As Western Europe’s vaccination rollout gained strength in the early part of 2021, many of the region’s leaders touted the shots as their immediate route out of the pandemic.
Press conferences took on an almost celebratory tone as Presidents, Prime Ministers and Chancellors announced road maps away from Covid-19 restrictions, hailing their country’s uptake rates and speaking colorfully about a return to normalcy.
But as another Covid-struck winter grips Europe, many of those countries are now reversing course.
Ireland introduced a midnight curfew on the hospitality industry earlier this week amid a surge in cases, despite having one of Europe’s best vaccination rates. In Portugal – the envy of the continent, where 87% of the total population is inoculated – the government is mulling new measures as infections inch upwards.
Britain has meanwhile endured a lengthy and stubborn wave of infections despite its Prime Minister, Boris Johnson, often trumpeting the country’s early lead in administering jabs. And in the Netherlands new restrictions have come into force, prompting protests that turned violent in Rotterdam on Friday night.
This is all taking place despite one central fact remaining true – the vaccines are working, and working well.
Some might wonder how both things can be true. But as nations are discovering, even a relatively strong vaccination rate is not enough alone to stop the spread of Covid-19 – and warning signs from Germany and Austria, where infections have skyrocketed in recent weeks – show the dangers of complacency. Austria will enter a total national lockdown on Monday, just days after it imposed a lockdown on unvaccinated people.
The vaccine “continues to provide very good protection – the immunity against severe disease and death is very well maintained,” Charles Bangham, a professor of immunology and the co-director of Imperial College London’s Institute of Infection, told CNN.
“But we know that the Delta variant is very much more infectious,” he said. “At the same time, there have been changes in society and behavior … and in many countries, some of the precautions are being less stringently observed.”
To put it simply, when it comes to stopping transmission, even a very good vaccination rate isn’t always good enough.
“Vaccinations help,” said Ralf Reintjes, professor of epidemiology and public health surveillance at the Hamburg University of Applied Sciences in Germany. “They’re one stone in the process of stopping the virus. But it’s not strong enough alone.”
What counts as ‘highly vaccinated’?
Ireland is home to one of Europe’s highest vaccination rates – 89.1% of people over the age of 12, and three-quarters of all people, having been immunized – but it recently imposed a midnight curfew on bars, restaurants and nightclubs as it battles a growing surge in cases and hospitalizations.
And that shouldn’t be surprising, experts say – because even small pockets of unvaccinated people can drive transmission. In Ireland’s population of 5 million, around a million are still not protected.
“What we have now is an epidemic of the unvaccinated – about 10% of our population over 12 is unvaccinated, and we’re seeing an epidemic in those people, predictably,” said Sam McConkey, head of the International Health and Tropical Medicine department at the RCSI University of Medicine and Health Sciences in Dublin.
McConkey noted that most children are unvaccinated, that elderly and vulnerable people with co-morbidities can still suffer breakthrough cases, and asymptomatic, healthy people are catching and passing on the virus.
“The combination of those four or five things has meant that our hospitals are getting quite full,” he said.
Leaders around Europe have increasingly become frustrated at the unvaccinated pockets of their societies. In a dramatic step on Friday, Austria announced it would make vaccinations mandatory for everyone from February – a move met with a protest of around 10,000 people in Vienna on Saturday.
From Monday in neighboring Czech Republic, home of one of the EU’s worst uptake rates, confirmation of a vaccination or recovery will be needed to enter various hospitality venues after the country recorded its highest number of new cases to date on Friday.
But exasperation is mounting in better-vaccinated nations, too. On Wednesday, Ireland’s deputy Prime Minister Leo Varadkar told CNN that unprotected people are “causing a lot of the trouble” – and that Ireland “wouldn’t be imposing the restrictions we are imposing now” if everyone was vaccinated.
The difference between vaccination rates of 70% and 80% is huge, experts say, because each extra percentile further isolates the virus and eases pressure on hospitals. But McConkey said that given the transmissibility of the current Delta variant, no country can truly consider themselves “highly vaccinated” – he argued that until they inoculate a percentage in the mid-90s of their total population, unvaccinated pockets of society would still drive transmission.
And so while vaccines are arguably the most important tool in fighting the virus, they can’t be expected to stamp out transmission by themselves.
“The new viral variants are just intrinsically more infectious than the old strains,” said McConkey, who in addition to his research works as a consultant at Beaumont Hospital Dublin.
Vaccines continue to dramatically reduce the likelihood of serious illness and death, he noted – and they have therefore changed the make-up of those needing treatment in intensive care units. There are far fewer admissions than in previous waves, and “it’s now mostly unvaccinated young people, or very elderly people,” he said.
According to Varadkar, about 50% of people in ICU in Ireland currently are unvaccinated.
But any trickle of new admissions can put strain on a country’s health service. Of Ireland’s 294 staffed intensive care beds, 118 are occupied by Covid-19 patients and just 17 remained available, according to the Irish government’s daily update on Thursday.
“A significant chunk of health care staff quit after the first two waves – there’s a sense of fatigue and exhaustion that wasn’t there before,” says McConkey, summarizing the morale of his hospital’s team as it battles a new wave of cases.
“We’d just like this thing to be over.”
Waning immunity comes to the fore
Europe’s initial vaccine rollout accelerated quickly in the early months of 2021, but nations are now reckoning with the gradually waning immunity of those doses.
Two real-world studies published last month confirmed that the immune protection offered by two doses of Pfizer’s Covid-19 vaccine begins to drop off after two months or so, although protection against severe disease, hospitalization and death remains strong. Studies have shown similar outcomes for the AstraZeneca and Moderna shots, which are also in use in Europe.
