Covid-19 vaccine roll-out in England: A qualitative evaluation.

BACKGROUND: The UK was the first country to launch a national pandemic COVID-19 vaccination programme, which was implemented swiftly despite significant vaccine supply constraints. The delivery strategy used a combination of mass vaccination sites operated by NHS secondary care providers and local sites led by Primary Care Networks, and local pharmacies. Despite nation-wide rollout, persistent gaps in coverage continued to affect particular populations, including ethnic minority and marginalised social groups. AIM: The study examined sub-national immunisation commissioners and providers' perspectives on how the COVID-19 vaccine programme was operationalised, and how delivery strategies impacted inequalities in access to vaccination services and uptake. The study aimed to inform national programme implementation, sustainability and future pandemic preparedness. METHODS: Qualitative research was conducted in eight local NHS areas in 4 regions of England. Semi-structured interviews were performed with 82 sub-national NHS and public health vaccine providers and commissioners. RESULTS: England's COVID-19 vaccination programme was described as top down, centralised and highly political. The programme gradually morphed from a predominantly mass vaccination strategy into more locally driven and tailored approaches able to respond more effectively to inequalities in uptake. Over time more flexibility was introduced, as providers adapted services by "working around" the national systems for vaccine supply and appointment booking. The constant change faced by providers and commissioners was mitigated by high staff motivation and resilience, local collaboration and pragmatism. Opportunities for efficient implementation were missed because priority was given to achieving national performance targets at the expense of a more flexible sub-national tailored delivery. CONCLUSION: Pandemic vaccination delivery models need to be adapted for underserved and hesitant groups, working in collaboration with local actors. Learnings from the initial COVID-19 vaccine roll-out in England and elsewhere is important to inform future pandemic responses, in tailoring strategies to local communities, and improve large-scale vaccination programmes.

Adapting SARS-CoV-2 vaccination delivery in England to population needs: a thematic analysis of providers and commissioner's perceptions.

BACKGROUND: A national SARS-CoV-2 vaccination programme was implemented in England from 8th December 2020, adopting a series of local level service delivery models to maximise rollout. The evidence base informing service design programme at inception was limited. We examined the real-world implementation of the programme through an assessment of sub-national providers' and commissioners' perspectives on the service delivery models used, to strengthen evidence on the acceptability, effectiveness and efficiency of the service delivery approaches used for SARS-CoV-2 vaccination in England or elsewhere. METHODS: Qualitative, cross-sectional analysis based on semi-structured interviews conducted with 87 stakeholders working in SARS-CoV-2 vaccination delivery across four regions in England. Localities were selected according to geography and population socio-economic status. Participants were purposively sampled from health service providers, commissioners and other relevant bodies. Interviews were conducted between February and October 2021, and transcripts were thematically analysed using inductive and deductive approaches. RESULTS: Various service delivery models were implemented over the course of the programme, beginning with hospital hubs and mass vaccination sites, before expanding to incorporate primary care-led services, mobile and other outreach services. Each had advantages and drawbacks but primary care-led models, and to some extent pharmacies, were perceived to offer a better combination of efficiency and community reach for equitable delivery. Common factors for success included availability of a motivated workforce, predictability in vaccine supply chains and strong community engagement. However, interviewees noted a lack of coordination between service providers in the vaccination programme, linked to differing financial incentives and fragmentated information systems, among other factors. CONCLUSION: A range of delivery models are needed to enable vaccine rollout at pace and scale, and to mitigate effects on routine care provision. However, primary care-led services offer a tried-and-trusted framework for vaccine delivery at scale and pace and should be central to planning for future pandemic responses. Mass vaccination sites can offer delivery at scale but may exacerbate inequalities in vaccination coverage and are unlikely to offer value for money. Policymakers in England should prioritise measures to improve collaboration between service providers, including better alignment of IT systems.

Effectiveness of a pay-it-forward intervention compared with user-paid vaccination to improve influenza vaccine uptake and community engagement among children and older adults in China: a quasi-experimental pragmatic trial.

