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.

Implementation of covid-19 vaccination in the United Kingdom

Our new paper in the British Medical Journal reviews the implementation of the UK’s Covid-19 vaccination programme. The programme is essential in keeping down the number of serious cases, hospitalisations and deaths from Covid-19 and allowing society to function more normally. Overall the programme performed well. But it’s important to address some common misconceptions about the programme. Firstly, the rapid implementation of the Covid-19 in vaccination in the UK was not due to Brexit. When the programme started, the UK had not finalised Brexit. Secondly, the vaccination programme was good and all those who supported the programme are to be congratulated for their efforts but it was not “world-leading” as some politicians have claimed. Many other countries have outperformed the UK in areas such as vaccine uptake.

One limitation of current vaccines is that although they are very successful in reducing the number of serious cases of covid-19, they are less effective in preventing infection from SARS-CoV-2, which means that vaccinated people can still become infected and infect others. Early in the vaccination programme, this was often not communicated well to the public, leading to unrealistic expectations about how well vaccines would suppress the risk of infection, particularly with the emergence of new variants that reduced vaccine efficacy.

The UK became the first country in Europe to grant emergency use authorisation for a covid-19 vaccine when the MHRA gave approval for use of the Pfizer-BioNTech vaccine in adults on 2 December 2020. This decision took place when the UK was still operating under EU law. Overall, the policy for prioritising people for vaccination was fair but was criticised for not including ethnic minority groups or key occupational groups other than health and care workers, such as people working in public transport or teaching. The pandemic had major effects on the education of children, for example, and it could be argued that staff working in schools should have been prioritised in the same way as NHS staff to reduce the disruption caused by the pandemic to children’s education.

Shortly after the start of the vaccination programme in the UK, the government decided to prioritise delivery of the first dose of vaccine over the second dose, based on advice from the JCVI. This meant a delay in giving the second dose of vaccine from 3-4 weeks after the first dose to 12 weeks. The immunisation programme was disrupted by this decision, with many people having their appointments for their second doses cancelled. A key question for the Covid-19 Inquiry is why the JCVI did not consider a delayed second dose policy before the programme started. The Inquiry also needs to look at what plans were in place for evaluating the effects of the delayed second dose on clinical outcomes such as infection, hospital admission and case fatality rates and on the delivery of the vaccine programme.

Although the UK was an early adopter of covid-19 vaccines for use in adults, it was slower than many other countries to implement vaccination for 16-17 year olds, then for 12-15 year olds, and finally for 5-11 year olds. This also needs careful review by the Covid-19 Inquiry. Additional problems arose after the decision to give some immunocompromised people a third primary dose of vaccine. The rationale was that immunocompromised people often had a poor response to two doses of vaccine and that a third dose would give improved protection. The third dose programme was rolled out with little central or local planning, resulting in considerable confusion among both the public and NHS staff and leading to delays in many eligible people getting their third primary vaccine dose. Key lessons from this component of the vaccination programme were the need to give the NHS adequate time to plan and to ensure that NHS staff are fully briefed in advance of any public announcement or media briefing about vaccination policy. It’s also essential to look at the method of vaccine delivery. In England, there is now a very fragmented system. In the longer term, we need to look to integrate Covid-19 vaccination with other vaccine programmes in primary care and schools.

One area in which the UK excelled internationally was using data from the NHS, covid-19 testing, and national mortality records to monitor vaccine uptake, safety, and effectiveness. Congratulation to PHE and then to the UKHSA who set up this work.

The UK is currently very reliant on overseas manufactured vaccines. We must plan consider how we ensure that the UK can develop, test, and manufacture vaccines for the current and any future pandemics at the speed and quantity needed.

The feedback on our article from patients emphasised the importance of clear, positive messages about vaccination for the public; and personalised support for people who were vaccine hesitant or who had concerns about vaccination to help increase vaccine uptake. Access to vaccination at a local site was also important, particularly for older people or those with limited mobility. Finally, there are many questions about vaccination that the UK’s Covid-19 Inquiry will need to consider. Some of these are summarised below.

