Despite success so far in vaccinating millions of people, there is still a long way to go. And, as Kaye McIntosh and Nicola Merrifield find out, important questions remain
The vaccination programme has been a great success, with more than 87 million doses given across the UK by mid-August. Much of this success is down to GPs, who have been leading the way.
Yet this success means there will be no let-up. A booster campaign to administer a third dose for the most vulnerable is expected to begin this month.
Meanwhile, there is a new cohort to vaccinate for the first time. A change in policy from the Government means 16- to 17-year-olds are now eligible, as well as those aged 12 to 15 years in vulnerable groups and those living with clinically extremely vulnerable people.
The booster campaign brings further challenges. Just weeks before the next stage of the vaccination programme, GPs still don’t know whether it can safely be co-administered with the flu vaccine, which is what the Government is hoping.
And whereas the first stages of the Covid vaccination programme were carried out at a time of restrictions, the easing of measures means many of the venues used are no longer available.
The booster vaccines
GPs in England at least have the enhanced service specification for the Covid booster programme as a guide.
But even at this stage, it is not clear what vaccine brands are to be used. In his very first speech as health secretary in June, Sajid Javid said a ‘mixed schedule of jabs – such as having AstraZeneca first then Pfizer second – could give our booster vaccination programme more flexibility, and possibly even some better immune response’. However, the relevant research is still at a preprint stage, and there has been no indication of what vaccines should be given as boosters.
For practices, this creates difficulties in planning. If different brands are used for the booster, staff may need to be re-trained. GPs also don’t know whether to build in a 15-minute observation period; this is currently required for the Pfizer vaccine and also means more space is needed for patients to wait. Co-administration with flu jabs will also take more time, but it’s unclear how long.
Dr Freda Bhatti, a GP and clinical director of Tendring PCN in Essex, says: ‘We’ve got just weeks to go and we don’t know what vaccine it is going to be.
‘It is hard to work out your strategy with regard to capacity and how you will flow through the practice, and how many minutes you will need to co-administer two vaccines.’
There is also little certainty over what additional level of protection a third jab will offer. The Government has called its trial looking at different vaccine boosters a ‘world first’ and the National Institute for Health Research, which commissioned the research, says it is not aware of any other studies that have published peer-reviewed results in this area. A recent preprint, however, published by The Lancet, showed a University of Oxford study found a third dose of the AstraZeneca vaccine given at least six months after the second boosted antibody levels sixfold and maintained T-cell response.
But Dr Peter English, a retired consultant in communicable disease control, and former chair of the BMA public health medicine committee, says: ‘I’m on the fence about boosters. As far as I know, there does not yet appear to be a significant drop-off in vaccine effectiveness, even in the older people who were vaccinated first.
‘Whether modellers have good reason to believe waning of immunity is likely to be a significant problem in autumn and winter will play in their decision making.’
It is also unclear how much the most vulnerable will benefit from a booster. Public Health England issued a release in July that immunosuppressed patients benefited most from the second Covid vaccines, with 4% effectiveness from the first dose rising to 74% after the second, and the JCVI has prioritised this cohort for boosters. But PHE issued a retraction, after charities pointed out that ‘immunosuppressed’ was a general term, and effectiveness differed based on the condition. As a result, it remains unclear how effective boosters will be in, for example, solid organ transplant patients.
For GPs, one of the most pressing matters is where the vaccinations will take place. When the Covid enhanced service specification came out, there was a sting in the tail: NHS England said it was not operationally feasible to offer jabs at practice level and GPs wishing to take part had to operate as part of primary care network groupings.
GPs remain keen to offer jabs at their own practices, rather than via the PCN. During the first two stages of the programme, GPs were able to administer vaccines at practice level (with the exception of the Pfizer version) although the payments were still offered at PCN grouping level. A Pulse survey revealed 15% of GPs were offering vaccinations at their practice as the designated site for their PCN, while a further 22% said their practice was one of several within their PCN delivering the service.
However, it seems there is a potential opening for practice-level vaccination. NHS England director of primary care vaccination Caroline Temmink said last month that officials are ‘working with the MHRA to make sure that PCNs will be permitted to transport and administer vaccines at a practice level’.
Peter Higgins, chief executive of Lancashire & Cumbria LMCs, says allowing the flexibility to give the vaccine at practice level would be beneficial to GPs and patients: ‘I think the natural place for patients to get the vaccination is their own practice. It makes sense. But if practices agree collaboration is a more efficient way of doing it, that’s fine as well.
‘The concern was there appeared to be no choice – it all had to be at the PCN site.’
