Tag: Vaccination

Defining the determinants of vaccine uptake and under-vaccination in migrant populations in Europe

Our new article in Lancet Infectious Diseases discusses why some migrants in Europe are at risk of under-immunisation and show lower vaccination uptake for routine and COVID-19 vaccines. Addressing this issue is critical if we are to address vaccination inequities and meet the goals of WHO’s new Immunisation Agenda 2030.

We carried out a systematic review exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of under-vaccination among migrants in the EU and European Economic Area, the UK, and Switzerland.

We identified multiple access barriers—including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals—for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines.

Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of under-vaccination in migrants, including African origin, recent migration, and being a refugee or asylum seeker.

We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants’ barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake.

These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

DOI: https://doi.org/10.1016/S1473-3099(22)00066-4

Why should I other getting a Covid-19 vaccine booster?

I have much bigger healthcare concerns than getting COVID-19, and the NHS doesn’t help me with them. Why should I bother to help them by getting this vaccine?

This is a question that some people often ask. By getting the Covid-19 vaccine, you are protecting yourself as well as reducing pressures on the NHS. Over 10 billion Covid-19 vaccines have been giving globally; and they have proven to be very safe and effective. The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill or dying from Covid-19.

By getting vaccinated against Covid-19, you are substantially reducing your risk of a serious illness that may lead to you requiring hospital treatment or even dying. Even if you don’t need hospital treatment, Covid-19 can still be an unpleasant illness that can make you unwell for a few weeks or leave you with long-term complications.

The risks from Covid-19 are particularly high in those who are over 50 years of age, obese or who have underlying medical problems such as diabetes or kidney disease. Vaccination reduces all these risks to you. Furthermore, if too many people remain unvaccinated, this will increase the likelihood of the government having to introduce measures to control the spread of Covid-19 and reduce pressures on the NHS. This could mean, for example, bringing in restrictions on people attending large, indoor gatherings – or closing pubs, night clubs and restaurants – like the measures we have seen at times over the last two years.

It could even lead to another lockdown if pressures on the NHS were very high. These measures have had a big impact on people’s social lives and mental health, as well as on the economy, and we don’t want to see them brought back.

Finally, many countries across the world are now requiring proof of vaccination for tourists and visitors. If you are not vaccinated, you will find it difficult to visit these countries, thereby limiting your leisure opportunities or the chance to meet friends and family living overseas. So by getting vaccinated, you are not only helping the NHS. You are also helping yourself.

A national vaccination service for the NHS in England

The Health Secretary, Sajid Javid, announced on 26 January that a ‘national vaccination service’ is required to provide mass covid-19 vaccination to the population of England.[1] Speaking at a House of Commons Health and Social Care Committee meeting, Mr Javid suggested the proposed service could cover other vaccines as well as vaccines for covid-19. The rationale is that NHS General Practice is under great strain, and by removing some services that can be provided elsewhere, it will free up time for primary care teams to concentrate on their core work.

Traditionally, mass vaccine programmes in England have relied largely on general practices, increasingly supported by community pharmacies in recent years. This was demonstrated to great effect during the first wave of covid-19 vaccinations where the majority of vaccines were delivered by primary care teams. GP teams have secure electronic patient record systems, and are experienced in cold storage chains, and have medical support on site, including resuscitation equipment. Patients often know and trust their family doctors, and generally respond better to recalls for vaccination when these come from their own general practices. A move towards mass vaccine centres and away from primary care delivery may explain some of the recent slow-down in England’s covid-19 vaccine programme.[2]

The public need to be fully informed about what a national vaccination service will mean for them individually as well as the NHS. The majority of all NHS contacts occur in general practice, with around one million contacts per day.[3] This means that vaccines can be offered opportunistically when patients are attending for other reasons as well as in dedicated vaccine clinics. It also allows primary care teams to have discussions about vaccination during these consultations in patients who have concerns or questions about vaccines, or who are vaccine hesitant.

When attending for vaccination, patients also have the opportunity to discuss other issues in their health with their primary care team and to benefit from opportunistic health promotion. All this helps to ensure that vaccination is viewed holistically and not just as a transactional activity. This is particularly important for children where non-attendance for vaccination can sometimes be a safeguarding issue which requires a sensitive approach from primary care teams, as well as effective inter-agency working.

