Medical Centre

As the global covid-19 vaccine rollout continues, uncertainties regarding the association between thromboembolic events and the Oxford-AstraZeneca vaccine have dominated the news during March, leading 18 European countries to suspend its use whilst this association was investigated by the European Medicines Agency. This suspension of the vaccine will have serious implications for vaccine confidence in general and, in particular, for global vaccination programmes. It has already  heightened anxiety levels and affected vaccine uptake especially among vaccine-hesitant groups due to claims about side effects that are not supported by real world data or data from clinical trials.

Read Covid-19 vaccine adverse events: balancing monitoring with confidence in vaccines in full

Should I really be worried about blood clots?

The AstraZeneca vaccine has been given to many millions of people across the world (over 10 million in the UK). A few of these people have suffered from blood clots after receiving the vaccine but no causal relationship has been found and the number of people affected is not above what we would expect in the general population in people who did not receive the vaccine.

How safe is the vaccine?

The clinical trials in which the vaccine was tested showed it was very safe, with a very low level of serious side effects and this has been confirmed subsequently in the wider use of the vaccine in the UK and elsewhere. The benefits of the vaccine far outweigh any risks. The clinical events that led to concerns about the vaccine are very rare with only a small number of episodes among the many millions of people who have received the vaccine.

Why are so many countries suspending it?

When a possible side effect is linked to a drug or vaccine, some countries will temporarily suspend use of the product until this has been investigated further. This does not mean that the vaccine is unsafe and we would expect further review of the data to confirm its safety.

Can I reduce the risk of a blood clot by taking an aspirin?

It’s probably not advisable to use aspirin in this way because no link between blood clots and the vaccine has been confirmed and there is a small risk of suffering a serious stomach bleed after taking aspirin.

What are the other possible side effects of the vaccine?

The most common side effects of the vaccine are pain and tenderness at the injection site, headache, tiredness, generalised muscle pain, shivering and a fever. These side effects usually resolve within a few days.

Does your age affect the likelihood of side effects? (For instance, do younger people feel worse because their immune systems are better?)

Side effects can occur at all ages but tend to be less common in older people. This is thought to be because the immune system gradually weakens with age, which also leaves older people more susceptible to infection.

Won’t I still be protected if I refuse the vaccine, because so many other people have had it?

It’s important that as many people as possible receive the vaccine. If a large number of people are not vaccinated, we will continue to see outbreaks of Covid-19, with some people suffering a serious infection that could result in hospital admission or death. The vaccine is not 100% effective and children are not currently being immunised, so there will be many people in the population who can still become infected.

What’s the down side of not having the vaccine?

If you don’t receive the vaccine, you are at much higher risk of contracting a Covid-19 infection. These infections can be serious, leading to long-term complications and death in many people. You may also infect others, including elderly relatives who may be at high-risk of serious illness. Furthermore, the more people who receive the vaccine, the more likely we are to an end to the pandemic and the lockdown measures it has led to.

Read Questions and Answers about the AstraZeneca Covid-19 Vaccine in full

Our new paper published in the Journal of the Royal Society of Medicine discusses whether the government should take ethnicity into account when establishing priority groups for Covid-19 vaccination as one component of a strategy to target health inequalities.

COVID-19 has disproportionately affected Black, Asian and Minority Ethnic (BAME) groups, resulting in higher rates of infection, hospitalisation and death. The COVID-19 pandemic has also exposed the pre-existing racial and socioeconomic inequalities in the UK. However, the Joint Committee on Vaccination and Immunisation has omitted ethnic minorities from the top priority groups which include older age, frontline health and social care workers, and care home staff and residents. The invisibility of these vulnerable groups from the priority list and the worsening healthcare inequities and inequalities are putting ethnic minorities at a significantly higher risk of COVID-19 illness and death.

The UK’s vaccine allocation strategies have the potential to further exacerbate the pre-existing, persistent but avoidable, racial inequalities that the COVID-19 pandemic and the wider governmental and societal response have harshly exposed and amplified. Dismissing the racial and socioeconomic disadvantages that ethnic groups face may result in a devastating impact lasting far beyond the end of the pandemic.

Controlling further outbreaks and, ultimately, ending the pandemic will require implementation of approaches that target ethnic minorities as well as ensuring that vaccine allocation strategies are effective, fair and justifiable for all.

