Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

What are the arguments in favour of reducing the gap between doses of the Pfizer Covid-19 vaccine to 3-4 weeks?

Early on during the pandemic, the UK government took the decision to give second doses of the Pfizer Covid-19 vaccine after 12 weeks rather than the recommended 3-4 weeks. It has now reduced the gap to 8 weeks and is considering reducing the gap to 3-4 weeks. What are the arguments in favour of reducing the gap between doses to 3-4 weeks?

1. Giving the two doses of the Pfizer vaccine 3-4 weeks apart is in line with the manufacturer’s guidance.

2. This is what most other countries using the Pfizer vaccine are doing.

3. Evidence from randomised controlled trials and subsequent evidence from real-world data provides strong evidence that two doses of Pfizer vaccine given 3-4 weeks apart provide excellent protection against severe disease and death

4. Data from Public Health England shows that two doses of vaccine provide much better protection against the delta variant than one dose. Hence, giving second doses after 3-4 weeks instead of after 8-12 weeks could help reduce the current ratee of infection in the UK

5. Many people are keen to get their second dose of Pfizer vaccine quickly because of concerns about other family members or to help them travel.

 

Why we should continue to wear face masks

The government’s chief medical officer says he will continue to wear a face mask when appropriate. We should follow his example. Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but only if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification mask is worn that filters out more droplets when the wearer breathes in air.

Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19. Vaccines are essential and can protect us from developing a more serious illness. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic.

Lifting of Covid-19 restrictions in England – What are the implications for public health?

Why are all restrictions being lifted even though Covid cases are rising?

The number of cases of Covid-19 has been increasing since May and there are now nearly 30,000 cases each day in the UK. In the past, such a high number of cases would have led to a large number of people admitted to hospital and also an increase in deaths. Fortunately, because of vaccination, the number of people with a severe Covid-19 illness is now much lower than previously. For example, in the last week, there have been around 20 deaths per day on average from Covid-19 across the UK. This compares to more than 1,000 deaths per day during some days in January. The number of hospital admission is also low, with around 300 hospital admission each day in the UK. The government believes that vaccination is breaking the link between the number of cases and the number of people with severe illness; and it therefore safe to end Covid-19 restrictions in England on 19 July. The government accepts that the number of Covid-19 cases will remain at a high level.

Will the 1m social distancing rule be scrapped everywhere?

The 1m social distancing rule will end in England on 19 July, meaning that people can mingle indoors and outdoors in larger groups. Indoor businesses like night clubs will also be allowed to open.

Will we still be advised to wear masks even though it’s no longer a rule, and why?

The government has said that wearing masks will be a personal choice, except in a few higher risk settings such as care homes. Many scientists, doctors and public health specialists disagree with this decision and would like to have seen mask wearing remaining compulsory until the number of Covid-19 cases was at a much lower level than it is now.

Should I keep wearing a mask in public transport?

My advice would be to continue to wear a mask on public transport after 19 July as this protects others from the risk of infection. However, this will be optional once Covid-19 regulations end in England. It is possible though that some airlines will continue to make mask use mandatory on their flights.

What’s the risks of maskless shopping?

The risk of acquiring an Covid-19 infection is much higher in crowded, poorly-ventilated indoor settings. Once the 1m rule is scrapped, shops will be much more crowded than they are now, which will make them a higher-risk setting for transmission of infection. If you are in a vulnerable group – such as the elderly or with a serious medical problem – you may wish to consider wearing a more protective FFP2 mask when you are shopping or in other crowded, indoor spaces.

And of singing in church?

A number of large Covid-19 outbreaks have been linked to places of worship. When people sing, they expel more air and make transmission of infection more likely in crowded, indoor settings, such as churches. Because churchgoers are often elderly, churches may wish to retain some social distancing measures after 19 July to protect the members of their congregation.

If my employer wants me to go back to the office but I don’t feel safe, can I refuse?

Employees with at least 26 weeks of service have the right to ask for flexible working, which can include working from home. Employers must consider the request but can decline it if there are good business or operational reasons for doing so. If you do have to work in the office, your employer should carry out a risk assessment to ensure your working environment is safe for you.