Questions for the UK’s Covid-19 Inquiry

  1. What should we be doing to secure the legacy of the covid-19 vaccine research and delivery strategy for vaccine science, vaccine manufacturing, public health, and pandemic preparedness?
  2. Why hasn’t the UK established a pipeline for the rapid development of RNA vaccines?
  3. Why did the UK lag behind many other countries in recommending covid-19 vaccines for children?
  4. How would we respond to a future pandemic causing high levels of morbidity and mortality in children?
  5. Was sufficient attention paid to targeting groups who were likely to be vaccine hesitant?
  6. What can be done to build on the JCVI’s communications and operations—particularly around public and patient involvement and engagement and its position on equality, diversity, and inclusion?
  7. Why did the JCVI not recommend a delayed second dose strategy in its initial recommendations to the government in 2020? What impact did this have?
  8. What is the best method of covid-19 vaccine delivery in the future?
  9. Should staff working in schools also have been included in the initial occupational groups targeted for vaccination (such as health and care workers) reduce the effect of the pandemic on schools, given the many adverse effects of the pandemic on the education, social development, and the physical and mental health of children?
  10. Did the UK government take the correct decisions about vaccine procurement? Was the UK correct to work alone on procurement or should there have been greater collaboration with the EU?
  11. What impact did the over-procurement of vaccines by developed countries such as the UK have on vaccine equity and on the supply of vaccines for lower income countries early in the pandemic?

Why you should get your flu vaccination

The NHS is now starting to rollout flu vaccinations for eligible people. Although the public health focus since early 2020 has been very much on Covid-19, flu remains a major threat to vulnerable individuals and the NHS in the UK.

We have been fortunate that in the last few years, flu rates have been very low in the UK. However, there are signs from Australia that we may see much higher rates of flu in the UK this winter. Australia has seen its highest flu rates since the start of the Covid-19 pandemic and this may be a predictor of what the UK may face during our own winter.

Because flu rates have been low in recent years, this means that people will have less immunity from a previous infection. The end of Covid-19 control measures – such as face masks and social distancing – combined with the return of normal social activities also increase the likelihood of a large flu outbreak this winter.

This makes flu vaccination essential – particularly for the elderly, the clinically vulnerable, and people who work in health and social care. You can get your flu vaccine at a range of sites such as your GP surgery or a local pharmacy. Getting the flu vaccine reduces your risk of being infected and of suffering a more severe illness that may result in hospital admission or death. By getting vaccinated, you are also helping to reduce pressures on the NHS at a time when it is facing unpresented demands for care.

So don’t delay. Get your flu vaccine if you are eligible to protect yourself and to protect the NHS.

Writing your student dissertation: Some tips on how to do it well

It’s the time of year when academics – including myself – are marking MSc and MPH dissertations. Once again, I see many errors in how students write their dissertations. What are these errors and how can students avoid them to make their dissertations more readable?

  1. Most importantly, spend time planning the outline of your dissertation with chapter headings and subsection headings for each chapter. Decide what key tables, figures and graphs you need to include to reinforce what is in the main text of your dissertation.
  2. Many students assume that longer words are “more scientific” and therefore preferable than shorter words. For example, using terms like perspiration rather than sweat or haemorrhage rather than bleed. Imagine if Churchill had written his speeches in this “more scientific” way.
  3. Use shorter sentences when possible. Longer sentences are more difficult to read and can lead to the examiner missing the key points you are trying to make. The same applies to paragraphs – don’t make them too long and look for natural breaks when you can start a new paragraph.
  4. Use active voice rather than passive voice in your text. For example, “I reviewed the literature” rather than the “literature was reviewed by me”. Active voice is easier to read and makes it clear to your examiner that you were the one who carried out all this work.
  5. Remove superfluous words. For example, “based on” is better than “on the basis of” and “even though” is better than “despite the fact that”. Getting rid of superfluous words gives more space get across the work you have done and makes it easier to stay within the allotted word count.
  6. Avoid using cliches and colloquial expressions. These are not often used in scientific writing and may be difficult for some examiners and readers to understand, particularly if they are not native English speakers. They can always be replaced by other terms that are clearer.
  7. Spelling, punctuation and grammar. When you are writing your dissertation is not the time to be learning how to get these correct. If you need help, most universities will offer some tuition. Do these courses early in your course and also get yourself a guide on good grammar.
  8. Spend some time trying to improve your scientific writing. Many journals offer the opportunity to reply online to their articles. You can use this facility to improve your critical thinking and ability to collate your arguments. Working in a writing group can also help.
  9. Read examples of good scientific writing. Seeing how others have achieved this task can help you in your own writing. For example, read “From Creation to Chaos: Classic Writings in Science” by Bernard Dixon for some excellent examples.
  10. Check your spelling, punctuation and grammar before you finally submit your dissertation to your examiners. It’s surprising how many errors remain the text of a dissertation that could have been pick up by running the spell and grammar check options in word processing software.