BACKGROUND: China has low seasonal influenza vaccination rates among priority populations. In this study, we aimed to evaluate a pay-it-forward strategy to increase influenza vaccine uptake in rural, suburban, and urban settings in China. METHODS: We performed a quasi-experimental pragmatic trial to examine the effectiveness of a pay-it-forward intervention (a free influenza vaccine and an opportunity to donate financially to support vaccination of other individuals) to increase influenza vaccine uptake compared with standard-of-care user-paid vaccination among children (aged between 6 months and 8 years) and older people (≥60 years) in China. Recruitment took place in the standard-of-care group until the expected sample size was reached and then in the pay-it-forward group in primary care clinics from a rural site (Yangshan), a suburban site (Zengcheng), and an urban site (Tianhe). Participants were introduced to the influenza vaccine by project staff using a pamphlet about influenza vaccination and were either asked to pay out-of-pocket at the standard market price (US$8·5-23·2; standard-of-care group) or to donate any amount anonymously (pay-it-forward group). Participants had to be eligible to receive an influenza vaccine and to have not received an influenza vaccine in the past year. The primary outcome was vaccine uptake. Secondary outcomes were vaccine confidence and costs (from the health-care provider perspective). Regression methods compared influenza vaccine uptake and vaccine confidence between the two groups. This trial is registered with ChiCTR, ChiCTR2000040048. FINDINGS: From Sept 21, 2020, to March 3, 2021, 300 enrolees were recruited from patients visiting three primary care clinics. 55 (37%) of 150 people in the standard-of-care group (40 [53%] of 75 children and 15 [20%] of 75 older adults) and 111 (74%) of 150 in the pay-it-forward group (66 [88%] of 75 children and 45 [60%] of 75 older adults) received an influenza vaccine. People in the pay-it-forward group were more likely to receive an influenza vaccine compared with those in the standard-of-care group (adjusted odds ratio [aOR] 6·7 [95% CI 2·7-16·6] among children and 5·0 [2·3-10·8] among older adults). People in the pay-it-forward group had greater confidence in vaccine safety (aOR 2·2 [95% CI 1·2-3·9]), importance (3·1 [1·6-5·9]), and effectiveness (3·1 [1·7-5·7]). In the pay-it-forward group, 107 (96%) of 111 participants donated money for subsequent vaccinations. The pay-it-forward group had a lower economic cost (calculated as the cost without subtraction of donations) per person vaccinated (US$45·60) than did the standard-of-care group ($64·67). INTERPRETATION: The pay-it-forward intervention seemed to be effective in improving influenza vaccine uptake and community engagement. Our data have implications for prosocial interventions to enhance influenza vaccine uptake in countries where influenza vaccines are available for a fee. FUNDING: Bill & Melinda Gates Foundation and the UK National Institute for Health Research.

"We've all got the virus inside us now": Disaggregating public health relations and responsibilities for health protection in pandemic London.

The COVID-19 pandemic has disproportionately impacted ethnic minorities in the global north, evidenced by higher rates of transmission, morbidity, and mortality relative to population sizes. Orthodox Jewish neighbourhoods in London had extremely high SARS-CoV-2 seroprevalence rates, reflecting patterns in Israel and the US. The aim of this paper is to examine how responsibilities over health protection are conveyed, and to what extent responsibility is sought by, and shared between, state services, and 'community' stakeholders or representative groups, and families in public health emergencies. The study investigates how public health and statutory services stakeholders, Orthodox Jewish communal custodians and households sought to enact health protection in London during the first year of the pandemic (March 2020-March 2021). Twenty-eight semi-structured interviews were conducted across these cohorts. Findings demonstrate that institutional relations - both their formation and at times fragmentation - were directly shaped by issues surrounding COVID-19 control measures. Exchanges around protective interventions (whether control measures, contact tracing technologies, or vaccines) reveal diverse and diverging attributions of responsibility and authority. The paper develops a framework of public health relations to understand negotiations between statutory services and minority groups over responsiveness and accountability in health protection. Disaggregating public health relations can help social scientists to critique who and what characterises institutional relationships with minority groups, and what ideas of responsibility and responsiveness are projected by differently-positioned stakeholders in health protection.

