“We don’t routinely check vaccination background in adults”: A national qualitative study of barriers and facilitators to vaccine delivery and uptake in adult migrants through UK primary care (preprint)

Background The COVID-19 pandemic has highlighted shortfalls in the delivery of vaccine programmes to some adult migrant groups; however, little is known around care pathways and engagement of these older cohorts in routine vaccinations in primary care, including catch-up programmes. Guidelines exist, but the extent to which they are put into practice and prioritised is unclear. Objectives To explore the views of primary care professionals around barriers and facilitators to catch-up vaccination in adult migrants (defined as foreign born; over 18 years) with incomplete or uncertain vaccination status and for routine vaccines to inform development of future interventions to improve vaccine uptake in this group and improve coverage. Design Qualitative interview study with purposive sampling and thematic analysis Setting UK primary care, 50 included practices. Participants 64 primary care professionals (PCPs): 48 clinical including GPs, Practice Nurses and healthcare assistants (HCAs); 16 administrative staff including practice managers and receptionists (mean age 45 years; 84.4% female; a range of ethnicities). Results Participants highlighted direct and indirect barriers to catch-up vaccines in adult migrants who may have missed vaccines as children, missed boosters, and not be aligned with the UK’s vaccine schedule, from both a personal and service-delivery level, with themes including: lack of training and knowledge of guidance around catch-up vaccination among staff; unclear or incomplete vaccine records; and lack of incentivization (including financial reimbursement) and dedicated time and care pathways. Adult migrants were reported as being excluded from many vaccination initiatives, most of which focus exclusively on children. Where delivery models existed they were diverse and fragmented but included a combination of opportunistic and proactive programmes. PCPs noted that migrants expressed to them a range of views around vaccines, from positivity to uncertainty, to refusal, with specific nationality groups reported as more hesitant to get vaccinated with specific vaccines, including MMR. Conclusions WHO’s new Immunization Agenda (IA2030) has called for greater focus to be placed on delivering vaccination across the life-course, targeting under-immunised groups for catch-up vaccination at any age, with UK primary care services therefore having a key role to play. Vaccine uptake in adult migrants could be improved through implementing new financial incentives or inclusion of adult migrant vaccination targets in QOF, strengthening care pathways and training, and working directly with local community groups to improve understanding around the benefits of vaccination at all ages.

Clinical outcomes and risk factors for COVID-19 among migrant populations in high-income countries: a systematic review (preprint)

BackgroundMigrants, including refugees, asylum seekers, labour migrants, and undocumented migrants, now constitute a considerable proportion of most high-income countries populations, including their skilled and unskilled workforces. Migrants may be at increased risk of COVID-19 due to their health and social circumstances, yet the extent to which they are being affected and their predisposing risk factors are not clearly understood. We did a systematic review to assess clinical outcomes of COVID-19 in migrant populations (cases, hospitalisations, deaths), indirect health and social impacts, and to determine key risk factors. MethodsWe did a systematic review following PRISMA guidelines, registered with PROSPERO (CRD42020222135). We searched databases including PubMed, Global Health, Scopus, CINAHL, and pre-print databases (medRxiv) via the WHO Global Research on COVID-19 database to Nov 18, 2020 for peer-reviewed and grey literature pertaining to migrants (defined as foreign born) and COVID-19 in 82 high-income countries. We used our international networks to source national datasets and grey literature. Data were extracted on our primary outcomes (cases, hospitalisations, deaths) and we evaluated secondary outcomes on indirect health and social impacts, and risk factors, using narrative synthesis. Results3016 data sources were screened with 158 from 15 countries included in the analysis (35 data sources for primary outcomes: cases [21], hospitalisations [4]; deaths [15]; 123 for secondary outcomes). We found that migrants are at increased risk of infection and are disproportionately represented among COVID-19 cases. Available datasets suggest a similarly disproportionate representation of migrants in reported COVID-19 deaths, as well as increased all-cause mortality in migrants in some countries in 2020. Undocumented migrants, migrant health and care workers, and migrants housed in camps and labour compounds may have been especially affected. In general, migrants have higher levels of many risk factors and vulnerabilities relevant to COVID-19, including increased exposure to SARS-CoV-2 due to high-risk occupations and overcrowded accommodation, and barriers to health care including inadequate information, language barriers, and reduced entitlement to healthcare coverage related to their immigration status. ConclusionsMigrants in high-income countries are at high risk of exposure to, and infection with, COVID-19. These data are of immediate relevance to national public health responses to the pandemic and should inform policymaking on strategies for reducing transmission of COVID-19 in this population. Robust data on testing uptake and clinical outcomes in migrants, and barriers and facilitators to COVID-19 vaccination, are urgently needed, alongside strengthening engagement with diverse migrant groups.