What might happen in schools if measures are scrapped but children aren’t vaccinated?

In recent weeks, many schools have experienced Covid-19 outbreaks, with around 640,000 children across England currently at home because there has been a case in their bubble. As most schools will close around 19 July for the summer holiday, there won’t be an immediate effect on schools. However, when schools re-open in September, there will be a risk that we will see further outbreaks in schools because children have not been vaccinated. We should be looking at implementing other mitigation measures to reduce the risk of infection in schools, such as ventilation and air cleaning systems, as has been done in countries such as the USA.

I’ve had both vaccines – can I still catch it, and how bad could it be?

The vaccines used in the UK provide good protection against symptomatic infection (around 80% after two doses) and even better protection (over 90%) against hospital admission and death. However, some people who are fully immunised can still get infected and a small proportion of these people will develop a severe illness that could result in hospital admission or death as no vaccine is 100% effective.

I haven’t had the vaccine – what precautions should I take?

You should continue to follow government regulations on social distancing and wearing face masks until 19 July. After then, you need to bear in mind that Covid-19 infections remain at a high level and so you should continue to be cautious in crowded, poorly-ventilated indoor spaces; particularly if you are from a more vulnerable group at higher risk of a serious illness if you become infected.

Is there a risk scrapping Covid measures could send us back into lockdown?

It’s likely that Covid-19 cases will remain at a high level during the summer because of the ending of Covid-19 rules and greater mixing of people in indoor settings. However, vaccination should keep deaths and, to a lesser extent, hospital admissions at a low enough level to avoid another lockdown. There is though always a risk that even more infectious variants of the coronavirus may emerge that will make current vaccines less effective and precipitate another lockdown.

What about vaccination?

Currently, around 86% of adults in the UK have had one dose of vaccine and 64% have had two doses. As two doses of vaccine are needed to provide effective protection, this means there are still many people who are at risk. Do attend for your first vaccination if you have not already done so and attend for your second vaccination when this is due. Many areas are offering walk-in vaccination clinics, which you can attend without an appointment.

How risky are pubs now people can order and drink at the bar?

Crowded, poorly ventilated locations such as pubs will be high risk settings for transmission of Covid-19 once restrictions end on 19 July. Because people in pubs will be drinking and lose some of their social inhibitions, and also speaking loudly, this adds to the infection risk.

Testing for Covid-19 in schools in place of isolation for case contacts

More than 375,000 pupils in England are currently are out of school for Covid-related reasons, an increase of more than 130,000 in a week. Not being at school is very disruptive for children’s education and their social development, and also for their families. The government is therefore considering other options for managing children in whom there has been a Covid-19 case in their school bubble. This could include daily testing  rather than exclusion from school. If the policy for children does change, it is likely to start in the new school term in September.

Will there be regular testing in schools even without any positive cases?

The current policy of testing secondary school children twice each week is likely to continue in the new school year in September. This will be the case even in schools where there are no cases.

What will happen someone in my child’s class tests positive?

Currently, everyone in the class and the wider school bubble is excluded from school and has to isolate at home. The proposal is that instead of isolating at home, children in the class would be tested daily in school and only sent home if they had a positive test.

What will happen if my child tests positive?

If your child tests positive, they will have to isolate at home for legal isolation period, which is currently 10 days. Other household members would also have to isolate, unless the government changes the rules and allows testing, rather than isolation for them.

Will the tests be voluntary? What if I don’t want my child to be tested?

Testing of children is voluntary in the UK and only carried out with the consent of parents.

Will there be any difference between primary and secondary schools?

The government has not confirmed this but it is likely that the policy on daily testing of contacts of cases would be the same in primary and secondary schools in England.

What type of test will be used and how accurate is it?

Lateral flow tests will be used as these can give a result within 30 minutes, whereas PCR tests have to be sent to a laboratory and it is typically  1-2 days before the test result is available. The lateral flow tests can pick up 50%-80% of cases of Covid-19, depending on how well the test is carried out. They are more likely to detect the children who are most infectious.

