Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Covid-19 vaccination hesitancy

The rollout of Covid-19 vaccination is well underway, with more than 700 million doses given worldwide as of April 2021. Vaccination is highly effective at reducing severe illness and death from Covid-19. Vaccines for Covid-19 are also safe, with extremely low risks of severe adverse events. A major threat to the impact of vaccination in preventing disease and death from Covid-19 is low uptake of vaccines. In article published in the British Medical Journal, we give on overview of vaccine hesitancy and some approaches that clinicians and policymakers can adopt at the individual and community levels to help people make informed decisions about Covid-19 vaccination.

The World Health Organization defines vaccine hesitancy as a “delay in acceptance or refusal of safe vaccines despite availability of vaccine services.” It is caused by complex, context specific factors that vary across time, place, and different vaccines, and is influenced by issues such as complacency, convenience, confidence, and sociodemographic contexts. Vaccine hesitancy may also be related to misinformation and conspiracy theories which are often spread online, including through social media. In addition, structural factors such as health inequalities, socioeconomic disadvantages, systemic racism, and barriers to access are key drivers of low confidence in vaccines and poor uptake. The term vaccine hesitancy, although widely used, may not adequately convey these wider determinants that influence decisions to delay or refuse vaccination.

DOI: https://doi.org/10.1136/bmj.n1138

Measuring the impact of Covid-19: Why mortality alone is not enough

In an editorial published in the British Medical Journal, we discuss why we must look beyond mortality to the wider burden of pandemic related harms. Over the course of the covid-19 pandemic, daily releases of national statistics on cases and deaths have been widely reported and used to support interventions and judge the success or failure of control measures around the world. However, differences in rates of testing and in reporting of deaths have led to uncertainty about whether national headline figures on deaths are directly comparable. Excess mortality is an alternative metric, which gives a measure of the number of deaths above that expected during a given time period and thus accounts for additional deaths from any cause during the pandemic, irrespective of how covid-19 deaths are defined.

Measuring excess mortality alone offers only partial insights into the impact of the covid-19 pandemic on the health of nations. If we are to truly understand and intervene to mitigate the impact of the pandemic, we must also look to quantify excess morbidity within and between nations. A focus on deaths alone gives only a partial picture of the impact of covid-19 on populations, particularly among younger people in whom death from covid-19 is rare. The importance of “long covid,” for example, has recently been highlighted, but the true burden of this condition has yet to be quantified, and policies are urgently needed to overcome its long term challenges.

The covid-19 pandemic has resulted in widespread disruption to health systems across the world. Diagnostic and treatment pathways for cancer and other time sensitive conditions have been disrupted, and the monitoring of long term conditions has often taken place through novel telemedicine platforms, if at all. By April 2021 more than 4.7 million people in England were waiting for hospital treatment, the highest number since records began. Such disruption is likely to lead to poorer health and earlier deaths in countries across the world for many years to come, particularly where covid-19 remains endemic and where health services are unable to function normally. Establishing where health systems have fallen behind, and characterising the true extent of unmet need, is a critical step towards reducing these ongoing harms.

There has been a huge toll of the covid-19 pandemic on mortality in high income countries in 2020. However, its full impact may not be apparent for many years, particularly in lower income countries where factors such as poverty, lack of vaccines, weak health systems, and high population density place people at increased risk from covid-19 and related harm. In the UK, life expectancy in lower socioeconomic groups has fallen in recent years, an inequality likely to be exacerbated by the covid-19 pandemic, without concerted action.

Finally, although mortality is a useful metric, policy informed by deaths alone overlooks what may become a huge burden of long term morbidity resulting from covid-19. An urgent need exists to measure this excess morbidity, support people with long term complications of covid-19, and fund health systems globally to tackle the backlog of work resulting from the pandemic.

DOI: https://doi.org/10.1136/bmj.n1239

Questions and answers about Covid-19 vaccination

1. I’d rather wait to see if vaccines really are safe. What’s wrong with that?

Covid-19 vaccines were tested extensively before they went into general use. The data from this research and subsequent data from their widespread use in the UK and other countries in many millions of people show that all the vaccines are very safe and that serious side effects are very rare. If you delay getting vaccinated, you are at risk of getting infected and also put at the risk the people you are in contact with.

