The covid-19 pandemic has exacerbated long standing health inequalities experienced by socially excluded groups and without an inclusive approach to covid-19 vaccination these inequalities could be widened further by the vaccine rollout.
The Doctors of the World UK Rapid Needs Assessment of Excluded People in England During the 2020 covid-19 Pandemic revealed that inclusion health populations, including people experiencing homelessness, migrants in vulnerable circumstances, Gypsy, Roma, and Traveller communities, and sex-workers are:
- at increased risk of being exposed to covid-19 due to crowded and shared living conditions, reduced access to hygiene and sanitation facilities, or high-risk working conditions;
- more likely to have poorly managed chronic health problems that increase their risk of morbidity or mortality from covid-19;
- less likely to access timely healthcare if they become unwell with covid-19;
- less able to self-isolate and therefore at increased risk of experiencing outbreaks, a particular concern in view of increased transmissibility of the new covid-19 variant.
In acknowledgement of this, on 24 February 2021, an NHS England (NHSE) communication stated that inclusion health populations “should be considered a priority for vaccination.” Similarly, in a letter to the Secretary of State for Health, dated 1 March 2021, the JCVI advised local teams “consider a universal offer to people experiencing homelessness and rough sleeping, alongside delivery of the programme to priority group 6, where appropriate.” The NHS mobilisation guidance published 12 March 2021 to support this recommendation also explicitly mentions asylum seekers, refugee, and migrant populations who may need additional routes to the vaccine. This approach recognises the need to take into account the complex inter-play of health and social risk factors for serious illness from covid-19 when prioritising patients for the vaccine.
Despite their increased risk of morbidity and mortality from covid-19, inclusion health populations are more likely to face barriers accessing the vaccine. In England, Scotland, and Wales, everyone is entitled to register with a GP and receive the covid-19 vaccine free of charge irrespective of immigration status. To facilitate this NHSE has launched the GP Access campaign and updated its toolkit to increase GP registration among people who frequently face barriers to registration, including people with no fixed abode and migrant populations. GP registration would ensure individuals have an NHS number and are invited for a vaccination in line with the JCVI recommendations. However, vaccine access issues go beyond GP registration as in order to access a covid-19 vaccination using the current mainstream delivery model an individual must also:
- be identified on the GP system as eligible to receive the vaccination – which relies on up-to-date medical records, documented clinical diagnoses and recorded risk factors required for Population Risk Assessment;
- have a consistent address to receive the vaccine invitation;
- be able to read and understand the vaccine invitation and have the language, literacy and digital skills to engage with the booking system;
- be able to access the vaccination centre;
- feel confident that accessing the vaccine is free and independent of immigration control activities;
- believe they would benefit from having the vaccination.
For the above reasons, tailored and outreach vaccination delivery services should run in parallel to an inclusive mainstream delivery approach.
Approval of the AstraZeneca vaccine has made an outreach delivery model possible and mobile devices with access to the vaccine recording system Pinnacle enable live documentation of vaccination. Government guidance is clear that vaccination can be offered without an NHS number thus allowing outreach vaccination of people not registered with a GP. Good practice would include vaccination with simultaneous support to register with a GP for long term healthcare benefit and to facilitate delivery of the second vaccine dose. Several areas in the UK including Oldham, Shrewsbury, Manchester, Redbridge, Liverpool, Brighton, Watford, Leeds and Bradford are already successfully vaccinating inclusion health populations.
The JCVI recently updated its guidance to advise that unvaccinated adults aged under 40 years who are not in a clinical priority group at higher risk of severe covid-19 disease, should be preferentially offered an alternative to the AstraZeneca covid-19 vaccine. Every effort should be made to support adults encountered on outreach who are aged under 40 years to access an alternative vaccine. However, the JCVI advises that where this is not possible and the risk of acquiring or experiencing adverse health outcomes from covid-19 outweigh the rare risk of blood clots from the AstraZeneca vaccine then the AstraZeneca vaccine should be offered.
Improving vaccine accessibility is crucial to increasing vaccine uptake, but it is also necessary to inspire confidence in the covid-19 vaccine and in the system and personnel delivering it. Accurate information that accounts for language and literacy needs delivered via trusted channels is essential for developing confidence in vaccine safety and effectiveness. In response to this need Doctors of The World have translated information on the covid-19 vaccine. Areas that have vaccinated inclusion health populations emphasise the value of partnering with housing providers; voluntary, community and social enterprise organisations; community leaders; and representatives and peer advocates from inclusion health groups. These partners can assist with identifying potential clinic sites, inform culturally appropriate services, and encourage engagement by acting as bridges of trust between vaccine providers and patients.
While the swift roll out of mass vaccination in the UK is something to be celebrated it is imperative that partners responsible for covid-19 vaccine roll-out do not neglect their duty to ensure vaccine access is equitable and that no one is left behind. Inclusion health populations have been identified as a priority for vaccination and vaccine delivery efforts must reflect this.
Amy Stevens is a public health specialty registrar with the Yorkshire and the Humber Deanery currently working with Doctors of the World UK and Bevan Healthcare CIC. She has a special interest in migrant health and health inequalities.
Competing interests: none declared.