When the Prime Minister, Boris Johnson, announced that he wanted all adults England to be offered a covid-19 vaccine before the end of 2021 he looked to GPs to help. As a result, GPs were asked to drop all non-essential work and focus on vaccination for the remainder of the year. This caused much debate in the national and medical press about what the priorities should be for the NHS and for primary care. Suspending “non-essential work” will have adverse effects on people’s experience of the NHS and risks worsening health outcomes, particularly for poorer groups.[4] It is clearly also a policy that cannot be sustained for long or repeated frequently (for example, for another covid-19 vaccine booster programme later this year).

The current plan to consider a separate national vaccination service for covid-19 and possibly other vaccinations seems to be an effort to ensure that GPs are not asked to stop routine medical care again. Although investment in the NHS is welcome, and removing some workload from general practice might have merits, there are some caveats that must be considered before a new national vaccination service is established.

Firstly, any new vaccination service must be more cost-effective than existing models of delivery of vaccines, such as through general practices and pharmacists. At a time when NHS budgets are under great pressure, NHS funding must be used cost-effectively and services delivered efficiently. A new national vaccination service would require substantial funding to establish and run. For example, it is difficult to see how a national vaccine service could run effectively without full access to patients’ electronic medical records. It would also require premises from which to operate, and staff to manage and deliver the programme. We need the government to show how this investment in a new service would compare in terms of cost-effectiveness with a similar investment in primary care teams.

Secondly, a national vaccination service must achieve a high uptake of vaccination. We currently have very good uptake of most childhood vaccines in England and in 2021-22, primary care teams also achieved a record uptake of flu vaccines, for an extended group of patients compared to previous years. Vaccinations must also be delivered quickly and at scale when in a pandemic, and there must be a safe and robust system to target high risk groups; such as those with frailty, long term conditions, the housebound, people living in care homes, and patients from marginalised groups.[5]

Thirdly, creating a separate vaccination service risks further fragmentation of primary care. As we have already seen with the covid-19 NHS 119 service, many patients will still contact their GPs about vaccination queries, even if this is no longer part of the NHS GP contract. This risks creating extra work for primary care teams that is not part of their core contract and for which they will not be paid; and will also be very frustrating for patients who will have to deal with more than one healthcare provider to have any issues they have about their vaccinations and how these vaccinations are recorded are dealt with. Finally, a newly established national vaccine service may recruit staff from primary care teams, both clinical and non-clinical, thereby further worsening the current shortages of staff in NHS primary care.[6]

The government must therefore carefully examine the merits of a separate national vaccination service; and any problems it may cause for existing services; including how it might affect vaccine uptake. Investing in and strengthening existing NHS primary care infrastructure in general practices and pharmacies may be a more cost effective option. Because of the importance of vaccination in allowing England to move to “living with covid-19”, vaccinations programmes must be implemented well and achieve a high take-up, particularly in the groups most at risk of serious illness, complications and death from infectious diseases such as covid-19. We cannot risk undermining the current vaccination systems that already work efficiently and cost-effectively in England’s NHS. Any proposals for a new national vaccination service must therefore be assessed with the same rigour we would with any new medical treatment with serious consideration of the risks as well as the benefits.

 A version of this article was first published in the British Medical Journal.

DOI: https://doi.org/10.1136/bmj.o338

References

  1. Health secretary proposes ‘national vaccination service’ to relieve GPs.https://www.pulsetoday.co.uk/news/breaking-news/health-secretary-proposes-national-vaccination-service-to-offload-gps/
  2. Where are we with covid-19 vaccination in the United Kingdom?https://blogs.bmj.com/bmj/2021/07/09/where-are-we-with-covid-19-vaccination-in-the-united-kingdom/
  3. Appointments in General Practice.https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice–weekly-mi/current
  4. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.
  5. Covid-19 vaccines: patients left confused over rollout of third primary doses.https://blogs.bmj.com/bmj/2021/10/15/covid-19-vaccines-patients-left-confused-over-rollout-of-third-primary-doses/
  6. Oliver D. Act on workforce gaps, or the NHS will never recover BMJ 2022; 376:n3139

Boosting the nation against covid-19: are the vaccination targets feasible?