Transmission dynamics of SARS-CoV-2 in a strictly-Orthodox Jewish community in the UK.

Some social settings such as households and workplaces, have been identified as high risk for SARS-CoV-2 transmission. Identifying and quantifying the importance of these settings is critical for designing interventions. A tightly-knit religious community in the UK experienced a very large COVID-19 epidemic in 2020, reaching 64.3% seroprevalence within 10 months, and we surveyed this community both for serological status and individual-level attendance at particular settings. Using these data, and a network model of people and places represented as a stochastic graph rewriting system, we estimated the relative contribution of transmission in households, schools and religious institutions to the epidemic, and the relative risk of infection in each of these settings. All congregate settings were important for transmission, with some such as primary schools and places of worship having a higher share of transmission than others. We found that the model needed a higher general-community transmission rate for women (3.3-fold), and lower susceptibility to infection in children to recreate the observed serological data. The precise share of transmission in each place was related to assumptions about the internal structure of those places. Identification of key settings of transmission can allow public health interventions to be targeted at these locations.

Childhood COVID-19 vaccine acceptance and preference from caregivers and healthcare workers in China: A survey experiment.

With approval of more COVID-19 vaccines for children, vaccine attributes may influence parental acceptance and choices. We aimed to assess effects of vaccine attributes and information on herd immunity on childhood COVID-19 vaccine acceptance. A survey experiment was conducted with caregivers of children aged 6 months to 11 years old and health care workers (HCWs) in China from September 14 to November 18, 2021. Respondents were randomly assigned to receive differing information on herd immunity (> 80% of the entire population must be vaccinated; or no information). Respondents then completed eight discrete choice tasks to assess vaccine acceptance based on attributes. 2331 (90.07%) of 2588 surveyed caregivers and 1576 (92.71%) of 1700 surveyed HCWs would accept COVID-19 vaccination for children, respectively. High Odds Ratios (OR) were found for acceptance of a vaccine with 90% over 50% efficacy (OR 6.70 [95% CI 6.11-7.35] for caregivers; 11.44 [10.12-12.95] for HCWs); and risk of adverse reactions to be 1 over 10 in 10,000 (3.96 [3.72-4.22] for caregivers; 2.98 [2.76-3.22] for HCWs). To achieve herd immunity target (> 80% vaccination coverage), vaccine efficacy should reach over 70% and risk of adverse reactions lower than 1 in 10,000. Knowledge on herd immunity target increased the odds of vaccine acceptance (1.82 [1.34-2.46] for caregivers; 2.42 [1.58-3.72] for HCWs). Childhood COVID-19 vaccine acceptance was high in China, independent of child's age, and depended on vaccine attributes.

Tailoring immunisation programmes in a time of SARS-CoV-2: What can be learnt by comparing the findings of childhood and COVID-19 vaccine evaluation studies in an underserved population?

Objectives: A WHO Tailoring Immunization Programmes (TIP) evaluation was conducted in 2014-16 to investigate suboptimal childhood vaccination coverage in the north London Orthodox Jewish community. In 2021-22 a qualitative evaluation of the COVID-19 vaccine programme (CVP) was conducted in the same setting. This paper examines whether the issues identified by the TIP affected the CVP and what differences emerged between these two vaccine programme evaluations. Study design: Qualitative study. Methods: The CVP evaluation involved conducting 28 semi-structured interviews with public health professionals, Orthodox Jewish welfare and religious representatives, and household members in February-May 2021. The key considerations arising from the thematic analysis of this data was then compared systematically with the overarching findings from the TIP study. Results: The issues identified in the TIP study diverged and converged with results from the CVP evaluation: i) participants did not express concerns of unmet CVP information needs; ii) the social value of COVID-19 vaccines was influenced by international travel requirements; iii) in contrast to commissioning constraints noted to have limited flexible delivery of childhood immunisations in the TIP evaluation, the CVP was characterised by a flexible commissioning and delivery model. This model was facilitated by significant government investment as part of the COVID-19 pandemic response. Conclusions: The comparative analysis indicates that flexible vaccine commissioning and fit for purpose public health investment can influence how documented knowledge is translated into action. Implications are raised for how routine vaccination services are equipped to serve the needs of minority populations with historically suboptimal coverage levels.