A digital solution to streamline access to smoking cessation interventions

Traditional face-to-face smoking cessation interventions may result in significant delays between the patient’s decision to quit and access to effective pharmacological support or behavioural therapies. In a study published in the journal Public Health in Practice, we evaluated digital solution to streamline access to smoking cessation interventions

This was the first attempt in the UK where a GP-led online portal with added functionality was used to streamline timely access to pharmacotherapy for smoking cessation using an asynchronous formal request for treatment. We evaluated the findings of a primary care pilot from two general practices in West London where 4337 patients who are registered as smokers were contacted with unique link to access the portal.

Whereas smoking is the major avoidable cause of preventable morbidity and mortality in the UK and internationally, there are surprisingly few examples of a patient-facing primary care led IT system to streamline the delivery of evidence based smoking cessation interventions in the community setting. The use of a primary care-led online portal could enable patients to make an asynchronous request for treatment without the need to visit the general practice.

Update on Polio Vaccination for Health Professionals

One of my educational roles is update staff in my medical practice about topical public health issues in our weekly clinical meeting. In the most recent meeting, I gave an update on polio in London, including some key facts that health professionals need to understand.

1. Understand the difference between the two types of polio vaccines: inactivated and live. The inactivated polio vaccine has been used in the UK since 2004. Once polio has been eradicated from a country, it is safer to use the inactivated vaccine.

2. Check each patient’s polio vaccination status and encourage those patients who are not vaccinated or only partly vaccinated to receive a full course of vaccinations. Ensure that vaccine status is recorded on the patient’s electronic medical record.

3. Support the booster programme for children aged 1-9 years old that is currently being rolled out across London. Address vaccine hesitancy and any concerns about vaccination in parents sympathetically and aim to understand why people may have concerns about polio vaccines.

4. Direct parents to evidence-based resources that provide further information about both polio vaccination and childhood vaccination more generally. There are many excellent online resources published in different languages by the NHS and other government organisations.

My technological journey as a student and academic

I was explaining to a student recently how we did literature searches in the 1980s and 1990s. We had to look up articles in a printed copy of Index Medicus, and then pushed a trolley around the library to collect the journals so we could photocopy the articles. There was an incredulous look in her eyes. We had to pay for the photocopies, which made us very selective about the articles we used in our literature reviews.

And when we got to the photocopier, we had to hope that it had not broken down or that the queue to use it was too long. Arriving well before library closing time was also important. Online articles did not exist then and sometimes we had to wait for weeks for articles to arrive using the Inter-Library Loan Service if they were not in the library’s own collection. Eventually, printed copies of Index Medicus were replaced by a CD-ROM version (which you have to book a slot in advance to use) and then eventually by online bibliographic databases. And now, we have immediate access to online journal articles.

I then went onto explain that the terms ‘cut’ and ‘paste’ in modern computer programs are there because that is once what we had to do. We cut out graphs and diagrams with scissors and then pasted them into documents using glue. More incredulous looks followed. When we presented our work, we used hand written acetates on an overhead projector. Moving to printed acetates was a big step forwards (or so it seemed at the time). Presenting at professional conferences meant using (expensive) slides. Errors that you couldn’t correct were common. Eventually acetates and slides were replaced by PowerPoint projectors.

When I was a student in the 1980s, all our course work was hand-written. Most of us did not have typewriters and very few of us could type. When word processing software became common later in the decade, it meant no more Tippex or retyping whole documents to correct errors.