With the number of covid-19 cases from the Omicron SARS-CoV-2 variant rising exponentially in the UK, Boris Johnson, the prime minister addressed the nation on 12 December 2021, announcing a target to deliver a booster covid-19 vaccine to all eligible adults in England by the end of December. The devolved governments in Wales, Scotland, and Northern Ireland are expected to set similar targets. This extremely ambitious target will involve delivering over one million covid-19 vaccines per day in England over the next couple of weeks. So far, 81.3% of adults have received two vaccine doses in England, but despite this the covid-19 alert system in England moved from 3 to 4 as a result of the large increase in daily case rates and the concerns that the latest variant is overwhelming the NHS.12 In response, the Joint Committee on Vaccination and Immunisation has recommended reducing the time between second doses and boosters from six months to three months, rendering 14 million more individuals eligible for boosters.34 Across the NHS, staff are once again having to rapidly mobilise to ensure that as many people are vaccinated as quickly and as safely as possible, while not compromising other important areas of healthcare.

The UK’s initial vaccination programme was world leading, but then faltered mid-2021, before picking up speed again more recently.5 The covid-19 vaccination programme is delivered in multiple venues, including mass vaccine centres, schools, and workplaces, but the majority of vaccines are still administered in primary care, placing additional pressure on already overstretched GP and community pharmacy teams. There is a well documented GP crisis: falling numbers of GPs are failing to keep up with population growth and the increase in primary care workload, leading to fewer physicians caring for more patients in a chronically underfunded primary care system.6 7 This has led to increased waiting times and access issues, with a knock-on effect on hospitals at a time when there are also shortages of other key NHS professionals in secondary care.8 With a rising number of Omicron cases requiring further medical care, more resources are urgently required to safely manage this ambitious booster campaign, along with ongoing core NHS work and the usual winter demands. NHS England and the British Medical Association have agreed some pragmatic changes to focus on essential work and deprioritise some of the bureaucracy that has limited patient benefit.9

Despite the proposed acceleration of the booster rollout, frontline NHS staff were not given advance notice and GPs are yet to be informed about key details, including when they should expect deliveries of vaccines. To ensure efficient ramping up of the vaccination programme, the UK’s chief medical officers have agreed to temporarily waive the 15 minute wait policy as the majority of adverse reactions occur in the first two minutes following vaccinations, with case rates of 4.7 per million vaccinations reported for anaphylaxis.10 11

The success of the covid-19 vaccination programme has required essential healthcare services to be compromised. The pandemic has exacerbated already existing challenges in the NHS, further compounding a severe backlog for specialist care, which has now reached six million, and will take many years to resolve.12 While the public health benefits of covid-19 vaccinations are clear, specific groups remain disadvantaged by mass vaccination. Some have argued that the suspension of services, including urgent and elective surgical services, may require more equitable decision-making processes as they may not be in line with the four pillars of medical ethics: beneficence, non-maleficence, autonomy, and justice.13 With the booster rollout now escalated, primary care teams are having to increase vaccination uptake without recommendations set out to address patient’s concerns, and alleviate the impact this may have on other healthcare services.

The UK is well placed to deliver large scale vaccination programmes, with all four devolved nations achieving some of Europe’s highest vaccination rates pre-pandemic.11 Appropriate and timely government planning and preparation are still needed to mitigate the risks, including economic decline and additional lockdowns, and to prevent exacerbating the impact observed across non-covid-19 healthcare services. For several months, the government ignored warnings from experts requesting an urgent move to “Plan B,” and requests to mandate standard public health measures, including mask wearing, ventilation measures (i.e. installing air filtration devices in schools), working from home, lateral flow testing before social events, and physical distancing. These have become the norm in the other three UK nations and in many European countries. The government also ignored calls to establish a sustainable, cost-effective system for covid-19 vaccination that could respond rapidly to any new demands, including the requirement for booster vaccinations.5 At this critical time, it is essential that the government invests in the systems that it relies on so heavily and that it adapts its covid-19 roadmap accordingly.

