NHS and Care Home Mandates Should Take Account of Natural Immunity to COVID

by Dominic Wilkinson, Jonathan Pugh, Julian Savulescu

 

Yesterday, the health secretary, Sajid Javid announced that COVID vaccines would become mandatory for frontline NHS staff from April.

Meanwhile, from tomorrow care home workers in the UK will not be able to work if they don’t have a vaccine certificate and are not medically exempt. This vaccine mandate has been controversial, with providers raising concerns that as many 70’000 employees could leave the sector putting beds and care at risk. However, its advocates have argued that it is a proportionate public health measure due to the need to protect vulnerable care home residents.

Proportionality is one key ethical criterion in public health ethics; public health interventions are only permissible if their benefits outweigh their costs. However, another key ethical criterion is necessity; public health interventions are only permissible if they are necessary for achieving a certain benefit.

One striking feature of the current UK care home and NHS staff mandate is that it does not allow an exemption for those who have proof of natural immunity.

There is now evidence to suggest that natural immunity confers comparable protection to vaccine-induced immunity. Studies have found a durable immune response in individuals eight months after infection, as well as low infection rates amongst those who have previously had covid-19. Recent data also suggest that the antibodies elicited by vaccination have less potency and breadth than those generated by natural infection, although the overall neutralizing potency of plasma is greater following vaccination.

The strength and durability of natural immunity is still not completely understood, and it does not always enjoy the same status as vaccine-induced immunity. In the USA, federal vaccine mandates do not allow an exemption for those with natural immunity. In a landmark judgment, a legal challenge to this failed at the end of September; however, this controversy is likely to continue.

We believe that based on what is now known, individuals with sufficient proof of natural immunity should be granted a medical exemption to the care home vaccine mandate. This would be a simple ethical policy adjustment. It would prevent the unnecessary loss of valuable workers who do not pose an increased risk of transmitting coronavirus to vulnerable residents/patients.

It is not justifiable to significantly restrict the liberty of those who are already immune to coronavirus by subjecting them to a vaccine mandate.

Ultimately, the question here is one of necessity – is vaccinating those with natural immunity necessary to achieve an acceptable level of protection in care homes? Unless there is compelling evidence that immunisation is much more effective than natural immunity at reducing spread of the virus, the case for a vaccine mandate cannot be convincingly made.

There are still some gaps in our understanding of the differences between natural and vaccine-induced immunity. Furthermore, there are pragmatic reasons why it may seem attractive to focus on vaccination rather than natural immunity. Proof of vaccination status is simple, binary and verifiable, whilst immunity measures might be more complex and require additional resources. Yet, the UK government already recognises the protective effect of natural immunity, and the practicality of using it as sufficient proof of a low transmission risk. It is possible to obtain an NHS COVID pass with proof of natural immunity, shown by a positive PCR test result for COVID-19, lasting for 180 days from the date of the positive test and following completion of the self-isolation period. If needed, for the purposes of exemptions to professional vaccine mandates, it would be possible to obtain more robust proof of natural immunity with serological evidence of neutralising antibodies.

Finally, it is important to be clear. Accepting this exemption from a vaccine mandate is not to support the anti-vaccination movement. Natural immunity is not better than vaccine acquired immunity just because it is ‘natural’. It is much much more risky to gain immunity through infection, than through vaccination. Care home and NHS workers who are not immune (naturally or otherwise), should have the vaccine.

But for NHS and care home workers who have been unfortunate enough to have already had coronavirus (and fortunate enough to have recovered), their naturally acquired immunity is likely to make them at low risk of passing on the virus. This is something that ethical, evidence-based public health policy should reflect.

 

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3 Responses to NHS and Care Home Mandates Should Take Account of Natural Immunity to COVID

  • Nasreen Burtally says:

    Hi, I got COVID in March 2020. I did an antibody test on 11.11.21 last week and got my test results today. It says I have antibodies either from previous infection or from a vaccine. However, I got COVID 20 months ago! Now, due to mandate, I have to be double jabbed!
    Firstly, I don’t understand why I should since I have antibodies. Secondly, even if I did, it may be only 1 jab so as not to spike my autoimmune response since my immune cells are still present after such a long time. But it means I may still not be able to work in April under the double jab criteria. The interesting thing is that I have been patient-facing all this time with all precautions yet not spread any virus but now it seems not being vaccinated means I am a risk?!

    Please advise what can I do? Under the medical exemption, this is not considered at all.

    • A practising doctor says:

      1. In light of new evidence just published by the CDC it would appear that immunisation, at least with one of the mRNA vaccines, confirms significant clinical benefit over immunity acquired from infection.
      Laboratory-Confirmed COVID-19 Among Adults Hospitalized with COVID-19–Like Illness with Infection-Induced or mRNA Vaccine-Induced SARS-CoV-2 Immunity — Nine States, January–September 2021. Weekly / November 5, 2021 / 70(44);1539–1544. https://www.cdc.gov/mmwr/volumes/70/wr/mm7044e1.htm?s_cid=mm7044e1_w
      “Among COVID-19–like illness hospitalizations among adults aged ≥18 years whose previous infection or vaccination occurred 90–179 days earlier, the adjusted odds of laboratory-confirmed COVID-19 among unvaccinated adults with previous SARS-CoV-2 infection were 5.49-fold higher than the odds among fully vaccinated recipients of an mRNA COVID-19 vaccine who had no previous documented infection (95% confidence interval = 2.75–10.99).”

      2. Whilst further evidence is awaited, the safest and most reliable strategy for the personal protection of individuals and hence their families, friends and patients, is to have a full course of vaccination [including a 6 month booster]. Neither prior infection nor vaccination is 100% effective.

      3. All evidence to date suggests that the risks and severity of short and long term pathology caused by COVID are far greater than the risks and severity of adverse reactions / pathology from any of the vaccines, though these also occur.

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