Will schoolchildren be asked to take the vaccine?

There are currently no plans to offer children in the UK the Covid-19 vaccine. If this does happen, it is likely to be for older children, those aged 12 years and over, and only if parents give their consent for vaccination.

What else can be done to keep schools safe

It’s essential that staff working in schools are fully vaccinated. Good ventilation and air filtration systems should also be a priority, as is the case in some other countries, as they have been shown to substantially reduce the risk of infection in schools.

Why foreign travel rules are important during the Covid-19 pandemic

The rapid spread of the delta variant of SARS-Co-V-2 ( coronavirus) in the UK in recent weeks shows the importance of foreign travel rules, such as on testing, immunisation and quarantine, to limit the import of Covid-19. Countries need to look at their own situation and put in place the most appropriate rules for them. This will including rules on Covid-19 testing for inbound and outbound travellers, and when and for how long travellers should quarantine; as well as guidance on whether travellers who are fully immunised can be exempted from some of these rules.

Holidays in foreign destinations carry risks. Settings such as restaurants, bars, night clubs and indoor concert venues have all been linked to large outbreaks of Covid-19. We all need to do our part to reduce these risks when we travel by following the local rules on social distancing and on the use of other preventive measure such as wearing face masks; and ensuring we get tested if we have symptoms of Covid-19 or have been caught up in a Covid-19 outbreak. The delta variant of the coronavirus has proven to be much more infectious than previous variants, and it is very likely that it will spread rapidly across Europe in the summer months, putting travellers at risk of infection.

By following the Covid-19 rules in the UK and in the countries we visit, we can help protect ourselves and others from the risk of infection, and limit the international spread of the delta variant and any other new variants of the coronavirus that may emerge in the future.

Questions and answers about Covid-19 vaccination in children

Countries globally are considering the implementation of Covid-19 vaccination programmes for children. In this article for the Daily Mirror, Matt Roper and I answer some of the common questions from parents about Covid-19 vaccination for children. 

I’m worried about vaccinating my child – how safe is it?

Clinical trials of Covid-19 vaccines in children aged 12-15 years in the UK and USA confirm that the vaccines are very safe. The rate of side effects in children in these studies was similar to that seen in young adults. As in young adults, most side effects were mild to moderate, such as a sore arm or tiredness.

Will children need two jabs like adults?

Children will need two doses of vaccine because this provides much better protection against serious illness than one dose of vaccine.

How likely is it they will suffer from side effects?

The most common side effects in children aged 12 to 15 years of age are pain at the injection site (> 90%), tiredness and headache (> 70%), muscle pains and chills (> 40%), joint pains and a high temperature (> 20%).

Is there anything I can do to offset any side effects?

Following the vaccination, paracetamol can help provide some relief from side effects such as muscle pain and headache. The side effects are generally transient and will resolve within a few days.

We’ve been told Covid doesn’t affect children as severely as adults, so why do we need to vaccinate them?

Although hospitalisation and death are rare in children following a Covid-19 infection, children can still sometimes have a prolonged illness and can also develop complications such as Multisystem Inflammatory Syndrome or other types of “Long-Covid”. Vaccination of children also helps to protect older members of the family, such as parents and grandparents, and teachers.

Is Long Covid a concern in relation to children, and will the vaccine help there?

Long Covid can occur in children. At present, we don’t yet know if vaccination will protect against Long Covid but we hope that if vaccines reduce the risk of symptomatic infection and serious illness, they will also reduce the risk of the long-term complications of Covid-19.

Will they need regular boosters later on?

Because the virus that causes Covid-19 is continually mutating, it is likely that booster doses of vaccine will be needed for both adults and children. For protection against current strains, it is possible that immunity may gradually weaken over time and this would be another reason for providing booster doses.

If they don’t get their jab, do we think they might be exposed to more risky variants in the future?

The vaccines do protect against serious illness even for the newer, more risker variants such as the delta variant. Children who are not vaccinated will be at higher risk of a serious illness if they are exposed to a new variant of the coronavirus in the future.