We have seen an “unimaginable” £37 billion squandered on test-and-trace—much of it on private consultants—and highly criticised by the government’s own watchdog.14 The booster rollout can showcase the power and flexibility of UK’s primary care system—but not immediately; it must be planned effectively by local NHS teams and the government. The number of booster doses will increase gradually albeit not at the rate the government hopes, and boosters take two weeks to be fully effective. We must hope that what we can achieve with boosters in the coming weeks will be sufficient to limit the impact of Omicron on public health, attenuate NHS pressures, and prevent the introduction of more severe measures.

Tasnime Osama, honorary clinical research fellow,  Simon Hodes, NHS GP partner,  Mohammad S Razai, NIHR in-practice fellow in primary care,  Azeem Majeed, professor of primary care and public health

A version of this article was first published in the British Medical Journal.

 

Covid-19 booster vaccination questions answered

When am I allowed to have my booster?

You can have your booster Covid-19 vaccine once you are three months past your second vaccine dose. The gap was previously six months but has now been reduced.

Who is eligible for a booster?

Anyone aged 18 and over is now eligible for a booster. People aged 16-17 with underlying health conditions that put them at higher risk of severe Covid-19 are also eligible for a booster. The NHS will aim to vaccinate people in order of clinical priority.

Can I have a booster if I’ve never been vaccinated?

You can’t have a booster until you are three months past your second Covid-19 vaccination. If you have not been vaccinated, you will need to have your first two vaccine doses eight week apart and then get your booster three months after your second dose People who are not vaccinated are at much greater risk of a serious Covid-19 illness, hospitalisation and death. So please do come forwards for vaccination if you are currently unvaccinated.

Does anything stop me from receiving a booster? (e.g., you need to wait if you’ve have Covid recently or received a flu jab)

If you have recently had another vaccine (e.g., flu) and your Covid-19 vaccine booster is due, you should still go ahead with this rather than delay your booster. Getting your booster promptly means that there is then not a delay in getting further protection from the booster. The only exception to this is the shingles vaccine, where a seven day interval should be observed between the vaccines.

Are booster jabs safe for everyone?

Research has shown that Covid-19 vaccines, including boosters, are very safe with only a very small risk of serious side-effects. The risks from a Covid-19 infection are far higher than from vaccination.

Why are boosters all of a sudden more urgent?

The immunity provided by Covid-19 vaccines begins to weaken after a few months. A booster vaccine substantially increase people’s protection from serious illness. Another reason why boosters have become more important is that the UK is now facing a wave of infection from a new Coronavirus variant, Omicron, which is more infectious than the previous Delta variant. Two doses of vaccines work less well against Omicron than Delta. A booster dose will provide a lot more protection against Omicron than provided by two doses. Ensuring that people receive a booster dose will reduce the number of people who are seriously from Covid-19, and keep down deaths and pressures on the NHS.

Can pregnant women have boosters?

Pregnant women are eligible for boosters and should get one when this is due. The vaccines being used for boosters have been shown to be safe during pregnancy for both the mother and baby.

Where can I get my Covid booster?

Boosters are available from a range of sites. This includes NHS vaccine centres, GP surgeries and pharmacies. You will need to check where the sites are in your local area as not all hospitals, pharmacies and GP surgeries are offering boosters.

Do I need to book or can I go to walk-in centre?

In the past, it was possible to go to a walk-in centre for a Covid-19 vaccination. However, because of the very high demand that there will now be for boosters, you may find that there is a very long queue or that you are turned away if you attend without an appointment.

What advice would you give to someone who is hesitant about the booster?

Covid-19 is a very serious illness. Vaccines are a safe way to protect yourself from these risks. By getting vaccinated, you are also helping to protect others – such as older family members or family members who are clinically vulnerable because of their medical problems. Vaccines have been fully tested and were shown to be safe and effective in clinical trials before they went into general use. We have now given many billions of vaccine doses globally, so we have excellent data in their safety and effectiveness from countries across the world.

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

The JCVI is recommending booster Covid-19 vaccines for all adults – why is this essential for the UK’s pandemic response?