 

2. Other people need a vaccine more than me. Isn’t it OK to let others have theirs first?

People are prioritised for vaccination based on factors such as age and medical history. When you receive your invitation to be vaccinated, you are being called for vaccination at the right time for you and are not disadvantaging anyone else.

 

3. Aren’t people dying from blood clots because of the vaccine?

Reports of serious blood clots are very rare, with typically only a few cases per million doses of vaccine administered.

 

4. I don’t trust the government, so why should I trust a vaccine they’re trying to get us to have?

Covid-19 vaccines were tested rigorously before they were used in the general population. No short cuts were taken in this testing. The safety of the vaccines continues to be assessed continually.

 

5. The odds of me dying from Covid are so low I’d rather take the risk of not being vaccinated.

Many people who survived a Covid-19 infection have been left with long-term complications such as heart and lung damage. Vaccination reduces the risks of you suffering a serious illness, and also helps protect more vulnerable people such as your elderly relatives and older work colleagues.

 

6. Haven’t lots of people died after having their first Covid shot?

Reports of people dying after their first Covid-19 vaccine are very rare. In most cases, death was due to natural causes and not linked to their vaccination.

 

7. I’m suffer from a lot of allergies, so I’m worried I’ll have a serious reaction to the jab too.

Many millions of people who suffer from allergies have safely received a Covid-19 vaccination.

 

8. Can the Covid vaccine affect fertility?

Covid-19 vaccines do not affect fertility.

 

9. BAME communities have been treated badly in the past by health authorities. Why should we trust them now?

BAME communities are at much higher risk of serious illness and death from Covid-19. Vaccines will protect them from these risks. BAME organisations and health professionals have advised the members of their communities to get vaccinated when they are invited, so it is not only health authorities that are recommending the vaccines.

 

10. Are vaccines halal?

Covid-19 vaccines have been confirmed to be halal and acceptable for use in Muslims by religious scholars across the world. No Muslim country has refused to use Covid-19 vaccines.

 

11. I’ve seen videos where doctors say vaccines are dangerous and even change your DNA. Why should I believe another doctor who says it is safe and not those who have concerns?

Vaccines are safe and do not change your DNA. Extensive research has confirmed the safety of the vaccines.

 

12. This vaccine was developed in record time. I’m worried they cut corners to get it out in such a rush.

Vaccines were developed and tested in record time because of advances in medical technology in recent years and because bureaucratic obstacles to setting up research trials were minimised. No corners were cut in the development and testing processes.

 

13. You might seem OK after having your vaccine, but who knows how it might affect your health in several years’ time?

We now have evidence from many millions of people that vaccines substantially reduce the risks of serious illness and death. Ongoing research has shown the vaccines are safe and highly effective. The risks from Covid-19 infection in contrast are immediate and serious.

 

14. I’ve already had Covid so I don’t think I need a vaccine. Won’t I already have immunity?

Natural immunity to Covid-19 can wear off and people can sometimes suffer a second infection. A vaccine boosts your immune response and gives you additional protection from infection.

 

15. I’ve heard that vaccines can cause autism. What’s the truth?

There is no link between vaccines and autism.

 

16. I don’t want the dangerous chemicals in vaccines like formaldehyde, mercury and aluminium getting in to my body.

Vaccines are extensively tested to prove that the chemicals in them are safe.

 

17. Wasn’t the Spanish Flu vaccine responsible for 50 million deaths?

The deaths from Spanish Flu were caused by a virus, not by a vaccine.

How is the Covid-19 lockdown impacting the mental health of parents of school-age children?

The Covid-19 pandemic has affected educational systems worldwide, leading to the near-total closures of educational institutions in the UK. As of 6 May 2020, schools were suspended in 177 countries affecting over 1.3 billion learners worldwide, and in many cases closures have resulted in the universal cancellation of examinations. UNICEF estimated that almost 4 months of education will be lost as a result of the first lockdown.

