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COVID-19 vaccination: what's next

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Vaccination The rollout of the vaccine was the Government’s top priority when combatting COVID-19

The COVID-19 pandemic (caused by the SARS-CoV-2 virus) has led to more than 180 million infections and 4 million deaths worldwide.1 Since December 2020, effective vaccines have been available and deployed in the UK.2 By 12th August 2021, a total of 70,942,841 doses of COVID-19 vaccine had been given in England. Almost 32 million of these were second doses.3 This equates to 63.9% overall uptake for first dose and 55.9% for the second dose. Public Health England estimated that 105,900 deaths and 24,088,000 infections were prevented up to 20th August 2021. Over 82,100 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.2 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.4

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.5,6,7 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.8 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.9 It is large outbreaks and widespread transmission of the virus that drives its mutation giving raise to new variants.10

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.2 However, effectiveness against hospitalisation is equivalent.2 Connected to this are the concerns around the potential waning of immunity at 6 months.11,12 At time of writing, we are still waiting the definitive word on whether a booster programme will be offered this winter. However, the Joint Vaccination and Immunisation Committee (JCVI) have issued interim advice on which groups of people should be prioritised should a booster programme be required.13 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).2 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.14 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.15

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.16 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.17 Studies have also found mistrust in government and health care services as contributing factors18 but equally there is evidence that health care professionals remain the most trusted source of information about vaccinations.

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 Connect on Coronavirus | British Society for Immunology, which includes a resource on how to start a conversation about COVID-19 vaccine (see Vaccine engagement starts at home | British Society for Immunology). Finally, use the first dose as a reminder for the second dose and a reminder to follow recommended protective behaviours.

Dr Catherine Heffernan, BA, MSc (Sci Comm), MSc, D.Phil, FFPH, Consultant in Public Health,


References

1.Dong E, Du H, Gardner L. 2021. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis. 2020 May;20(5):533-534.

2. Statistics » COVID-19 Vaccinations (england.nhs.uk) (accessed 20/08/21)

3. COVID-19 vaccine surveillance report - week 34 (publishing.service.gov.uk) (accessed 26/08/21)

4. Harris RJ, Hall JA, et al. 20201. Effect of Vaccination on Household Transmission of SARS-CoV-2 in England. N Engl J Med. 2021 Aug 19;385(8):759-760..

4. Keeling M, Moore S. 2021. Relaxation of NPI as vaccination proceeds. University of Warwick, 2021. https://assets.publishing.service.gove.uk/government/uploads/system/uploads/attachment_data/file/963360/S1077_Vaccination_and_NPIs_Warwick.pdf.

6. Voysey M, Clemens S, Madhi et al. 2021. Single dose administration and the influence of timing of the booster dose on immunogenicity and efficacy of ChAdOx1 nCoV-19 (AZD1222) vaccine. https://papers.ssrn.com/sol3/papers.cfm?abstract_i...

7. Whittles LK, Imai N, Knock ES et al. 2021. Strategies for gradually lifting NPIs in parallel to COVID-19 vaccine roll out in the UK. S1078_SPI-M_vaccination_ask_Imperial_College_.pdf (publishing.service.gov.uk)

8. Wagner C, Saad-Roy C et al. 2021. Vaccine nationalism and the dynamics and control of SARS-CoV-2. Science 10.1126/science.abj7364.

9. Eaton L. 2021. COVID-19:WHO warns against ‘vaccine nationalism’ or face further virus mutations. BMJ 372.n292 (2021).

10. English P. 2021. The UK Approach to COVID-19 vaccination: why was it so different? Drugs in Context 2021;10:2021-4-5.

11. Spike-antibody waning after second dose of BNT162b2 or ChAdOx1 (thelancet.com) (accessed 22/8/21)

12. Is COVID vaccine protection fading? (joinzoe.com) (accessed 22/8/2)

13. JCVI interim advice: potential COVID-19 booster vaccine programme winter 2021 to 2022 - GOV.UK (www.gov.uk)

14. NIHR Policy Research Unit in Behavioural Science. 2020. Factors associated with vaccine intention in adults living in England who either do not want or have not yet decided whether to be vaccinated against COVID-19. (PDF) Policy Brief - COVID-19 vaccine intention (researchgate.net) (accessed 13/8/21)

15. Healthwatch., Getting to vaccine centres more of a barrier for Black communities. February 2021. Getting to vaccine centres more of a barrier for Black communities | Healthwatch (accessed 13/8/21)

16. Robertson E et al. 2021. Predictors of COVID-19 vaccine hesitancy in the UK Household Longitudinal Study. MedXriv. January 2021. doi.org/10.1101/2020.12.27.20248899

17. Sherman S et al. 2020. COVID-19 vaccination intention in the UK: Results from the COVID-19 Vaccination Acceptability Study (CoVAccS), a nationally representative cross-sectional survey. Human Vaccine & Immunotherapeutics. November 2020.

18. Jennings W et al. 2021. Lack of trust and social media echo chambers predict COVID-19 vaccine hesitancy. medRxiv. January 2021. doi:10.1101/2021.01.26.21250246

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