On 11 March 2020, Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization (WHO) declared that COVID-19 could be characterised as a pandemic. This was due to the rapid increase in the number of cases outside China within two weeks, spreading through a growing number of countries (WHO, 2020a). This was followed by an announcement on 23 March 2020 from the UK Prime Minster that a national lockdown would commence, the easing of which began in June 2020 (Prime Minister's Office, 2020). The COVID-19 pandemic placed enormous stress on the NHS and, similar to other European countries, health services had to reorganise (Tanne et al, 2020). Chronic and non-urgent care in hospital was suspended to increase the capacity of emergency and respiratory care. In primary care, changes in practice management and consultation strategies had to be quickly adapted. Remote triaging and delivering telephone and video consultations were adopted as the default position. Practices had to identify and prioritise support for the clinically extremely vulnerable, who were shielding, and for care home cohorts. They had to reorganise face-to-face consultations to minimise risk to themselves and to their patients using designated teams and facilities or premises (NHS England and NHS Improvement, 2020a; 2020b). All practices were expected to comply with Public Health England's (PHE) guidance on social distancing and infection control (PHE, 2020a). Studies showed that patients were consulting less frequently for health problems other than COVID-19, and there were concerns about the long-term implications for chronic care, psychological and socioeconomic wellbeing, and vulnerable people (Verhoeven et al, 2020; Losada-Baltar et al, 2020; Chung et al, 2020).
Good coverage of immunisations is crucial to prevent outbreaks of vaccine-preventable diseases that could further increase the number of patients requiring health services
Declines in immunisation rates
Delivery of the national immunisation programmes in general practice did not cease. Good coverage of immunisations is crucial to prevent outbreaks of vaccine-preventable diseases (such as pertussis and measles) that could further increase the number of patients requiring health services. Moreover, vaccinations are needed to prevent the development of meningococcal meningitis, pneumococcal pneumonia and to protect against other diseases like rotavirus and tetanus. However, declines were noticed in the uptake of childhood immunisations across the country. Nationally, MMR vaccination counts fell from February 2020 and were 19.8% lower in the 3 weeks after the introduction of social distancing measures than the same period in 2019 (McDonald et al, 2020). However, these figures only included data extracted from one system provider for general practice (SystmOne) and there were regional variations, with greater falls in the more urban areas of Manchester, London and Yorkshire. In London, 25% fewer infants had their 2, 3 and 4 month vaccinations on time in April 2020 compared to April 2019 and there was a 20% drop for MMR first dose at 12 months (NHS England, 2020a). These drops are consistent with those seen in other countries. In the USA, uptake rates started declining a week after COVID-19 was declared as a national emergency, with declines also observed in the orders for vaccines (Santoli et al, 2020). The WHO estimates that vaccinations have been disrupted in 68 countries with at least 80 million infants affected worldwide (Joseph, 2020).
Dropping immunisation rates are concerning. In the UK, national coverage rates were already falling, and 86.4% of 5 year olds had completed their routine childhood immunisation schedule in 2019 (NHS Digital, 2019). This is below the recommended WHO 95% level, which is needed to provide herd immunity. The UK's children and their communities are facing risks of outbreaks of vaccine-preventable diseases. This is especially so as the social distancing requirements are relaxed. Compliance with the ‘stay at home’ messaging and parental fears about potentially exposing their children to COVID-19 by visiting general practice have been observed as contributory factors. There were also concerns about overburdening the NHS (Saxena et al, 2020). In May 2020, NHS England and PHE developed social media imagery to help encourage the public to attend vaccinations by emphasising that it was a medical appointment and that they could attend (NHS England, 2020b). General practices across the country have modified their vaccination services to ensure social distancing and introduced personal protective equipment (PPE) and hygiene measures. Many have introduced innovative ways of delivering childhood immunisation services safely, such as drive-in vaccine clinics to reduce face-to-face contact with parents (Hussain, 2020).
The purpose of this article is to share some of the principles that practices have adapted. It is not intended to be prescriptive, merely to illustrate what the London-based Screening and Immunisation team have learned from our colleagues on the frontline. This has been gleaned from consultation with clinical colleagues across PHE, NHS England, the Royal College of General Practitioners and the Royal College of Nursing, as well as frontline practice staff (NHS, 2020a). We also commissioned a series of training webinars for the 1248 practices across London, which were well attended and through which some fantastic ideas and practical advice were shared.
