. Around 96% of people aged 40 and over have received two doses, but uptake of a second dose remains lower in people in their 30s (77.5%) and 18-29 (68.9%).

Existing vaccine certification scheme

The scheme was announced on 1 September 2021, and while there are emerging data on some of these effects, there is as yet incomplete information about the longer term effects on the pandemic, wider society, and the economy. The COVID status app has been downloaded 1.5 million times as of 13 November. 478,014 paper copies and 1.2 million PDF versions have also been downloaded. These figures do not represent unique users as the app can be used on several devices and paper/pdf copies produced several times by individuals. Vaccine uptake has slightly increased since the scheme was announced, although it is not possible to directly attribute rises to the introduction of certification. The proportion of those aged 12+ with a first dose rose from 86.0% to 90.5%. The proportion of those aged 12+ with a second dose rose from 77.6% to 82.2%.

Current situation in Europe

Cases, hospitalisations and deaths have been increasing in Europe since late September. Governments are increasing the strictness of, or reintroducing, interventions - including vaccine certification. Norway and Denmark have reintroduced vaccine certification in response to rising cases. Certification is widespread across other countries in Europe and in some other parts of the world. In most cases these schemes include indoor hospitality and leisure facilities in addition to events and nightclubs currently certified in Scotland. The majority of comparator countries accept a negative antigen test or recovery as a condition of entry as well as vaccination, although a negative test is no longer accepted in Austria and some parts of Germany. Wales extended the scope of vaccine certification on 15 November to include cinemas, theatres and concert halls, where both a negative antigen test and vaccination status is accepted.

Extending the vaccine certification scheme

Looking at the approaches adopted in other countries and advice from SAGE, the potential approaches to extending the current Scottish scheme would be to: Extend the range of settings; include testing, either as an option or alongside vaccination; include recovery as well as testing or vaccination; timestamp for boosters to allow for waning.

There are no real life studies directly comparing the effect on transmission for certification schemes based on testing only, vaccination (or previous infection) only, or both. However, EMG/SPI-M/SPI-B (SAGE subgroups) state that all these approaches could be considered to increase the potential impact on transmission and vaccine uptake. There is evidence of vaccine waning in some groups. The effectiveness of certification over the next 4-6 weeks and across the festive season on transmission therefore depends on boosters being rolled out quickly. If booster take up is high, certification will retain its effectiveness against transmission until there is more waning.

Including testing as an alternative depends on the accuracy of the tests and how they will be used by the public. The optimal testing strategy in order to gain access to a higher risk setting would be to take the test as close as practically possible to entry. LFTs are less sensitive than PCR but have the advantage of providing rapid results, and SAGE has endorsed the benefits that rapid antigen testing (such as LFTs) could have on reducing transmission. Awareness and use of LFTs in Scotland is high. Opinion polling carried out by YouGov on 5/6 October indicated that almost nine in ten are aware that everyone can now access testing. 41% have ordered or collected self-administered LFD tests, an increase since late August (35%). Of those who have ordered or collected tests, nine in ten have used them.

It should be noted that proof of vaccination can be open to manipulation, including fake certificates. Some countries have implemented fines and prosecution for individuals found using counterfeit certificates and for businesses found not to be checking certificates. Including testing as part of the scheme could address some of these risks.

Public attitudes and societal impacts

A key objective of the certification scheme is to encourage vaccine take-up. For some vaccine hesitant people, vaccine passports are perceived to be a reason why they would get vaccinated in the future. However, for others, vaccine passports were seen as coercive measures to control the population and violate privacy.

YouGov polling from Oct 5/6 found that 74% of respondents agree that the certification scheme has advantages, in particular encouraging people to get vaccinated (52% agree), making venues and events safer places to visit (49% agree), and in helping to prevent businesses having to close (44% agree). Overall support for the scheme is 59%, with around a quarter (24%) opposing it and 13% neither supporting nor opposing. The most commonly selected disadvantage of the scheme (62% agree) is that people who are vaccinated can still be carrying the virus, followed by it will be difficult for venues and events to check (47%).