DOI: https://doi.org/10.1177%2F01410768211001581

Media Coverage

https://www.nwemail.co.uk/news/national/19148392.ethnic-minorities-put-risk-colour-blind-vaccine-distribution-strategy/

https://www.eurekalert.org/pub_releases/2021-03/s-uc030821.php

https://news.sky.com/story/covid-19-ethnic-minorities-at-higher-risk-of-dying-with-coronavirus-because-of-colour-blind-vaccine-rollout-doctors-warn-12241078

https://www.independent.co.uk/news/health/covid-vaccine-doses-uk-ethnic-minorities-latest-b1814699.html

https://www.walesonline.co.uk/news/uk-news/vaccine-strategy-puts-ethnic-minorities-20031089

https://www.dailymail.co.uk/news/article-9342467/BAME-communities-risk-UKs-colour-blind-Covid-vaccine-strategy-experts-warn.html

https://www.three.fm/news/uk-news/covid-19-ethnic-minorities-at-higher-risk-of-dying-with-coronavirus-because-of-colour-blind-vaccine-rollout-doctors-warn/

https://www.morningstaronline.co.uk/article/splash-74

Read COVID-19 vaccine allocation: addressing the United Kingdom’s colour-blind strategy in full

In an editorial published in the British Medical Journal, we discuss the highly topical issue of Covid-19 vaccine hesitancy among ethnic minority groups. With mass Covid-19 vaccination efforts under way in many countries, including the UK, we need to understand and redress the disparities in its uptake. Data to 14 February 2021 show that over 90% of adults in Britain have received or would be likely to accept the covid-19 vaccine if offered. However, surveys have indicated much greater vaccine hesitancy among people from some ethnic minorities. In a UK survey in December 2020, vaccine hesitancy was highest among black, Bangladeshi, and Pakistani groups compared with people from a white ethnic background.

The legitimate concerns and information needs of ethnic minority communities must not be ignored, or worse still, labelled as “irrational” or “conspiracy theories.” We need to engage, listen with respect, communicate effectively, and offer practical support to those who have yet to make up their minds about the vaccine. Covid-19 vaccination is one of the most important public health programmes in the history of the NHS. Tackling vaccine hesitancy and ensuring that vaccination coverage is high enough to lead to herd immunity are essential for its success.

DOI: https://doi.org/10.1136/bmj.n513

Read Covid-19 vaccine hesitancy among ethnic minority groups in full

The Prime Minister Boris Johnson has set a target of offering a first dose of a covid-19 vaccine to all adults in the UK by the end of July 2021. What do we need to do to achieve this target? The first step is to ensure we have enough vaccines to offer first and second doses to all adults. There are around 53 million people aged 18 and over in the UK. If everyone took up the offer of a vaccination, we would require about 106 million vaccine doses, along with a small amount of vaccine for people under 18 who are classed as clinically extremely vulnerable.

Currently, we are using two vaccines in the UK: from AstraZeneca and Pfizer-BioNTech. A third vaccine from Moderna has been licensed in the UK but is not yet in use. Other vaccines—such as the candidate from Novavax—are in the late stages of development and approval; and may come into use in the UK by the early summer. The government will need to ensure that these companies can supply enough vaccines for use in the UK to meet its target date of 31 July.

How quickly do we need to vaccinate the UK population to meet the target? By 20 February, the UK had administered around 18 million doses of covid-19 vaccines (17.2 million first doses and 0.6 million second doses). This means that we need to administer around a maximum of another 88 million doses of vaccines if all adults in the UK accepted the offer of a vaccination and received two doses of vaccine.

In recent weeks, about 2.9 million doses of vaccine have been administered each week in the UK. As there are around 23 weeks until 31 July, we would be able to administer about a further 66 million vaccine doses by the target date, bringing the total doses administered to 84 million. This would be sufficient to provide all 53 million adults in the UK with at least one dose and also to provide 31 million of these people with two doses of vaccine.

Maintaining the same pace of vaccination after July would allow all adults in the UK to receive two doses of vaccine by mid to late September. In practice, we may need less than a total of 106 million doses of vaccine to immunise adults in the UK because not everyone will take up the offer of a covid-19 vaccination. Hence, the target of “offering” all adults in the UK a first dose vaccine by 31 July looks achievable if the supply and administration of vaccines can both be maintained at their current rates.