School closures have far-reaching economic and societal consequences, including the disruption of everyday behaviours and routines. In the UK, over 2 million workers have already lost their jobs, and although the long-term impact of the pandemic on education is not yet clear, the pre-existing attainment gap between the poorest and richest children7 may widen significantly as a result of COVID-19. Children and young people make up 21% of the population of England,10 and by the time they returned to school after the summer break, some would have been out of education for nearly 6 months.

In a paper published in the journal BMJ Open, we explored how the lockdown affected the mental health of parents of school-age children, and in particular to assess the impact of an extended period of school closures on feelings of social isolation and loneliness.

We collected data for 6 weeks during the first 100 days of lockdown in the UK and found that female gender, lower levels of physical activity, parenting a child with special needs, lower levels of education, unemployment, reduced access to technology, not having a dedicated space where the child can study and the disruption of the child’s sleep patterns during the lockdown are the main factors associated with a significantly higher odds of parents reporting feelings of loneliness.

We concluded that school closures and social distancing measures implemented during the first 100 days of the COVID-19 lockdown significantly impacted the daily routines of many people and influenced various aspects of government policy. Policy prescriptions and public health messaging should encourage the sustained adoption of good health-seeking self-care behaviours including increased levels of physical activity and the maintenance of good sleep hygiene practices to help prevent or reduce the risk of social isolation and loneliness, and this applies in particular where there is a single parent. Policymakers need to balance the impact of school closures on children and their families, and any future risk mitigation strategies should ideally not be a further disadvantage to the most vulnerable groups in society.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-043397

Lancet Commission on the Future of the UK’s NHS

I would like to thank the Lancet for giving me the opportunity to contribute to their Commission on the Future of the NHS. I fully support the recommendation for a strong and sustained increase in NHS funding to address the current weaknesses in the NHS. For me, the most striking data in the Lancet Commission on the Future of the NHS was this figure, taken from Securing a sustainable and fit-for-purpose UK health and care workforce, showing the changes in the number of NHS GPs and consultants per 1,000 people between 2008-18. Note the decline in GP numbers compared to the increase in consultant numbers. Although we hear a lot from NHS managers and politicians about the need to shift the focus of the NHS to the community, staffing statistics do not support this. The reality is that NHS primary care funding and workload need to reflect staff levels, not meaningless rhetoric.

Figure: Numbers of GPs and hospital consultants across the UK per 1000 people, 2008–18

Assessing the long-term safety and efficacy of COVID-19 vaccines

In an article published in the Journal of the Royal Society of Medicine, myself, Professor Marisa Papaluca and Dr Mariam Molokhia discuss how health systems can assess the long-term safety and efficacy of COVID-19 vaccines. Vaccines for COVID-19 were eagerly awaited, and their rapid development, testing, approval and implementation are a tremendous achievement by all: scientists, pharmaceutical companies, drugs regulators, politicians and healthcare professionals; and by the patients who have received them.

Because these vaccines are new, we lack long-term data on their safety and efficacy. In surveys of people who define themselves as ‘vaccine hesitant’, this lack of long-term data is one of the main reasons given for their beliefs. Hence, providing this information is a public health priority and could help reassure vaccine-hesitant people that receiving a COVID-19 vaccine is the right choice for them. Emerging data from the UK and elsewhere are confirming the benefits of COVID-19 vaccines and this is one of the factors that is leading to a reduction in vaccine hesitancy in the UK population.

As long-term data on the safety and efficacy build globally, these can address many of the concerns that vaccine-hesitant people have about COVID-19 vaccines, thereby creating a positive environment that encourages higher uptake of vaccination. These data will also guide national public health policies, such as how frequently to provide booster doses of vaccine and whether limits should be placed on the use of a specific vaccine.

Vaccination remains the best way to control the COVID-19 pandemic, and countries globally should work together to generate the information needed to provide long-term data on safety and outcomes. Because of the very rare nature of some side effects, this will require international collaboration so that data from countries can be pooled to allow more precise estimates of risk to be calculated. This will include using data from low- and middle-income countries once vaccination programmes are established there, as well as from marginalised groups in higher-income countries, to ensure that the data are fully representative of the global population.