Extending the duration of Covid-19 control measures in England

There will be a lot of disappointment about the 4-week delay to the relaxation of Covid-19 control measures in England until 19 July that was announced today by the Prime Minister. But it is the right decision. A delay of a few weeks allows more people to be fully vaccinated with two doses of a Covid-19 vaccine. The vaccination programme in the UK is progressing well; with 79% of adults in the UK having received one dose of a vaccine and with 57% who have received two doses. But this still leaves many adults unvaccinated, including some people in the 50+ age groups who are at highest risk of serious illness, hospitalisation and death.

The delta variant in circulation in the UK appears to be more infectious and more likely to result in an illness severe enough to require hospitalisation than other strains of SARS-CoV-2; and now accounts for the vast majority of Covid-19 infections. One dose of a Covid-19 vaccine is less effective in preventing symptomatic infection from the delta strain than other variants (e.g. 33% protection after one dose for the delta variant v. 88% for alpha variant based on data from Public Health England). Two doses still provides good protection (81% protection against the delta variant v. 88% protection against the alpha variant for symptomatic infection, with even greater protection against hospitalisation), which is why it is essential to increase the number of fully immunised people before relaxing control measures. Delaying the relaxation of lockdown measures allows time for the NHS to proceed further with its vaccination programme.

We have seen around a 50% increase the in the number of cases of Covid-19 in the UK in the past week. The positive news is that hospital admissions, although increasing, are at a low level; and that deaths have changed little, remaining at a very low level compared to January 2021. This suggests that vaccines are protecting against more serious illness and confirms the need for eligible people at obtain their Covid-19 vaccination as soon as possible.

In the longer term, a high level of vaccination in the UK population offers the best route to a more normal society and an end to Covid-19 restrictions. This requires giving the NHS – in particular, general practices and pharmacies – the support they need to deliver vaccinations. If possible, the government also needs to increase the supply of vaccines; particularly the Pfizer and Moderna vaccines as these are the ones used in younger people who now comprise the majority of the unvaccinated adults in the UK. It’s also essential to address “vaccine hesitancy” to ensure that vulnerable, older people who have not yet attended for their vaccination appointments do get vaccinated to protect themselves and others. These actions will allow the NHS to meet the government’s updated target of offering all adults a Covid-19 vaccine by 15 July, as well as increasing the number of people who have received two doses of vaccine.

Building a sustainable infrastructure for Covid-19 vaccination

By mid-June 2021, the UK had administered over 70 million doses of covid-19 vaccines; with the majority (estimated around 75%) delivered by primary care-led vaccination sites. Since the start of the vaccine programme in December 2020, the UK has offered a variety of locations for covid-19 vaccination; GP led sites, mass vaccine sites, community pharmacies, and hospitals. The rollout of covid-19 vaccination is a major and much needed success for the NHS, and there are many positive lessons to be learned and taken forwards. However, we must not be complacent. We are still in the midst of a global pandemic, with covid-19 rife in many countries; and with new, more infectious variants of SARS-CoV-2 continually emerging. It is essential for the UK to maintain its vaccination momentum, as well as consider extending the vaccination programme to older children; and being prepared to offer booster doses to adults if these are required to maintain immunity. We must also focus on vaccine hesitancy, which is a major global health risk in its own right.

General practices in the UK are very experienced at mass vaccination programmes; being largely responsible for administering seasonal flu vaccines with support from community pharmacy sites. In 2020, the cohorts offered flu vaccines were extended to include household members of high risk patients, and all people aged 50-64. The same extended groups will be targeted for a flu vaccine next winter. General practices are embedded in their communities, are local and trusted, have health compliant regulated premises, rigorous cold storage systems, resuscitation equipment on site, hold full electronic patient records, and have long standing knowledge of their patients. For all these reasons, when the covid-19 vaccines became available, it was primary care teams nationwide who were able to quickly step forward and deliver the majority of vaccinations.