It’s also worth considering whether the UK should be more ambitious in its target. For example, if there was sufficient capacity in the NHS to offer 3.8 million doses of vaccine per week —an increase of 31% on the current vaccination rate—and vaccine supplies to allow this, all adults in the UK could receive two doses of vaccine by 31 July. In either scenario, 2.9 million doses weekly or 3.8 million doses weekly, the UK would have offered two doses of vaccine to all adults in the UK before the Autumn and thus would be better prepared for any seasonal increase in covid-19 infections than it was in 2020.

Maintaining an average of 2.9 million vaccinations per week for the next 23 weeks is ambitious, but it looks practical if vaccination sites can be guaranteed sufficient doses of vaccine.  Vaccination sites will also need to have deliveries timetabled well in advance so that clinics can be planned and patients booked in for appointments. It’s therefore critical that we avoid the problems seen in the earlier phase of the vaccination programme, when deliveries of vaccines to vaccination sites were often arriving late or being cancelled at short notice. This created logistical and planning difficulties for vaccination teams, as well as being very inconvenient for patients who had their appointments cancelled.

We also need to bear in mind that we have thus far been vaccinating groups of people, such as older or clinically vulnerable people and frontline healthcare professionals, where vaccine uptake has been very high. As we start to vaccinate younger, healthier groups of people, we may find vaccine uptake is lower than in older people because of greater levels of vaccine hesitancy. We need to ensure that we engage with vaccine hesitant groups—whether these are younger people or people from ethnic minority communities—to achieve a very high uptake of covid-19 vaccination. Broad population coverage is the vaccination programme’s best hope of success in helping to limit the spread of covid-19, allowing the UK to gradually relax its covid-19 control measures.

At this point, we also don’t yet know if booster vaccines will be required later in the year or in 2022 to deal with the effects of any decline in immunity following vaccination, or to provide protection against new variants of SARS-CoV-2 if older vaccines are less effective. If this is the case, we will need to put in place the infrastructure to deliver additional doses of vaccines to all adults in the UK, making the covid-19 vaccination programme like the influenza one but on a much bigger scale. It’s also possible that we will have vaccines licensed for use in children later this year, which will further increase the number of people who need to be vaccinated. The size of the covid-19 vaccination programme and its importance in allowing a return to a more normal way of life in the UK means that it must be meticulously planned and adequately funded for the indefinite future.

In conclusion, the government’s vaccination target looks achievable if it can guarantee sufficient supplies of vaccine; improve the planning of deliveries to vaccination sites; and provide vaccination teams with the required financial, administrative, and personnel support. This needs to be done at the same time as the NHS deals with all its other emergency and elective work, as well as with the large backlog of work caused by covid-19. As the majority of covid-19 vaccines have been delivered by primary care teams, particular emphasis must be placed on supporting NHS primary care during this period to ensure successful achievement of the vaccination target.

This article was first published in BMJ Opinion.

Read Can the UK meet the government’s target of offering all adults a covid-19 vaccine by 31 July? in full

Vaccination offers the UK the best exit strategy from the covid-19 pandemic. [1] To accomplish this objective, achieving high population coverage of covid-19 vaccination is essential. However, despite the good safety and efficacy of covid-19 vaccines, public scepticism about the vaccines persists. [2] Vaccine opposition has existed for as long as vaccinations and, despite the public’s increasing scientific sophistication, has been growing across high-income countries, leading the WHO to list it in the top 10 global health threats in 2019. [3,4] In the UK, the covid-19 vaccination programme continues to gather pace, giving the UK a rare pandemic win; however, those prioritised for vaccination represent groups with low vaccine hesitancy rates. There have been many surveys assessing covid-19 vaccine hesitancy. Potentially affecting as many as one in three individuals in the UK, vaccine hesitancy is pervasive, especially amongst young adults and ethnic minorities, threatening to undermine the pandemic response. [5-7] To avoid disrupting the vaccination programme’s success, developing strategies that address vaccine scepticism is essential.

To dispel vaccine misinformation and myths, differentiating between the under-vaccinated, the anti-vaxxers, and the vaccine-hesitant is required. The vaccine-hesitant represent those who are uncertain about getting vaccinated, but remain open to it if they are convinced that vaccines are safe, effective, and necessary. In the vaccine-hesitant, it is essential to differentiate between vaccine-associated misinformation and mistrust.