DOI: https://doi.org/10.1177/01410768211013437

Using the NHS App as a Covid-19 vaccine passport

The UK transport minister, Grant Shapps, announced on 28 April 2021 that the UK government plans to use the existing NHS App to provide proof of covid-19 vaccination status for international travel. For many years, proof of smallpox, polio, and yellow fever vaccinations have been an entry requirement for many countries. The World Health Organization “yellow card” scheme has been in place since 1969, and proof of ACWJ meningococcal vaccine is required for Hajj to Saudi Arabia.

So while discussions on “vaccine passports” are old, the scale of the covid-19 pandemic will require a large number of global travellers to use a vaccine passport, which is an unprecedented development; and the technological options are far more advanced than for the previous paper-based certificates used for other vaccines. There are arguments for and against vaccine passports. We are facing a global pandemic, with huge variations in disease prevalence and vaccine mobilisation between countries. And while we watch the tragic scenes from India, many people in the UK are preparing for their first opportunity this year to visit oversees relatives or take an international holiday.

In a statement on 5 February 2021, the World Health Organization (WHO) laid down their reasons (at that time) for not supporting the idea of vaccine certificates; based on ethical, legal, scientific, and technological reasons. WHO recommends that people who are vaccinated should continue to comply with other risk-reduction measures when travelling. WHO also stated that their recommendations will evolve as vaccine supply expands and as evidence about the efficacy of existing and new covid-19 vaccines increases. This however has not deterred some countries—notably Israel—pushing ahead with their digital “Green Pass” scheme, with the USA also exploring options for vaccine certification.

Should the UK government decide to proceed with a vaccine passport policy, what method would we use? General practitioners, who are already struggling to meet unprecedented demands, while delivering around 75% of covid-19 vaccines thus far, cannot be expected to provide proof of vaccinations. There are digital solutions available such as the NHS App, or possibly the NHS Covid-App. Many UK patients nationwide already use their NHS App for a range of services including to seek medical advice, view their GP records, make appointments, submit secure electronic enquiries to their GP, and to order repeat prescriptions. It is also possible for people to use the App to view their covid-19 vaccination record. This area of the existing NHS App, already used by millions of patients, is clearly a safe and obvious place to use as a digital “vaccine passport.” Increased downloads and use of the NHS App by those using it as their “vaccine passport” could have additional long term benefits for patients and the NHS through encouraging use of other digital NHS services.

However, detailed medical record access—currently required to view vaccination records—is not enabled by default when you register with the NHS App. Proof of covid-19 vaccination status would therefore need to be separate from the rest of the medical record so that it can be enabled by default for everyone without the need for individual permissions from general practices. The covid-19 vaccination record can also sometimes appear in the acute medication section of the NHS App, but not usually with all details (such as vaccine batch number). This needs to be rectified so that the vaccination details are always in the same place in the NHS App. We would expect NHS Digital to rectify these issues before the NHS App is enabled as a covid-19 vaccine passport.

Covid-19 vaccination is recorded using the national PharmaOutcomes (also known as Pinnacle) IT system. NHS England decided to use this rather than recording directly into GP patient record systems because data can be entered using a web browser, and thus the system can be used across all vaccine sites, including those that have no access to GP medical record systems such as EMIS or SystmOne. However, some people have reported that the information on their vaccination is not always transferred to their GP medical record, and indeed GP Teams have also noted other discrepancies.

When inaccuracies are noted, covid-19 vaccination data must then be entered manually by the GP practice. This is not an ideal solution as errors and omissions in data recording can then occur, in addition to creating extra work for hard-pressed primary care teams. If the NHS App is to be used to confirm vaccination status, it is essential that all IT issues are resolved promptly to ensure the NHS App contains an accurate record of people’s vaccination status and extra work is not created for primary care teams.

An editorial in The BMJ discusses some of the wider practical and ethical issues in the implementation and use of vaccine passports; such as the need to ensure they do not further exacerbate current health inequalities. For example, many people in the UK do not own a modern smartphone capable of running the NHS App, a feature of the “digital divide.” This may be because they either cannot afford a smartphone or because they lack the technical proficiency to use one. This will affect older people and those from poorer sections of society; groups that already have lower levels of vaccine uptake, and higher levels of illness and poor health. The UK government’s proposal of using the NHS App may work for the majority of the population, but we must consider alternative options for those without access to suitable technology so they are not prevented from overseas travel.

