The COVID-19 pandemic (caused by the SARS-CoV-2 virus) has led to more than 180 million infections and 4 million deaths worldwide (Dong et al, 2021). Since December 2020, effective vaccines have been available and deployed in the UK (NHS England, 2021). By 19 September 2021, a total of 77 510 471 doses of COVID-19 vaccine had been given in England. Over 37 million of these were second doses (Public Health England, 2021). This equates to 64.9% overall uptake for first dose and 59.5% for the second dose. Public Health England estimated that over 119 900 deaths and 24 million infections were prevented. Over 230 800 hospitalisations were averted.
In line with the programme rollout, coverage is highest in the oldest age groups. Over 95% of people aged 55 and older are fully vaccinated with two doses whilst uptake is 47.3% in 30–34 age group and 61% in 35-39 years (NHS England, 2021). COVID-19 vaccination was also seen to reduce onward transmission in a household by a third to a half where the confirmed case had been vaccinated with a single dose (Harris et al, 2021).
Without a doubt, the UK COVID-19 vaccination programme has been phenomenally successful. The vaccines have delivered on what they are supposed to do: prevent progression to severe disease, hospitalisation and death. An early decision to prioritise the rapid roll out of the first-dose protection against the alpha variant (with a 12-week prime boost interval between doses) across all priority groups meant that non-pharmaceutical interventions could be reduced earlier than we would otherwise have been able to do so (Keeling and Moore, 2021; Voysey et al, 2021; Whittles et al, 2021). However, there remains work to be done.
Are there storms ahead?
There are concerns that developed countries such as the UK have resorted to ‘vaccine nationalism’, that is stockpiling vaccines to prioritise rapid access for their citizens due to public or political pressure and fears of waning immunity (Wagner et al, 2021). The World Health Organisation has pointed out that such ‘vaccine nationalism’ means delayed access to vaccines in countries with low vaccine availability. This could lead to increases in transmission, thereby risking antigenic evolution of the virus and the emergence of novel variants and vaccine escape (Eaton, 2021). It is large outbreaks and widespread transmission of the virus that drives its mutation giving raise to new variants (English, 2021).
The emergence of the Delta variant brought into question the effectiveness of the vaccine. After a single dose there was an 14% absolute reduction in vaccine effectiveness against symptomatic disease with Delta compared to Alpha, and a smaller 10% reduction in effectiveness after 2 doses (NHS England, 2021). However, effectiveness against hospitalisation is equivalent (NHS England, 2021). Connected to this are the concerns around the potential waning of immunity at 6 months (Shrotri et al, 2021; Zoe, 2021). The JCVI advises that for the 2021 COVID-19 booster vaccine programme individuals who received vaccination in Phase 1 of the COVID-19 vaccination programme (priority groups 1 to 9) should be offered a third dose COVID-19 booster vaccine. This includes (JCVI, 2021):
- Those living in residential care homes for older adults
- All adults aged 50 years or over
- Frontline health and social care workers
- All those aged 16 to 49 years with underlying health conditions that put them at higher risk of severe COVID-19 (as set out in the green book), and adult carers
- Adult household contacts (aged 16 or over) of immunosuppressed individuals.
The JCVI are also looking into the safety of providing COVID-19 booster vaccination at the same time as the flu vaccine, which will greatly help with compliance and convenience for patients going forward. Focus on immunity waning detracts from COVID-19 vaccines protecting people from severe disease. Vaccinated individuals who contract the virus, have mild illness.
Variation in uptake
The overall high coverage rates in England mask the impact of health inequalities and inequities in accessing health services on uptake rates. There is variation between and among different demographic groups and geographical areas. At an England level, there is higher uptake in British white groups – 93.7% of those aged 50 and older are fully vaccinated – with the lowest uptake in Black minority groups – 61.8% for over 50s (Black Caribbean), 66.6% (Black African) and 64.9% (any other Black background) (NHS England, 2021).
Similar to other vaccination programmes, London performs at the bottom of the regions, with its uptake rates varying across the 32 different boroughs. The problem here is that communities or areas with low vaccination uptake are at risk of sustained transmission and if accompanied by waning immunity, there is a risk of antigenic evolution and new variant arising.
Younger people, women (particularly pregnant women), social media users, people living in deprived areas and ethnic minority groups are associated with low COVID-19 vaccination uptake in UK. In addition, people who have had past ‘flu vaccinations were more likely to have had the COVID-19 vaccines (NIHR, 2020). Despite provision of COVID-19 vaccinations through mass vaccination centres, mobile centres, roving provision (e.g. using a school bus or ice-cream van to deliver vaccinations) and provision by general practice and pharmacy, there remains inequities in access. Barriers include travelling costs to centres, difficulty getting time off work, location of centres and differing perceptions of ease of booking (Healthwatch, 2021).
Adults in black ethnic and Pakistani/Bangladeshi groups have been found to be significantly less likely to have received COVID-19 vaccines than other population groups (Robertson et al, 2021). There are myriad of reasons for this. Many barriers are similar to those of other immunisation programmes: low perceived risk of COVID-19, lack of confidence in vaccine safety and effectiveness and lack of information. Older generations, those with poor English language skills, not in secure housing and undocumented migrants are more susceptible to misinformation (Sherman et al, 2020). Studies have also found mistrust in government and health care services as contributing factors (Jennings et al, 2021) but equally there is evidence that health professionals remain the most trusted source of information about vaccinations.
‘The overall high coverage rates in England mask the impact of health inequalities and inequities in accessing health services on uptake rates. There is variation between and among different demographic groups and geographical areas.’
How can you help?
Check COVID-19 vaccination status at regular visits or routine touch points. Offer the vaccine or signpost the individual to where they can have the vaccine (e.g. at the GP practice, pharmacy, mobile unit or mass vaccination centre). You may need to devise and provide decision aids. However, taking the time to answer any questions your patients may have is crucial to helping them with vaccine acceptance. Having questions about vaccines is normal and it is worth taking the time to address them and can prevent them looking for the (wrong) information online. There are resources that can help you, such as https://campaignresources.phe.gov.uk/resources/ and https://www.immunology.org/coronavirus, which includes a resource on how to start a conversation about COVID-19 vaccine (see https://www.immunology.org/coronavirus/vaccine-engagement-starts-home). Finally, use the first dose as a reminder for the second dose and a reminder to follow recommended protective behaviours.