A recent survey carried out by the Royal College of General Practitioners demonstrated that people of Black, Asian and mixed ethnic backgrounds are 53%, 36% and 67% less likely to have been vaccinated when compared to their white counterparts. [8] In the US, 32% of Black adults would definitely, or probably, get vaccinated if made available at no expense, compared to 52% of White adults. [9] While these communities are not ill-informed regarding their heightened risk of severe illness and death from covid-19, hesitancy in ethnic minorities remains disproportionately high. [9] Mistrust felt by this population is not irrational and must be addressed with respect. In addition to a history of systemic racism, which affects many Black people globally, the pandemic has allowed mistrust of covid-19 vaccines to thrive; as stated by the WHO, “racist remarks”, including French doctors suggesting Africa should be a testing ground for coronavirus, are not helpful and this “colonial mentality has to stop.” [10] In the UK, 90.6% of covid-19 vaccine recipients are white. [8] To avoid increasing the health inequalities that covid-19 has harshly exposed, engaging with vaccine-hesitant subgroups is required to increase knowledge levels, reduce perceived risks, and enable informed decision-making. Enhancing vaccine access and convenience will also improve support for vaccination. [11]

As real-time evidence continues to emerge, and mass vaccination campaigns approach vaccine-hesitant groups, culturally sensitive and tailored risk communication and messaging, co-involving faith and influential community leaders, are required to continuously inform, update, and reassure the public. [12] Covid-19 vaccines are unlikely to be made mandatory. Nudging individuals, through choice-offering strategies, incentivises vaccination, and aligns intention with actions. [13] Scientists proactively listening to concerns of subgroups and sharing risks and benefits in a manner that does not impose, but persuades, will improve voluntary cooperation. [13] As there are genuine concerns regarding their record-breaking timescales, alleviating uncertainties about vaccine safety and efficacy is essential. Communicating carefully that their development has followed the same legal requirements for pharmaceutical quality, safety, and efficacy as other medicines, and circulating accurate information including how advances in Ebola, whooping cough, rabies, human papillomavirus and hepatitis A and B vaccine technologies were leveraged for covid-19 vaccine development is important. [14,15]

The availability of online anti-vaccine narratives represents the leading cause of the rise in vaccine hesitancy; accessing these platforms for five to ten minutes increases the perception of risk of vaccines and reduces the perception of risk of refusing vaccines and intention to vaccinate. [16,17] While a number of the “next generation” covid-19 vaccines are based on sequence information, as opposed to “classical” virus- or protein-based vaccines, these vaccines are built on years of developments in infrastructure, knowledge and technical capacity. [18] Removing seeds of doubt requires filling information voids through carefully-designed health surveys, observational qualitative research and social media listening that avoid information overload and the unintentional generation of misinformation through, for example, multiple-choice questions that can lead respondents to misremember false responses as correct. [19,20] Additionally, addressing science-based uncertainty and reduced confidence in public health requires clear communication about the science and building trust through community outreach, respectively. [19]

Drugs, including vaccines in vials, remain useless unless people take them. The WHO’s 10-year Blue Nile Health Project, in Sudan, demonstrated limited success of mass drug administration and confirmed that a holistic and sustainable approach, inclusive of political commitment, community engagement and socioeconomic development, are all required for disease control. [21] The 2009-2010 H1N1 pandemic also demonstrated that vaccine communication efforts were a big challenge and increasing public compliance and confidence in governments and medical facilities depend on coordinated efforts. [22-23]

Vaccines stand at the crossroad between an individual’s decision to accept an intervention and the public health benefits achieved when uptake is sufficiently high. At a time when unity is crucial, additional strategies are required to reach diverse communities, build civic awareness, develop a sense of collective purpose and, ultimately, arm the population with the information needed to defeat covid-19, the latest vaccine-preventable disease we face.

Tasnime Osama, Honorary Clinical Research Fellow, Department of Primary Care & Public Health, Imperial College London

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London

This article was first published by BMJ Opinion.