There is debate for and against vaccine passports, which are being implemented by several countries already, but are not currently recommended by the WHO. The UK government’s proposal to use the NHS App to provide proof of covid-19 vaccination status is a practical and pragmatic solution for most UK citizens. However, we suggest that IT issues need to be addressed before we can rely on the NHS App as a “covid-19 vaccination passport,” to prevent extra bottlenecks and delays in airports. GP teams, who are already struggling for time, need to be protected from a tsunami of requests for certification to travel; and solutions also need to be found in case of technology failure, and for those unable or unwilling to use the NHS App.

Simon Hodes, GP Partner, Watford, UK

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

This article was first published by BMJ Opinion.

High quality primary care and achievement of key quality targets lowers the risk of amputations in people with type 2 diabetes

Amputations are an important and largely preventable complication of type 2 diabetes mellitus that impact considerably on the life expectancy and quality of life of those affected. In England, more than 9000 diabetes-related amputations are performed each year, with decreasing rates but higher absolute numbers of major amputations, and the annual direct healthcare costs of diabetic foot ulceration and amputation are approximately £1 billion.

In an article published in BMJ Open Diabetes Research & Care, we investigated the associations between attainment of primary care quality clinical indicators, completion of National Diabetes Audit care processes, and non-traumatic lower limb amputations among people with type 2 diabetes. We observed that minor or major, as well as major-only, amputation rates were 26%–51% and 3%–51%, respectively, lower among those who met the HbA1c indicator and 14%–47% lower among those who met the cholesterol indicator for our primary outcome.

Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.

DOI: http://dx.doi.org/10.1136/bmjdrc-2020-002069

Safe management of full-capacity live events in the era of Covid-19

In an article published in the Journal of the Royal Society of Medicine, we discuss the safe management of full-capacity live events in the era of Covid-19. The importance of the live events industry to the UK economy is significant, with the creative industries1 alone contributing £117bn to the UK economy in 2018. However, the public health response to COVID-19 led to an unprecedented fall in theatrical sales of 93%, with the entertainment industry estimated to lose £110 m per month of full closure.

Several high-profile live music events have been cancelled. There has been limited experience of the reopening of live events in other countries; however, this has only been possible due to effective public health interventions to reduce community transmission to near zero levels. The sustainability of stringent border control measures to virus transmission is much debated; however, it is clear that the ability for the UK to achieve and then sustain low community transmission levels will require rigorously monitored borders and quarantine measures for inbound travellers.

Widespread population immunity through vaccination (and from previous infection) will help the UK to reach low transmission levels; however, the success of the vaccine programme will largely depend on convergent evolution of the virus but this remains unknown. Additional measures to stringent social distancing, isolating at home and high uptake of the vaccination programme to achieve herd immunity to existing and emergent mutant strains of coronavirus will all be required to maintain low transmission levels in the UK. However, because of vaccine hesitancy among some groups, there may be areas of the UK where COVID-19 outbreaks continue.

DOI: https://doi.org/10.1177/01410768211007759

Association between attainment of primary care quality indicators and diabetic retinopathy

Nearly three million people in England have type 2 diabetes. Diabetic retinopathy is a common complication, affecting nearly a third of patients with type 2 diabetes with considerable impacts on visual acuity and quality of life. In a paper published in the journal BMC Medicine, we examined the associations between attainment of primary care indicators and incident diabetic retinopathy among people with type 2 diabetes in England.

We found that that attainment of primary care HbA1c and BP indicators is associated with lower incidence of diabetic retinopathy in patients with type 2 diabetes. There is scope to enhance coverage of HbA1c and BP indicator attainment, and thus to potentially limit the incidence of diabetic retinopathy in England, through appropriate community-based measures. Further research is required to examine whether tighter glycaemic and/or BP control could achieve greater reductions in diabetic retinopathy.