Development of a multicomponent intervention to increase parental vaccine confidence and young people's access to the universal HPV vaccination programme in England: protocol for a co-design study.

INTRODUCTION: Persistent infection with HPV can result in cancers affecting men and, especially, women. Lower uptake exists by area and different population groups. Increasing parental confidence about, and adolescent access to, the universal HPV vaccination programme may help reduce inequalities in uptake. However, the evidence-base for interventions to address uptake for schools-based HPV vaccination programmes is currently lacking. This study protocol outlines how a multicomponent intervention to address this evidence gap will be codesigned with parents. METHODS AND ANALYSIS: The proposed research will be undertaken in localities covered by two immunisation teams in London and the south-west of England. The 'person-based approach' to intervention development will be followed. In the first phase, an exploratory qualitative study will be undertaken with key stakeholders (n=8) and parents (n=40) who did not provide consent for their adolescent child to be vaccinated. During the interviews, parents' views on ways to improve parental confidence about, and adolescents' access to, HPV vaccination will be sought. The findings will be used to inform the co-design of a preliminary plan for a targeted, multicomponent intervention. In the second phase, at least two parent working groups (n=8) will be convened and will work with creative designers to co-design communication materials aimed at increasing parents' confidence in vaccination. At least two workshops with each parent group will be organised to obtain feedback on the intervention plan and communication materials to ensure they are fit for purpose. These findings will inform a protocol for a future study to test the effectiveness of the intervention at increasing HPV vaccination uptake. ETHICS AND DISSEMINATION: The National Health Services Research Ethics Service and London School of Hygiene & Tropical Medicine Observational / Interventions Research Ethics Committee provided approvals for the study (reference 22/SW/0003 & 26902, respectively). We will work with parent advisory groups to inform our dissemination strategy and co-present our findings (eg, at community events or through social media). We will disseminate our findings with academics and healthcare professionals through webinars and academic conferences, as well as peer-reviewed publications.

Localising vaccination services: Qualitative insights on public health and minority group collaborations to co-deliver coronavirus vaccines.

Ethnic and religious minorities have been disproportionately affected by the SARS-CoV-2 pandemic and are less likely to accept coronavirus vaccinations. Orthodox (Haredi) Jewish neighbourhoods in England experienced high incidences of SARS-CoV-2 in 2020-21 and measles outbreaks (2018-19) due to suboptimal childhood vaccination coverage. The objective of our study was to explore how the coronavirus vaccination programme (CVP) was co-delivered between public health services and an Orthodox Jewish health organisation. Methods included 28 semi-structured interviews conducted virtually with public health professionals, community welfare and religious representatives, and household members. We examined CVP delivery from the perspectives of those involved in organising services and vaccine beneficiaries. Interview data was contextualised within debates of the CVP in Orthodox (Haredi) Jewish print and social media. Thematic analysis generated five considerations: i) Prior immunisation-related collaboration with public health services carved a role for Jewish health organisations to host and promote coronavirus vaccination sessions, distribute appointments, and administer vaccines ii) Public health services maintained responsibility for training, logistics, and maintaining vaccination records; iii) The localised approach to service delivery promoted vaccination in a minority with historically suboptimal levels of coverage; iv) Co-delivery promoted trust in the CVP, though a minority of participants maintained concerns around safety; v) Provision of CVP information and stakeholders' response to situated (context-specific) challenges and concerns. Drawing on this example of CVP co-delivery, we propose that a localised approach to delivering immunisation programmes could address service provision gaps in ways that involve trusted community organisations. Localisation of vaccination services can include communication or implementation strategies, but both approaches involve consideration of investment, engagement and coordination, which are not cost-neutral. Localising vaccination services in collaboration with welfare groups raises opportunities for the on-going CVP and other immunisation programmes, and constitutes an opportunity for ethnic and religious minorities to collaborate in safeguarding community health.