Delivering vaccinations during the ‘New Normal’
It is important to sustain on-time routine immunisations to prevent a resurgence of vaccine-preventable diseases. NHS England/Improvement and PHE have published clinical guidance on how to maintain immunisation programmes through COVID-19 (PHE, 2020b). This can be read in conjunction with the NHS Standard Operating Procedures for General Practice (NHS, 2020b) and the guidance from the Royal College of Nursing (2020).
There is a consensus that vaccination appointments need to be booked in advance and spaced out. This timing enables cleaning between patients and to ensure social distancing. Many practices have introduced one-way patient flow through their premises and reserve one room for vaccination that is well-ventilated and/or use rooms that can be accessed separately to the main entrance to the reception area. Some practices deliver vaccinations in a single appointment with other face-to-face contact (e.g. the baby's 6 to 8 week check). This reduces the number of visits for a family and the cleaning requirements for the practice. Practices across the country have produced alternative models of delivery such as ‘drive through’ models with babies vaccinated in their parents' cars or in their buggies. Others have opted for a gazebo in their outdoor space or used an alternative local venue. With any proposed model of delivery, a risk assessment should be undertaken before any model is implemented. It is important that the vaccinations are given as safely as possible with minimised risk to child, parent and health care worker.
Vaccination appointments can be divided up into three components—the pre-appointment, the appointment and the post-appointment. The pre-appointment has emerged as a crucial component of the vaccination appointment in the ‘new normal’. This consists of more than patient searches and patient invites and reminders. It incorporates communications with parents on how the risk of COVID-19 is being mitigated at the practice to encourage attendance. This can be done by text, letter or phone call. Having a telephone consultation with the parents or guardians prior to the appointment is a great way to complete the pre-immunisation discussion, discuss consent and give post-immunisation advice. This will reduce the face-to-face time of the appointment itself. It also enables the vaccinator to acknowledge the parent's or guardian's concerns around exposure to COVID-19 when attending for immunisations and communicate about the extra precautions and procedures that have been implemented to keep them safe, including if they need to attend a different venue. A risk assessment of whether they have COVID-19 symptoms should be made and it is a good opportunity to address any questions about the immunisations. This is important as health professionals remain the most influential and trusted source of information about vaccinations (Freed et al, 2011).
With most of the work done prior to the appointment, the appointment itself can be operated to observe social distancing and infection control guidance, including PPE (PHE, 2020c). If possible, it is a good idea to restrict the room occupancy to one child and one accompanying parent or guardian (or it could be a parent with accompanying siblings). Patient contact can be defined as being within 2 metres and the vaccination can be done side on to reduce face-to-face exposure. Another risk assessment of COVID-19 symptoms should be done at the appointment.
Post-appointment, the vaccination details are input onto the data management system for the child's practice and if provided, the details can be put into the Redbook. Parents can document vaccines in the Redbook themselves after the appointment. The environment is cleaned and preparations made for the next patient.
Conclusion
As the COVID-19 pandemic continues, vaccination services will continually need to adapt. The looming ‘flu season and potential second wave of COVID-19 will also bring additional pressures to general practice. Therefore, there is an urgency to get as many children up-to-date with their childhood immunisations as possible before September. WHO (2020b) recommend strategies to track and follow-up with individuals who missed vaccinations, assess immunity gaps and re-establish community demand. This, they state, will require innovation and creativity.
However, the occurrence of COVID-19 is not completely restrictive. It may help to improve the quality of vaccination services. Vaccine uptake in general practice is highest when practices have systems to ensure robust call and recall, and parents feel safe (Williams et al, 2011). Due to COVID-19, there are opportunities to further develop general practices' usage of technology to embed automatic patient invites and reminders. There is evidence that parents and guardians generally find it difficult to know which vaccination information source to trust and highly value a discussion with a health professional (Ames et al, 2017). The pre-appointment consultation provides a good opportunity to develop that parent–professional relationship and address any questions that parents or guardians may have. This helps to reduce vaccine hesitancy and in turn improves compliance with vaccinations. It is completely possible that because of COVID-19 we not only end up with new models of delivery but with better and more sustainable options.