My first printer was a 9-pin dot matrix. It was noisy, slow and the quality of the print was poor. But it produced much more legible output than hand-written documents. Moving to 24 pin dot matrix printers was a big advance in the quality of printed documents. Eventually, affordable ink jet and laser printers became common.

Moving from cassettes to floppy disks and then hard disks for storage were big advances. My first hard disk was 20MB in capacity. Such was the size of computer programs and their data files in the 1980s, I couldn’t come close to filling it. Now a word document with some embedded images can often be larger than 20MB.

My student clearly thought I had grown up in a technological stone age. In many ways, her reaction was like mine when older people used to tell me what life was like in the 1930s and 1940s during the Great Depression and World War Two. But although the 1980s and early 1990s were a more technologically-backwards era than now, there were benefits in being a student then. We had our course fees paid and received a grant to cover our living costs, so we did not graduate with the vast debts that current students have.

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza

Our recent study in the journal Thorax examined patient outcomes following emergency admission to hospital for COVID-19 compared with influenza. We used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.

The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).

We concluded that patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

The findings relate to 2020, a period before Covid-19 vaccination began and when different variants of SARS-CoV-2 were circulating in the UK. We aim to update the analysis to see how Covid-19 outcomes have changed since that period compared to outcomes from influenza.

Covid-19 rates are increasing again in the UK – What does the public need to know?

Why are so many people coming down with Covid again?

The current wave of Covid-19 infections is being caused by highly infectious subvariants (BA.4 and BA.5) of the Omicron variant that entered the UK in late 2021. These subvariants are more infectious than the previous variants of the coronavirus that the UK has faced. They are also more likely to cause reinfections. Other factors increasing the number of infections include greater mixing of people now that Covid-19 measures in the UK have ended and reduced protection from infection from vaccines because many people are more than six months since their last Covid-19 vaccination.

Are the new variants worse than the other variants?

Although they are more infectious than other variants, the new subvariants of Omicron do not cause more severe disease and on average, they probably cause a milder illness. However, because of the very large number of infections caused by these subvariants, some people will have a serious illness with a risk of being admitted to hospital or dying. The good news though is that vaccines still work very well at reducing the risk of serious illness and death. The number of deaths from Covid-19 in England is very low due to this protection given by vaccines.

How bad could this new wave get?

We will see a further increase in cases and hospitalisations during July. After July, we should see a decline in both cases and hospitalisations as we saw with the previous two Omicron waves in January and April. Although we will see additional pressures on the NHS, the number of deaths will remain much lower than in January 2021 when deaths from Covid-19 in the UK peaked.

Could any restrictions be brought back and if so, what?

It’s very unlikely the government will bring in any new legal restrictions but they may offer public health advice on the use of face masks in indoor settings and the importance of good ventilation in reducing the risk of infection. They will also encourage people to take up the offer of Covid-19 vaccination if they are eligible for a booster or have not yet had a full course of vaccines.

Wasn’t the colder season the worst time for Covid? How come it’s now spreading in the hot weather?

Respiratory infections are usually worse in winter when the weather is colder and people spend more times indoors. With Covid-19, however, we have seen new virus variants emerge that are highly infectious and which can increase the number of infections, including in the summer.

If I’ve already had Covid this year am I just as likely to catch this new variant, or if I do might the symptoms be milder?

People who have already had an infection this year are less likely to get a second infection. If they do get a second infection, it is likely to be milder, particularly if they are fully vaccinated. However, for some people, a second infection can be more severe than their first infection.

How could the new Covid surge affect the summer holidays?

The UK government has no plans to introduce restrictions on travel or requirements for Covid-19 testing like those we saw in previous years. However, if there is a large increase in the number of Covid-19 infections, it is possible some countries may introduce new measures. However, at this point, I would say this is unlikely to happen.

Will they bring back airport testing, and if not how easily could we catch Covid if there are positive people on the flight?

There are no plans to bring back Covid-19 testing before flights. It’s unlikely this will happen in the UK unless the number of serious Covid-19 cases become so high, the NHS is unable to cope. The best way to prevent this from happening is for everyone to be fully vaccinated. The risks of catching Covid-19 are probably higher in crowded airport terminals than on an airplane because of the ventilation and air filtration systems that modern airplanes use. If people are unwell, they should avoid travelling so that they do not infect others.