“The immune reaction of those people who are vaccinated is decreasing over a certain period of time … and as the vaccination campaign started in Germany at the beginning of this year, we now see some age groups and some people lose their immunity against Covid-19 quickly,” said Tobias Kurth, a professor of public health and epidemiology and the director of the Institute of Public Health at the Charité University Hospital in Berlin.
“This is probably one of the reasons why the numbers of vaccinated people who need hospitalization is slowly increasing at the moment – especially in the older population, who got vaccinated first,” added Reintjes.
Experts stress that the protection against serious illness and deaths remains strong in double-vaccinated people who have not yet received a booster.
“The good news is that both the antibodies and the T-cells [from vaccination] seem to be quite well maintained for months. There’s a slight drop in their concentration, but it’s very small,” Bangham said.
“It continues to provide very good protection – the immunity against severe disease and death is very well maintained,” he added. “You’re more likely to get symptoms, but you’re still quite well protected against severe disease.”
“The problem is that if you get symptoms, you’re probably more likely to pass it on. So the transmission is not so well controlled.”
And over time, that pushes up a country’s rate of infections and can impact hospital capacity.
“There certainly has been waning protection from infection, and the ability to transmit it. But thankfully, there’s been less waning protection from disease,” McConkey noted.
One study from Israel covered 4,800 health care workers and showed antibody levels wane rapidly after two doses of vaccine, “especially among men, among persons 65 years of age or older, and among persons with immunosuppression.” A second study from Qatar showed protection from the Pfizer vaccine peaked in the first month after vaccination and then began to wane.
Those findings add urgency to Europe’s rollout of booster shots, which is varying in pace around the continent.
“It’s certainly a concern. We vaccinated really fast in the beginning, and then it slowed very much down. So now the waning is probably happening faster than the new boosters [are being administered],” said Reintjes.
Dr. Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases, told CNN this week that recent data from Israel show that, among people age 60 and older, those who received a booster were less likely to become severely ill than vaccinated people who had not received a booster. Rates of severe disease remained highest among those who weren’t vaccinated.
A go-slow approach
No matter how impressive a country’s vaccination rate appears, experts insist that vaccines alone can’t be expected to halt a country’s epidemic.
“The vaccine is controlling deaths – but what we’re seeing is a virus that has established itself as endemic, and in some countries it’s made greater progress than others because there have been less rigid controls,” said David Heymann, a former executive director of the World Health Organization’s Communicable Diseases Cluster and a professor at the London School of Hygiene and Tropical Medicine..
Restrictions differ from country to country, and adherence to them can differ wildly too. And that means even well-vaccinated nations like Ireland can suffer serious surges.
“We’re very good at socializing in Ireland,” McConkey said. “We have to recognise that our socializing is culturally specific, and different between countries … In Spain and Portugal you eat outside at 10 o’clock at night – in Ireland, we squash into crowded restaurants.”
Spain and Portugal, with vaccination rates of 80% and 87% of the total population respectively, have seen uptake similar to that of Ireland and have also relaxed rules on social mixing in recent months. But so far, they have avoided the worst of the current wave – with experts pointing to the apparent success of their mitigation measures.
“Spanish people have been particularly careful regarding restriction measures, mostly the generalized use of face masks and [social] distance,” said Ana M Garcia, professor of Preventive Medicine and Public Health at the University of Valencia.
“The use of masks is only compulsory indoors, and this is generally accomplished, but also you can find many people still using masks outdoors,” she said.
Despite achieving high rates of vaccination, the Iberian peninsula has moved slowly and cautiously towards normality – as well as in indoor public spaces, masks are still required on public transport in Spain. In Portugal masks also remain mandatory on public transport, and Prime Minister Antonio Costa warned on Tuesday that restrictions could return amid a new rise in cases.
And some experts point to those two countries for a blueprint on how even well-vaccinated nations should approach the virus.
“In my view, the difference in vaccination coverage in different countries is making the big difference in incidence rates,” Garcia said. “(But) it’s not the only explanation … vaccines alone can’t fully contain a virus.”
Nonetheless, the importance of following Covid-19 measures is more keenly felt in countries where vaccination rollouts have stalled. And in Germany, which has one of Western Europe’s lowest inoculation rates, some experts blame a shift in public perception.
“One of the major factors is Corona fatigue – people are really tired of the pandemic,” said Reintjes.
“We’ve just had a general election [where Covid-19] was a bit out of focus; politicians were focusing on other things, and the impression lots of people received was that the problem is not that big anymore,” he said.
Germany on Thursday recorded more than 65,000 new daily Covid-19 infections and outgoing Chancellor Angela Merkel called the country’s situation ”dramatic.” But even amid skyrocketing cases, many German bars and Christmas markets are attracting large numbers, Reintjes noted. Cologne’s carnival season opened last week to big crowds, though only vaccinated or recovered people were admitted.
German ministers are urging more people to take up the vaccine, and are making life more difficult for those who choose not to – its likely incoming coalition government recently strengthened its Covid-19 response plan to require vaccination proof at a wide number of social venues.
But experts recognize that such attempts are too late to stem this surge. “Within a short period of time it’s not possible to achieve vaccination rates that would stop this wave,” Reintjes said.
Instead, they insist that following measures and reducing socialization can make the immediate difference.
“The autumn-winter season is the best season for transmitting the virus. People are indoors, and that plays an important role,” Reintjes said.
“People are fed up [with Covid-19] and they don’t stick to behavior which would limit the spread of the virus. So it’s spreading much better now.”