The NHS is now rolling out booster doses of Covid-19 vaccines. Today, the JCVI recommended that all adults in the UK should receive a booster. Why do we need these boosters?

The number of Covid-19 cases in the UK is currently around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than many of our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from the UK and elsewhere shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily. There also needs to be sufficient capacity in the vaccination programme to allow as many people as possible to be vaccinated before Christmas.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 40 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. The NHS will now be extending the booster programme to all adults based on the advice issued today by the JCVI.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further infection control measures. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like Omicron may spread further and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

Covid-19 vaccine boosters: Why they are important

The NHS is now rolling out booster doses of Covid-19 vaccines. Why do we need these boosters and who can receive them?

The number of Covid-19 cases in the UK is around 40,000 per day. This is amongst the highest rate of infection of any country in the world and higher than all our Western European neighbours. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill. However, some of these infections will still lead to a serious illness and death, even in people who have received two doses of a Covid-19 vaccine as no vaccine is 100% effective.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in those people with weak immune systems. Research from other countries shows that a booster (third) dose of a vaccine improves your immunity to Covid-19 and reduces your risk of a serious illness that may lead to hospitalisation or death. Some people with medical conditions or who are taking drugs that weaken their immune system will need four doses of vaccine to give them maximum protection.

The rollout of the NHS booster programme has been slower than we would have liked. We want as many people as possible to receive boosters before the onset of winter when pressures on the NHS increase. Because most Covid-19 restrictions in England ended in July, many people may think the pandemic is largely over and so do not think they need another vaccination. Some people may also lack confidence in vaccines or be concerned about side effects. Others may be struggling to get an appointment at a vaccine clinic that is convenient for them to attend.

To help people get their booster vaccines, the NHS needs to make it as easy as possible for people to book and attend their appointments. The NHS can do this by ensuring there are local sites offering boosters so that people don’t have to travel far to get one. The sites also need to have convenient opening hours (such as being open in the evenings and at weekends) that allow people who are working to attend easily.

It’s also important for the NHS to explain clearly why we need boosters, and remind people about the safety and effectiveness of vaccines. We now have data from many millions of people across the world to show how well Covid-19 vaccines work and how safe they are. The UK has led the world on much of this research thanks to the data collected by our NHS.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with medical conditions that put them at higher risk. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters.

If people don’t attend for their boosters, they will increase their risk of catching Covid-19 and having a more serious illness. This will lead to more cases of Covid-19 and increased pressures on the NHS during the winter. The number of deaths from Covid-19 will also increase.

This then may require the government to bring back some Covid-19 restrictions; and if the situation gets very bad, it may require a further lockdown. This is something we want to avoid because of all the problems that lockdowns cause. We all want a more normal way of life and don’t wish to see a repeat of last year when Christmas gatherings were not possible because of the Covid-19 rules that were in place at the time.

A high take-up of boosters will also reduce the chances of new virus mutations from developing. This year, we have seen the rapid spread of the delta variant of the SARS-CoV-2 virus across the world, including in the UK. Recently, a new version of the delta variant, the AY.4.2 subvariant, has been detected in the UK. This variant is causing concern because it may be more infectious than the original delta variant.

The good news is that our vaccines continue to work well against new virus variants when people are fully vaccinated. If, however, people are not fully protected by vaccination, new variants like AY.4.2 may spread and eventually lead to other variants arising against which current vaccines are less effective.

Covid-19 vaccines are safe and very effective. By getting a booster, you are protecting yourself and the other people you live and work with. You are also reducing the need for the government to introduce new Covid-19 restrictions this winter. So please go out and get your booster vaccine as soon as you can.

A version of this article was first published in The Sun.

On 15 November 2021, the JCVI announced that people aged 40-49 would also be eligible for booster doses of a Covid-19 vaccine.

Why you should get your Covid-19 booster and flu vaccine

The NHS is now rolling out booster doses of Covid-19 vaccines and flu jabs.

The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill.

However, no vaccine is 100% effective. Some Covid-19 infections will still lead to a serious illness, even in people who have received two doses of vaccine. Flu will also be a threat this winter.