Mr Higgins raises another unforeseen issue. ‘Some PCN sites are not available anymore, so flexibility is needed in the system to deal with local circumstances.’
In a bulletin in mid-August, the BMA GP Committee said it was ‘aware of a number of GP groups having problems sourcing, securing and/or funding venues for the booster programme, particularly when previous venues are no longer available’. LMCs have told Pulse that NHS buildings previously used for Covid jabs are no longer free because clinics need to revert to their regular function to help tackle the backlog of care, while other non-NHS buildings – such as leisure centres or those owned by local councils – are also returning to their former use.
Tower Hamlets GP and LMC chair Dr Jackie Applebee tells Pulse: ‘We had a fantastic council building – the Arts Pavilion – which is accessible on the ground floor with enough space for 11 cubicles. The council are taking it back
as they want to start hiring it out again for events.’
Flu jab co-administration
The issues involved in delivering the Covid vaccine at practice level have been compounded by the desire to administer the flu vaccine at the same time, which it is hoped will increase uptake of both vaccines. This is crucial – the 2021/22 flu season could be particularly severe as social distancing measures and local lockdowns may have reduced immunity. The Academy of Medical Sciences predicts the UK flu season could affect up to double the usual numbers, with the JCVI also warning it could begin earlier.
The JCVI says early evidence supports delivery of both vaccines at the same time but the MHRA has yet to announce the results of studies into co-administration or give the go-ahead, so it remains unclear how this will work.
Dr English says: ‘There have been problems co-administering vaccines sometimes but the reasons don’t apply to Covid vaccines. There have been no difficulties with similar types so there’s no reason to think there will be now.’
But practices have already had to start preparing for both programmes. Without the green light to co-administer them, they are moving ahead with flu plans separately. NHS England is this year allowing practices to give flu jabs to patients who aren’t registered with them, in an attempt to minimise those missed.
Peter Higgins does not expect the two jabs to take place simultaneously.
‘I’m advising practices, sort out your flu vaccination programme… and think separately about whether and how to do the Covid booster. I don’t think it’s practical to do both at the same time.’
One GP in Essex says in their PCN: ‘Pharmacists have been pre-booking our patients in September and if we do not plan now we will have unused supplies which are non returnable. Last year the practice incurred a significant loss as patients had their jabs via pharmacists because our delivery was delayed
‘The plan locally this year is for practices to do the flu vaccines in house because of all the uncertainty around co-administration with Covid boosters.’
But if the MHRA does approve co-administration, those practices who cannot or do not wish to offer it could face problems, with patients opting for the larger-scale sites that can do so. NHS England admitted in a FAQs document on the Covid vaccination programme that ‘we appreciate some patients may choose to access their flu vaccinations through a different provider than they might hitherto have done’.
Under-18s to be vaccinated
Alongside this, practices will have to contend with the new cohort of eligible under-18s. There are fears some could be put off, after a year of being told vaccines are reserved for adults, and that the virus is less serious for the young.
Peter Higgins says: ‘The more people we can get with some level of immunity, the more benefit to society as well as individuals. But we will have to wait and see if they’re as keen to come forward.’
But delivering these benefits to society will heap yet more pressure on GPs. They had already performed heroics in fully vaccinating three-quarters of UK adults by mid-August – but it seems their reward is to be handed even greater challenges in the months ahead.
Booster priority groups
In Stage 1 of a potential Covid booster programme for 2021/22, the following groups should be offered a booster dose and the flu vaccine from September:
- Adults aged 16 years and over who are immunosuppressed
- Those living in residential care homes for older adults
- All adults aged 70 years or over
- Adults aged 16 years and over who are considered clinically extremely vulnerable
- Frontline health and social care workers
In Stage 2, the following groups should be offered a booster dose as soon as practicable after Stage 1, with equal emphasis on the flu vaccine where eligible:
- All adults aged 50 years and over
- All adults aged 16 to 49 years in an influenza or Covid-19 at-risk group
- Adult household contacts of immunosuppressed individuals
Vaccination in numbers
- Fully vaccinated people are three times less likely to test positive for Covid-19*
- The Pfizer vaccine is 96% effective against hospitalisation from the Delta variant after two doses; the equivalent figure for the AstraZeneca jab is 92%**
- PHE said vaccination had saved 60,000 lives by late July
- Nine in 10 adults have received at least one Covid jab
- More than three-quarters of adults are fully vaccinated
- More than 250,000 of 18-30s came forward for their first or second dose in the first week of August
*REACT-1 trial from Imperial College London and Ipsos MORI
** Based on PHE analysis, which is still at the preprint stage