References

1. Majeed A, Molokhia M. Vaccinating the UK against covid-19. BMJ. 2020; 371 :m4654. doi: https://doi.org/10.1136/bmj.m4654
2. Markovitz G, Russo A. Survey Shows Rising Vaccine Hesitancy Threatening COVID-19 Recovery. World Economic Forum. 2020. https://www.weforum.org/press/2020/11/survey-shows-rising-vaccine-hesitancy-threatening-covid-19-recovery/
3. Wolfe RM, Sharp LK. Anti-vaccinationists past and present. BMJ. 2002;325(7361):430-432. doi:10.1136/bmj.325.7361.430
4. World Health Organization. Ten threats to global health in 2019. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019
5. Savage M. One in three ‘unlikely to take Covid vaccine’. The Guardian. 2020. https://www.theguardian.com/world/2020/dec/06/one-in-three-unlikely-to-take-covid-vaccine
6. Office for National Statistics. Coronavirus (COVID-19) weekly insights: latest health indicators in England, 18 December 2020. 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19weeklyinsights/latesthealthindicatorsinengland18december2020#preventative-measures-and-vaccine-attitudes
7. Scientific Advisory Group for Emergencies. Factors influencing COVID-19 vaccine uptake among minority ethnic groups. 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/952716/s0979-factors-influencing-vaccine-uptake-minority-ethnic-groups.pdf
8. Royal College of General Practitioners. GPs call for high-profile campaign backed by faith leaders and prominent figures from BAME communities to increase COVID-19 vaccine uptake. 2021. https://www.rcgp.org.uk/about-us/news/2021/february/gps-call-for-high-profile-campaign-backed-by-faith-leaders.aspx
9. Tyson A, Johnson C, Funk C. U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. Pew Research Center. 2020. https://www.pewresearch.org/science/2020/09/17/u-s-public-now-divided-over-whether-to-get-covid-19-vaccine/
10. World Health Organization. COVID-19 virtual press conference – 6 April, 2020. 2020. https://www.who.int/docs/default-source/coronaviruse/transcripts/who-audio-emergencies-coronavirus-press-conference-full-06apr2020-final.pdf?sfvrsn=7753b813_2
11. Thomson A, Robinson K, Vallée-Tourangeau G. The 5As: A practical taxonomy for the determinants of vaccine uptake. Vaccine. 2016;34(8):1018–24. doi: https://doi.org/10.1016/j.vaccine.2015.11.065
12. UNICEF. Partnering with Religious Communities for Children. 2012. https://sites.unicef.org/about/partnerships/files/Partnering_with_Religious_Communities_for_Children_(UNICEF).pdf
13. Dubov A, Phung C. Nudges or mandates? The ethics of mandatory flu vaccination. Vol. 33, Vaccine. 2015;33(22):2530–5. doi: 10.1016/j.vaccine.2015.03.048
14. European Medicines Agency. COVID-19 vaccines: key facts. 2020. https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/treatments-vaccines/covid-19-vaccines-key-facts
15. Wellcome. What different types of Covid-19 vaccine are there? 2021. https://wellcome.org/news/what-different-types-covid-19-vaccine-are-there
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17. Betsch C, Renkewitz F, Betsch T, Ulshöfer C. The influence of vaccine-critical websites on perceiving vaccination risks. J Health Psychol. 2010;15(3):446–55. doi: 10.1177/1359105309353647
18. van Riel D, de Wit E. Next-generation vaccine platforms for COVID-19. Nat. Mater. 2020;19: 810–12. doi: https://doi.org/10.1038/s41563-020-0746-0
19. MacDonald NE, Dubé E, Greyston D D, Graham JE. Beware the public opinion survey’s contribution to misinformation and disinformation in the COVID-19 Pandemic. Canvax. 2020. https://canvax.ca/brief/beware-public-opinion-surveys-contribution-misinformation-and-disinformation-covid-19
20. Roediger HL, Marsh EJ. The positive and negative consequences of multiple-choice testing [Internet]. Vol. 31, J Exp Psychol Learn Mem Cogn. 2005;31:1155–59. doi: https://doi.org/10.1037/0278-7393.31.5.1155
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Read How can we address Covid-19 vaccine hesitancy and improve vaccine acceptance? in full

I was invited to join a meeting of the All-Party Parliamentary Group on Coronavirus earlier today when I was questioned on the implementation of the Covid-19 vaccination programme in the UK, vaccine hesitancy and how this can be addressed, and how we can ensure the programme is successfully completed.

The UK has made an excellent start to its Covid-19 vaccination programme and we should build on this success by supporting and investing in local primary care and pharmacy teams. The mass vaccination centres set up by NHS England may have a role but we must ensure that they do not divert staff, funding and vaccines from local vaccination centres run by primary care teams. Local centres can work flexibly and are more accessible for patients.

Finally, vaccine hesitancy is an important issue and we must work locally, as well as nationally, with the public and patients, to address this in the groups where it is highest – such as young adults, ethnic minorities, and people from poorer backgrounds.

Vdeo: https://www.pscp.tv/w/1BRKjBVaogvKw

Read All-Party Parliamentary Group on Coronavirus in full