We know that the protection provided by Covid-19 vaccines can weaken over time – particularly in the elderly or in people with medical problems. A booster (third) dose of a vaccine improves your immunity and reduces your risk of a serious illness.

We want as many people as possible to receive Covid-19 boosters and flu jabs before the onset of winter when pressures on the NHS increase.

The people being targeted for boosters are those at highest risk of serious illness and death from a Covid-19 infection. This includes people aged 50 and over, and people under 50 with certain medical conditions. NHS staff, people who live and work in care homes, and people who are the main carer of someone at high-risk are also being invited for boosters. These groups are also eligible for a flu jab.

If people don’t attend for their vaccinations this will lead to more cases of Covid-19 and flu, and increased pressures on the NHS during the winter. The number of deaths will also increase. This then may require the government to bring back some Covid-19 restrictions.

By getting a Covid-19 booster and a flu jab, you are protecting yourself and the other people you live and work with. So please go out and get your vaccinations as soon as you can.

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

Setting up a Covid-19 vaccination programme for immunocompromised patients

On 1st September 2021 the JCVI  recommended that certain patients aged 12 and over, who were thought to be immuno-suppressed (through disease or medication) around the time of their first two doses of Covid-19 vaccine, should be offered a third primary dose 8 weeks after their second dose. There has been considerable confusion about these third primary doses as they are different from the booster doses that many people who are now over 6 months after their second dose are being offered. Many patients have reported they have been unable to obtain their third primary dose; or have only obtained after a lengthy dialogue with NHS clinicians and managers.

Here are the steps that could be followed to safely implement the third primary vaccine dose programme for immunocompromised patients in England’s NHS.

  1. Identify your target population. This is an essential first step in any vaccination programme (or in any public health programme). Identifying the target population requires searching NHS medical records held by hospitals and general practices.
  2. Clinical diagnoses (such as renal transplant) have to be turned into lists of clinical codes. This requires collaboration between hospital doctors, GPs, other health professionals and health informatics specialists to produce the code lists based on the ICD-10, SNOMED and Read clinical codes that are used by NHS organisations.
  3. Patients need to be identified who were prescribed medications around the time of their first two doses of Covid-19 vaccine that have been identified by the JCVI and specialist groups as possibly leading to a weaker response to their vaccinations. This might not be possible for GPs to do if they did not prescribe the medication themselves as is the case for many specialised drugs used for these patients.
  4. There needs to be adequate consultation with organisation such as NHS Digital, general practices, primary care networks, specialist medical societies, and patient organisations (for example, Versus Arthritis, Blood Cancer UK, Crohn’s & Colitis UK and Kidney Care UK amongst others).
  5. Once an agreed form of words and a unified approach have been reached, there should be a clear public health announcement via reputable sources, and NHS web pages available with clear easy to understand information and FAQs for clinicians, patient support organisations and the public. Clinicians and their teams should ideally be made aware of any announcements from NHS England before the public so that they are able to answer queries from patients, parents and carers.
  6. Those working at NHS 119, vaccine sites or the national covid-19 vaccine call centres must be fully briefed and updated on significant changes before any announcements are made, so that patients calling with queries or to book their Third Primary Doses are not met with a confused response and a lack of a clear process on how to access their vaccines (which damages public trust and confidence, and increases vaccine hesitancy).
  7. Programmes that use clinical codes to search NHS medical records have to be written. These require testing and debugging to make sure they work correctly on each different clinical record system used by the NHS. The NHS does not have a unified electronic medical record system and individual NHS Trusts and general practices will have different systems. These programmes need to be written centrally wherever possible to prevent local areas producing their own versions that may differ from each other and thus not identify patients correctly. This is more straightforward for general practices than hospitals because most general practices mainly use of one two electronic medical record systems (EMIS or SystmOne). The situation is more complex in NHS hospitals because of the many different IT systems used.
  8. Once the programmes are written, they need to be run by local NHS teams as it seems that NHS England is not yet able to run these searches centrally for all of England. In the case of general practices, local CCGs or GP Federations should be able to run the searches to identify patients. Hospitals will also need to run searches to identify eligible patients. The NHS should also make use of National Disease Registers, such as the NHS Blood and Transplant registry, for patient identification wherever possible.
  9. The list of patients generated by the programmes have to be cleaned to remove duplicates and any patients identified in error. Patients who may be unsuitable for vaccination such as the extremely frail or terminally ill need to be removed from the lists. Local NHS teams also need to consider how they approach patients who may have previously refused vaccination.
  10. Patients then need to be contacted about the vaccinations. Most general practices are no longer involved in the Covid-19 vaccination programme. These invitations therefore need to come from organisations that are offering Covid-19 vaccines. This might include hospital clinics, NHS vaccine centres, or GP-led vaccine hubs in areas where GPs are still offering Covid-19 vaccines.
  11. IT systems that record Covid-19 vaccinations (such as Pinnacle) need to be able to record the third primary dose correctly; so that it is not recorded as a standard booster dose or as another first or second dose. This ensures the patient’s vaccination status is accurate, that audits can be done accurately and that recalls can be generated for a booster in 6 months. Details of the vaccination also needs to be uploaded correctly into the patients’ usual electronic health record.
  12. The NHS app needs to correctly display that this is indeed a third primary dose, and that the patient is fully vaccinated; and IT systems need to ensure that the patients can then also be invited for their booster dose (effectively, a fourth vaccine dose for this special group of patients) in due course (typically likely to be six months after the third primary dose). A system for recording vaccines given abroad should also be made available.
  13. Please remember that in most parts of England, your general practice cannot offer you a Covid-19 vaccine or book you an appointment for one. In these circumstances, NHS 119 or your local NHS Covid-19 vaccine centre need to do this. To make access to vaccinations easier for patients, the NHS should ensure that a large number of locations are offering vaccinations so that patients can receive these close to home and do not have to travel long distances. Arrangements for vaccination also need to be made for the residents of care homes and for people who are housebound.
  14. NHS medical records are not always accurate or up to date. Each local area needs to have a named person who patients can contact if they feel they have been missed off the list incorrectly; or to help patients who continue to have any difficulties booking appointments.
  15. In order to provide a booster (fourth) dose for this group after six months, around April 2022, NHS IT systems need to be accurate and record third primary doses correctly and not as booster doses. This will ensure that this vulnerable group of patients do not experience further difficulties or delays in booking these appointments.