Delivering routine immunisations in London during the COVID-19 pandemic: lessons for future vaccine delivery. A mixed-methods study.

BACKGROUND: General practices in England have continued to care for patients throughout the COVID-19 pandemic by instigating major changes to service delivery. Immunisations have continued, although the number of vaccines delivered initially dropped in April 2020. AIM: To evaluate how COVID-19 impacted the delivery of immunisations in London and identify innovative practices to inform future delivery, including for COVID-19 vaccines. DESIGN & SETTING: A mixed-methods study of immunisation delivery in London, UK. METHOD: An online survey of London general practices was undertaken in May 2020 to produce a descriptive analysis of childhood immunisation delivery and identify innovative delivery models. Semi-structured interviews were conducted between August and November 2020 to explore innovative immunisation models, which were analysed thematically. RESULTS: Sixty-eight per cent (n = 830) of London practices completed the survey and 97% reported having continued childhood immunisation delivery. Common delivery adaptations included spaced-out appointments, calling parents beforehand, and having only one parent attend. Forty-three practices were identified as having innovative models, such as delivering immunisations outside practice buildings or offering drive-through services. The thematic analysis of 14 semi-structured interviews found that, alongside adaptations to immunisation delivery within practices, existing local networks collaborated to establish new immunisation delivery models. Local population characteristics affected delivery and provide insights for large-scale vaccine deployment. CONCLUSION: Immunisations continued during 2020 with practices adapting existing services. New delivery models were developed by building on existing local knowledge, experiences, and networks. Immunisation delivery during the pandemic, including for COVID-19 vaccines, should be tailored to local population needs by building on primary care immunisation expertise.

SARS-CoV-2 seroprevalence in a strictly-Orthodox Jewish community in the UK: A retrospective cohort study.

BACKGROUND: Ethnic and religious minorities have been disproportionately affected by SARS-CoV-2 worldwide. The UK strictly-Orthodox Jewish community has been severely affected by the pandemic. This group shares characteristics with other ethnic minorities including larger family sizes, higher rates of household crowding and relative socioeconomic deprivation. We studied a UK strictly-Orthodox Jewish population to understand transmission of COVID-19 within this community. METHODS: We performed a household-focused cross-sectional SARS-CoV-2 serosurvey between late-October and early December 2020 prior to the third national lockdown. Randomly-selected households completed a standardised questionnaire and underwent serological testing with a multiplex assay for SARS-CoV-2 IgG antibodies. We report clinical illness and testing before the serosurvey, seroprevalence stratified by age and sex. We used random-effects models to identify factors associated with infection and antibody titres. FINDINGS: A total of 343 households, consisting of 1,759 individuals, were recruited. Serum was available for 1,242 participants. The overall seroprevalence for SARS-CoV-2 was 64.3% (95% CI 61.6-67.0%). The lowest seroprevalence was 27.6% in children under 5 years and rose to 73.8% in secondary school children and 74% in adults. Antibody titres were higher in symptomatic individuals and declined over time since reported COVID-19 symptoms, with the decline more marked for nucleocapsid titres. INTERPRETATION: In this tight-knit religious minority population in the UK, we report one of the highest SARS-CoV-2 seroprevalence levels in the world to date, which was markedly higher than the reported 10% seroprevalence in London at the time of the study. In the context of this high force of infection, all age groups experienced a high burden of infection. Actions to reduce the burden of disease in this and other minority populations are urgently required. FUNDING: This work was jointly funded by UKRI and NIHR [COV0335; MR/V027956/1], a donation from the LSHTM Alumni COVID-19 response fund, HDR UK, the MRC and the Wellcome Trust.