The initial cohort for the covid vaccination programme—people aged 80 and over—were not easily reached by email or text messages, are sometimes not technically literate, and many needed phone calls to book their vaccination appointments. The amount of time and effort this took was considerable and it is a credit to overstretched primary care teams nationwide (with special praise for practice managers, receptionists, care co-ordinators, link workers, nurses, volunteers and other support staff) that our most vulnerable patients, including nursing home, housebound and clinically extremely vulnerable patients received their initial injections so quickly and efficiently.

As we moved to the “lower risk” cohorts, the range of vaccine sites quickly expanded, and without any consultation central recalls were sent out, resulting in many unnecessary queries, much confusion, and unnecessary travel for patients. The logistics around the storage and handling of the mRNA Pfizer BioNTech vaccine precluded the use of community pharmacy sites, but the Oxford AstraZeneca (like seasonal flu vaccine) has been widely administered in community sites. The more recent changes by the MHRA allowing up to 31 days storage in a vaccine fridge for the Pfizer vaccine has the potential to further expand the range of suitable sites for its use.

In England, GPs have been working in primary care networks (PCNs) since July 2019, representing groups of practices typically covering 30,000-50,000 patients. Primary care networks are ideally placed to offer population based health services including covid-19 vaccination. Some primary care networks have offered covid-19 vaccinations in house by reorganising their services, while others have worked with other primary care networks to use large sites such as sports centres, entertainment venues, and village halls. Many primary care networks have also offered “pop up clinics”—for example in homeless shelters, community centres, places of worship and hostels—with great success, to increase uptake in marginalised groups who are typically at higher risk of infection, serious illness, and complications from covid-19; and thereby help to reduce health inequalities.

There has been great commitment from both the existing primary care workforce and volunteers to deliver the covid-19 vaccination programme, with many retired staff coming back to help, primary care staff being redeployed, and volunteers acting in roles such as marshals, data entry clerks and car park wardens. In addition to all the administrative workload in booking appointments, there are huge numbers of queries from patients about their vaccines both before and after the event. This hidden work is also being carried out, unfunded, and largely unrecognised, by primary care teams. Each time there is a change in policy by the government or a health scare in the media, primary care teams are inundated with calls, and this workload and its importance in ensuring the continued high uptake of covid-19 vaccines needs to be recognised by the government.

The UK government has recently announced that they may offer a covid-19 booster in the Autumn 2021 and, with new variants emerging, this is likely to be a key health policy to protect the NHS over the winter. Hence, now is the right time to appraise the various options for vaccine delivery. Having a mixed range of sites able to offer mass vaccination in theory should speed up the process, but it has been clear throughout the vaccination programme that the limiting factor is actually vaccine supply, not capacity to vaccinate.

We recommend that NHS England publish data on the respective costs of delivering vaccines via primary care networks (general practice sites) versus mass vaccine centres. Any such calculations must include set up costs, running costs, and also explain where the clinical staff are coming from—knowing that staff shortages are already running at over 10% across the NHS. The work in dealing with queries from patients also needs to be factored into this evaluation—this is currently largely being directed at primary care teams, who are often left to deal with the most complex patients. We would also request an official breakdown of the percentage of vaccines given in each setting thus far, so that there is full transparency and also an appreciation for the huge efforts made by GP teams nationwide.

By using primary care sites for the vaccination programme, there is the potential to invest in and strengthen our infrastructure for local healthcare delivery, which will assist in the covid-19 NHS recovery plans, and leave a legacy for the future. By contrast, there is a risk that mass vaccine sites—like the Nightingale hospitals—will eventually be dismantled. Policy makers need to carefully evaluate the use of mass vaccine sites versus GP led sites, along with the desire of patients to receive their care closer to home and in a familiar setting. However, there must be adequate resources attached for this work, so that routine care and timely access to other primary care services is not compromised by delivering the covid-19 vaccination programme.

We know that many GP teams are at breaking point, and must be fully supported if they are expected to provide mass covid-19 vaccination in addition to their core work. Investment in primary care led vaccination sites, supported by local pharmacies, is likely to be the most cost-effective option for ongoing mass vaccination, as well as being the option that is preferred by most patients. It is essential therefore for the government and NHS managers to work with primary care teams, giving them the resources needed to put in place a sustainable, long-term infrastructure for vaccine delivery.