All these steps could have been better planned and communicated by NHS England; which would have made the process clearer for frontline NHS staff; as well as making it easier and less stressful for patients to receive their third primary Covid-19 vaccine dose. A well-planned and implemented vaccine programme maintains confidence in the vaccine programme which may reduce vaccine hesitancy, and helps patients and clinicians alike, improving vaccine uptake and reducing pressures on the NHS. It is essential that the problems experienced by immunocompromised patients in accessing their third primary Covid-19 vaccine doses are not repeated, appropriate lessons learned and steps taken by NHS England to ensure accurate recording of vaccinations and recall for future vaccinations for our most vulnerable patients.

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

Simon Hodes, NHS GP Partner, Watford, UK and private general practitioner at the Cleveland Clinic London.

Fiona Loud, Policy Director, Kidney Care UK, Twitter

Liz Lightstone, Professor of Renal Medicine, Imperial College London, Twitter

This article was first published in BMJ Opinion.

Covid-19 vaccines: patients left confused over rollout of third primary doses

How a society treats its most vulnerable is always the measure of its humanity is a well-known quote often attributed to Mahatma Gandhi. With the “levelling up” agenda being quoted widely by the UK government, and the effects of pre-existing health inequalities never more exposed than by the covid-19 pandemic, we all need to focus on the health of the most vulnerable in society. Our highest risk patients, and their household members, were rightly prioritised for covid-19 vaccination at the start of the rollout programme in December 2020.

Early in the pandemic, the UK government recognised that certain patients with complex medical conditions, or who were immuno-suppressed through disease or medication, would be most at risk from the complications of covid-19. These patients were advised to take careful infection control precautions, and were classed as clinically extremely vulnerable” (CEV). Among the advice given to them was to “shield” and to facilitate this, they were added to a “Shielding Patients List” (SPL) at their GP practices. Despite GP practices having robust disease registers and arranging seasonal flu vaccine recalls annually for mostly similar patients, NHS England decided to create centrally generated lists for CEV, and sent out letters to these patients.