Certification may have advantages for people who are more vulnerable to COVID-19 such as those with pre-existing conditions who are still choosing to avoid places where they believe risks are higher. Conversely, unvaccinated groups and those who have been vaccinated but with a non-MHRA recognised vaccine (unless this recognition changes) would be excluded from premises that require certification. The harms associated with this along with any issues related to wider societal and equality impacts should be carefully examined via EQIA and CRWIA assessments.

Potential economic impact

If the certification scheme is expanded it would affect a wider range of sectors and activities. In addition if testing is added to the existing scheme this would have implications for those already included. An expansion or changes could affect: the events industry; the sports sector; late night venues; entertainment venues and hospitality venues. This represents a significant number of businesses and organisations across Scotland.

The picture on impacts on business from the existing certification scheme is still emerging. From feedback received to date, nightclubs and late night settings have reported implementation challenges and substantial turnover losses among members affected by certification. Trade bodies have highlighted concerns regarding potential cancellations of Christmas bookings and the potential impact of footfall losses from certification on financial viability of affected businesses.

Large events affected have experienced additional implementation costs and report reductions in ticket sales and reduced capacities associated with certification. Public awareness of certification has been mixed and concerns have been expressed about non-MHRA vaccines not being accepted. There are reports of drop offs in attendance compared to ticket sales, increased waiting time to access venues and anecdotal feedback of increased aggression towards security staff and stewards in some contexts. A small number of sporting events in Scotland have been affected by the existing scheme although there has been generally good compliance with certification requirements among those attending matches. Stakeholders have reported that additional stewarding has been necessary to implement certification as currently designed.

If the scheme were expanded, the sectors that would be affected by certification are also those that have been hard hit by the long periods of closures and limits on their operating capacity as a result of measures taken to address the pandemic. Some of the sectors potentially affected are also seasonal businesses, with a substantial portion of annual turnover being generated in December. Businesses will incur increased costs if certification is expanded. The magnitude of these costs will be closely linked to the level of enforcement expected from businesses, the footprint of venues and flow of customers at venues and events. There may also be impacts on suppliers and those involved in the organisation and staging of live events.

Conclusion

Scotland already has in place a range of baseline measures to reduce the likelihood of infectious people mixing with others and transmitting the virus, including wearing face coverings in indoor public settings, testing and isolation, providing contact details when going to certain venues, requirements for international travel and guidance on working from home. We also have vaccination and boosters. But to suppress the virus further we are now faced with a choice. This is to limit social contacts and the risk of infection by closing venues, limiting group sizes and advising people not to meet other. Alternatively we can enable people to meet up in a lower risk way by using certification to reduce the risk that an infectious person will be present in a higher risk setting.

The current vaccine certification scheme has been in operation for a number of weeks. Over that time it has likely contributed to a small rise in vaccinations amongst the younger age group. SAGE advise that including a wider range of settings may increase the usefulness of certification as a measure to reduce infection. Wider international evidence suggests that expanding the settings included in any certification scheme may encourage older individuals who are not yet vaccinated to take up the vaccine.

Including a wider range of settings may also lead to a better understanding of the fact that the pandemic is still with us and continues to present a current threat. It will introduce some costs for a wide range of businesses. However, in a situation where cases are rising and hospitals are operating at capacity it allows higher risk settings to remain open as safely as possible, and to continue to trade.

There are advantages of including evidence of a negative test as an alternative to proof of vaccination. It will ensure that individuals not able to provide evidence of certification (those vaccinated with a non-MHRA approved vaccine, for example) can gain access to venues and may also address concerns about counterfeit certification. However, LFTs have limitations regarding their sensitivity and even proof of a negative test cannot completely remove the risk that someone is carrying the virus. These factors, as well as the wider body of evidence in this report, need to be carefully considered in any decisions about extending or modifying the vaccine certification scheme in Scotland.