Simon Hodes, GP Partner, Watford, UK, Twitter @DrSimonHodes

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter @Azeem_Majeed

Competing Interests: None declared

This article was first published by BMJ Opinion.

Covid-19 vaccination hesitancy

The rollout of Covid-19 vaccination is well underway, with more than 700 million doses given worldwide as of April 2021. Vaccination is highly effective at reducing severe illness and death from Covid-19. Vaccines for Covid-19 are also safe, with extremely low risks of severe adverse events. A major threat to the impact of vaccination in preventing disease and death from Covid-19 is low uptake of vaccines. In article published in the British Medical Journal, we give on overview of vaccine hesitancy and some approaches that clinicians and policymakers can adopt at the individual and community levels to help people make informed decisions about Covid-19 vaccination.

The World Health Organization defines vaccine hesitancy as a “delay in acceptance or refusal of safe vaccines despite availability of vaccine services.” It is caused by complex, context specific factors that vary across time, place, and different vaccines, and is influenced by issues such as complacency, convenience, confidence, and sociodemographic contexts. Vaccine hesitancy may also be related to misinformation and conspiracy theories which are often spread online, including through social media. In addition, structural factors such as health inequalities, socioeconomic disadvantages, systemic racism, and barriers to access are key drivers of low confidence in vaccines and poor uptake. The term vaccine hesitancy, although widely used, may not adequately convey these wider determinants that influence decisions to delay or refuse vaccination.

DOI: https://doi.org/10.1136/bmj.n1138

Measuring the impact of Covid-19: Why mortality alone is not enough

In an editorial published in the British Medical Journal, we discuss why we must look beyond mortality to the wider burden of pandemic related harms. Over the course of the covid-19 pandemic, daily releases of national statistics on cases and deaths have been widely reported and used to support interventions and judge the success or failure of control measures around the world. However, differences in rates of testing and in reporting of deaths have led to uncertainty about whether national headline figures on deaths are directly comparable. Excess mortality is an alternative metric, which gives a measure of the number of deaths above that expected during a given time period and thus accounts for additional deaths from any cause during the pandemic, irrespective of how covid-19 deaths are defined.

Measuring excess mortality alone offers only partial insights into the impact of the covid-19 pandemic on the health of nations. If we are to truly understand and intervene to mitigate the impact of the pandemic, we must also look to quantify excess morbidity within and between nations. A focus on deaths alone gives only a partial picture of the impact of covid-19 on populations, particularly among younger people in whom death from covid-19 is rare. The importance of “long covid,” for example, has recently been highlighted, but the true burden of this condition has yet to be quantified, and policies are urgently needed to overcome its long term challenges.

The covid-19 pandemic has resulted in widespread disruption to health systems across the world. Diagnostic and treatment pathways for cancer and other time sensitive conditions have been disrupted, and the monitoring of long term conditions has often taken place through novel telemedicine platforms, if at all. By April 2021 more than 4.7 million people in England were waiting for hospital treatment, the highest number since records began. Such disruption is likely to lead to poorer health and earlier deaths in countries across the world for many years to come, particularly where covid-19 remains endemic and where health services are unable to function normally. Establishing where health systems have fallen behind, and characterising the true extent of unmet need, is a critical step towards reducing these ongoing harms.

There has been a huge toll of the covid-19 pandemic on mortality in high income countries in 2020. However, its full impact may not be apparent for many years, particularly in lower income countries where factors such as poverty, lack of vaccines, weak health systems, and high population density place people at increased risk from covid-19 and related harm. In the UK, life expectancy in lower socioeconomic groups has fallen in recent years, an inequality likely to be exacerbated by the covid-19 pandemic, without concerted action.

Finally, although mortality is a useful metric, policy informed by deaths alone overlooks what may become a huge burden of long term morbidity resulting from covid-19. An urgent need exists to measure this excess morbidity, support people with long term complications of covid-19, and fund health systems globally to tackle the backlog of work resulting from the pandemic.

DOI: https://doi.org/10.1136/bmj.n1239