I’m back to working next to others in a busy office. What precautions should I take?

Try to ensure that the room is well ventilated. Ideally, everyone in the office should be fully vaccinated. You can also wear a face mask (preferably an FFP2 mask that provides better protection). If anyone is unwell with a possible Covid-19 infection, they should stay at home and not come into work. Employers have a duty of care to their staff and should not ask employees to come to work if they are unwell and may pass on a Covid-19 infection to others.

Am I still protected by the vaccine and booster?

If you are fully vaccinated, including with a booster, you are still very well protected against serious illness and death, although you can still be infected. When another booster is offered in the Autumn, you should take up this offer if you are in an eligible group.

When will another booster be available for people under 75 and will it be updated to protect against the new variant?

Another Covid-19 vaccine booster will be available in the Autumn. This will be offered to people living in care home for older adults and their staff. Frontline health and social care workers and people aged 65 years and over will also be eligible for a booster in the Autumn. Some adults aged 16 to 64 years who are in a clinical risk group will also be eligible for a booster but the government has not yet confirmed what medical conditions will make people eligible. There are now updated vaccines being tested that target Omicron. The government has not yet approved these updated vaccines for use in the UK but if the results from clinical studies are good, it’s very likely these vaccines will be offered in place of the original vaccines for the Autumn booster programme.

Why is there talk of an even worst Covid wave in the Autumn? What might happen?

We had a very high number of hospitalisations and deaths from Covid-19 in the winter of 2020-21. In the winter of 2021-22, thanks to vaccines, the number of hospitalisations and deaths was much lower. It’s very likely that the UK will experience another wave of Covid-19 in the Autumn and Winter when the weather is cooler and people spend more time indoors. This increase in Covid-19 cases may occur at the same time as a large flu epidemic. To reduce the impact of flu and Covid-19 on people’s health and the NHS, it’s essential that eligible people take up the offer of a flu vaccine and that as many people as possible are fully vaccinated against Covid-19, including with any boosters that are offered later this year.

A version of this article was first published in the Daily Mirror.

Healthcare workers potentially exposed to HIV: an update

Despite the very low risk of seroconversion, occupational HIV exposure is a very stressful situation. Our new article in the Journal of the Royal Society of Medicine provides guidance on how such exposures should be managed to minimise risks and improve health outcomes for staff exposed to contaminated body fluids.

Careful risk communication can help in addressing anxiety. Pre-Exposure Prophylaxis (PEP) is seldom indicated for occupational exposures if the index case is of unknown HIV status, as the transmission risk is very low. PEP is indicated to reduce the transmission risk following high-risk incidents – exposures where the index case is known to be HIV-positive with a detectable viral load – and is most effective if started promptly.

Why we need to put an end to the GANFYD culture in the UK

One of the causes of increased workload in general practice are the many requests that doctors get for letters from patients or from external organisations. It’s now so common that doctors have coined a term for it: GANFYD – Get A Note From Your Doctor.

It’s seems that large sections of society can’t function without these “letters from doctors”. Instead of using common sense or employing their own clinical advisers, external organisations make repeated requests to NHS doctors for letters which are not at all needed.

Often the worst offenders come from the public sector – e.g. universities who seem to look upon NHS general practice as a source of free occupational health advice for their students. Universities never – of course – offer to pay for this advice they get from NHS GPs.

Instead, university requests will come with a mealy-mouthed statement that any fee is the responsibility of the student. Like doctors are going to impose heavy fees on impoverished students who already have large debts and are who are often living in poverty.

Local government and schools are other frequent offenders, requesting letters for issues they could easily resolve themselves using some common sense. And perhaps surprisingly, the NHS is also a frequent offender (you would think that NHS Trusts would know better).

What’s the solution? I have concluded that to address the GANFYD problem, we need to remember the adage “money talks while bullshit walks”. But don’t charge patients. Change NHS regulations so the (suitably large fee) is the responsibility of the organisation making the request.

The NHS is under great pressure and we urgently need to do everything we can to reduce unnecessary work in the NHS so that NHS staff can focus on clinical work.