Unfortunately, NHS Digital wrote to many patients who probably should not have been included as CEV (for example those with a history of glandular fever; or with long resolved and fully treated cancers in full remission), and also failed to include many patients who should have been classed as CEV. At the time, a survey by Pulse reported that after assessing the list of shielded patients provided by NHS England, on average practices had to remove 30 patients from the list, while adding 53 patients who had been missed off.

GP teams nationwide spent many hours scrutinising these lists, using their electronic notes, disease registers, and personal patient knowledge. The list of CEV patients needed to be as accurate as possible to try to ensure that the most vulnerable were protected, pending the arrival of covid-19 vaccines.

The importance of the accuracy of these lists cannot be overemphasised. These patients were offered extra support from the government, and local volunteers such as regular check-up calls from social prescribers at GP practices and both the patients and their household members were prioritised for vaccines. The social and mental health impact of shielding has also been noted in practice and widely reported. When the Joint Committee on Vaccination and Immunisation (JCVI) announced the hierarchy of priority groups for vaccination, there was much debate about how high up the priority list CEV patients should be, with many surprised that they were left to be sixth in line, with priority for vaccination largely being determined by factors such as residential setting, health and social care occupation, and age.

We are now offering covid-19 vaccine boosters for many people who are over six months after their second dose. The JCVI also announced on 1 September 2021 that certain patients aged 12 and over, who were immuno-suppressed (through disease or medication) around the time of their first two doses, should be offered a third primary dose after eight weeks from their second dose. Once again, as seems to be a recurring theme throughout the pandemic, this process has been poorly announced with the media reporting it before healthcare professionals were instructed about the process; and without a clear plan for implementing the programme.

Our most vulnerable and naturally anxious patients are confused about who should be recalling them for a third primary dose, whether or not they will be given a booster (in effect their fourth vaccine) six months later, and where to access their vaccines. Kidney Care UK for example has been deluged with enquiries from patients, many of whom have tried calling the national NHS 119 helpline to find that the staff there are often unaware of the process for arranging third primary doses. Although the JCVI wrote to specialists on 2 September 2021, it clearly takes time to review notes, run searches, and contact patients, with many patients now contacting their GP practices for support and advice. Furthermore, many of these immune-suppressed patients may receive their medication from hospital clinics, and thus might not easily show up on medication searches in their general practices.

To add further complications, the software used (called Pinnacle) to record covid-19 vaccines is not yet able to recognise a third primary dose, so they are currently being recorded as boosters, which is technically not correct. This will make any audits of vaccine uptake in this group extremely challenging, and may cause confusion in the future. In addition, patients are reporting that their third primary doses are not displayed correctly on their NHS app, presumably for the same reason. Once again, this highlights the need for joined up thinking before rolling out plans. It is worth noting that GPs add seasonal flu vaccines on our fully electronic patient records (which are later uploaded to Pinnacle), but the covid vaccines have to be added on Pinnacle only (which is later uploaded to GP-held electronic medical records and the NHS app). This is the reverse of what we would expect and is once again an example of NHS staff being forced to adapt to IT systems rather than the IT systems being designed to support NHS staff in their day-to-day work.

The government must look at how they communicate with both the public and professionals to ensure that our ongoing covid-19 vaccination programme is fit for purpose, and maintains the trust of the public to ensure high take up and prevent vaccine hesitancy. Unfortunately, after a promising start, the UK has slipped down the covid-19 vaccination league tables, and we are becoming an international covid-19 hotspot because of our high infection rates. The covid-19 vaccination programme has allowed us to come out of lockdown, and its ongoing success will depend on public confidence and effective messaging from the centre. As we enter the winter, with many other non covid-19 seasonal infections already in circulation, it is crucial that we try to protect our most vulnerable in society by making our vaccination programme as easy as possible for patients to access and navigate.

Simon Hodes, GP Partner Watford, Twitter: @DrSimonHodes

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

This article was first published in BMJ Opinion.