Sociodemographic predictors of variation in coverage of the national shingles vaccination programme in England, 2014/15

Social determinants of health and vaccine uptake during the first wave of the COVID-19 pandemic: A systematic review

Social determinants of health significantly impact population health status. The aim of this systematic review was to examine which social vulnerability factors or determinants of health at the individual or county level affected vaccine uptake within the first phase of the vaccination program. We performed a systematic review of peer-reviewed literature published from January 2020 until September 2021 in Medline and Embase (Bagaria et al., 2022) and complemented the review with an assessment of pre-print literature within the same period. We restricted our criteria to studies performed in the EU/UK/EEA/US that report vaccine uptake in the general population as the primary outcome and included various social determinants of health as explanatory variables. This review provides evidence of significant associations between the early phases of vaccination uptake for SARS-CoV-2 and multiple socioeconomic factors including income, poverty, deprivation, race/ethnicity, education and health insurance. The identified associations should be taken into account to increase vaccine uptake in socially vulnerable groups, and to reduce disparities in uptake, in particular within the context of public health preparedness for future pandemics. While further corroboration is needed to explore the generalizability of these findings across the European setting, these results confirm the need to consider vulnerable groups and social determinants of health in the planning and roll-out of SARS-CoV-2 vaccination programs and within the context of future respiratory pandemics.

Forecasting sub-national trends in COVID-19 vaccine uptake in the UK before vaccine rollout

Vaccines have reduced the burden of COVID-19 disease in the UK since their introduction in December 2020. At the time of their introduction, it was unclear the extent to which COVID-19 vaccines would be accepted and how spatial variations in uptake would emerge, driven by socio-demographic characteristics. In this study, data from a large-scale cross-sectional study of over 17,000 adults, surveyed in September and October 2020, was used to provide sub-national forecasts of COVID-19 vaccine uptake across the UK. Bayesian multilevel regression and poststratification was deployed to forecast COVID-19 vaccine acceptance before vaccine rollout across 174 regions of the UK. Although it was found that a majority of the UK adult population would likely take the vaccine, there were substantial heterogeneities in uptake intent across the UK. Large urban areas, including London and North West England, females, Black or Black British ethnicities, and Polish speakers were among the least likely to state an intent to vaccinate. These predicted spatial trends were validated by comparison to observed observed COVID-19 vaccine uptake in late 2021. The methodological approaches deployed in this validated forecasting study may be replicable for the prediction of routine childhood immunisation uptake. Given recent pandemic-induced disruptions to routine immunisation systems, reliable sub-national forecasts of vaccine uptake may provide policymakers and stakeholders early warning signals of potential vaccine confidence issues.

Drivers of and barriers to routine adult vaccination: A systematic literature review

We performed a systematic literature review in PubMed and Embase (2016-2021) to investigate the drivers of and barriers to routine vaccination in adults aged 50 and older globally. A thematic assessment identified three categories across 61 publications: sociodemographic, health-related, and attitudinal. The most common sociodemographic determinants (factors identified in studies; n = 47) associated with vaccination uptake were economic status, age, education, and household composition, which had mixed effects on vaccine uptake. For health-related determinants (n = 27), individuals with comorbidities and health care consumption were the most common factors, both increased vaccine uptake. The most common attitudinal factors (n = 42) were self-efficacy, provider or other's recommendations, and vaccine-preventable disease awareness; across studies, all attitude factors had a positive effect, unlike the sociodemographic and health status categories. Findings suggest that patient and provider awareness and education campaigns are effective ways to increase uptake of routine vaccinations in older adults.

Recording of 'COVID-19 vaccine declined': a cohort study on 57.9 million National Health Service patients' records in situ using OpenSAFELY, England, 8 December 2020 to 25 May 2021

BackgroundPriority patients in England were offered COVID-19 vaccination by mid-April 2021. Codes in clinical record systems can denote the vaccine being declined.AimWe describe records of COVID-19 vaccines being declined, according to clinical and demographic factors.MethodsWith the approval of NHS England, we conducted a retrospective cohort study between 8 December 2020 and 25 May 2021 with primary care records for 57.9 million patients using OpenSAFELY, a secure health analytics platform. COVID-19 vaccination priority patients were those aged ≥ 50 years or ≥ 16 years clinically extremely vulnerable (CEV) or 'at risk'. We describe the proportion recorded as declining vaccination for each group and stratified by clinical and demographic subgroups, subsequent vaccination and distribution of clinical code usage across general practices.ResultsOf 24.5 million priority patients, 663,033 (2.7%) had a decline recorded, while 2,155,076 (8.8%) had neither a vaccine nor decline recorded. Those recorded as declining, who were subsequently vaccinated (n = 125,587; 18.9%) were overrepresented in the South Asian population (32.3% vs 22.8% for other ethnicities aged ≥ 65 years). The proportion of declining unvaccinated patients was highest in CEV (3.3%), varied strongly with ethnicity (black 15.3%, South Asian 5.6%, white 1.5% for ≥ 80 years) and correlated positively with increasing deprivation.ConclusionsClinical codes indicative of COVID-19 vaccinations being declined are commonly used in England, but substantially more common among black and South Asian people, and in more deprived areas. Qualitative research is needed to determine typical reasons for recorded declines, including to what extent they reflect patients actively declining.

Access to Vaccination among Disadvantaged, Isolated and Difficult-to-Reach Communities in the WHO European Region: A Systematic Review

Vaccination has a significant impact on morbidity and mortality. High vaccination coverage rates are required to achieve herd protection against vaccine-preventable diseases. However, limited vaccine access and hesitancy among specific communities represent significant obstacles to this goal. This review provides an overview of critical factors associated with vaccination among disadvantaged groups in World Health Organisation European countries. Initial searches yielded 18,109 publications from four databases, and 104 studies from 19 out of 53 countries reporting 22 vaccine-preventable diseases were included. Nine groups representing the populations of interest were identified, and most of the studies focused on asylum seekers, refugees, migrants and deprived communities. Recall of previous vaccinations received was poor, and serology was conducted in some cases to confirm protection for those who received prior vaccinations. Vaccination coverage was lower among study populations compared to the general population or national average. Factors that influenced uptake, which presented differently at different population levels, included health service accessibility, language and vaccine literacy, including risk perception, disease severity and vaccination benefits. Strategies that could be implemented in vaccination policy and programs were also identified. Overall, interventions specific to target communities are vital to improving uptake. More innovative strategies need to be deployed to improve vaccination coverage among disadvantaged groups.

Characteristics associated with COVID-19 vaccine uptake among adults aged 50 years and above in England (8 December 2020-17 May 2021): a population-level observational study

OBJECTIVE

To determine characteristics associated with COVID-19 vaccine coverage among individuals aged 50 years and above in England since the beginning of the programme.

DESIGN

Observational cross-sectional study assessed by logistic regression and mean prevalence margins.

SETTING

COVID-19 vaccinations delivered in England from 8 December 2020 to 17 May 2021.

PARTICIPANTS

30 624 257/61 967 781 (49.4%) and 17 360 045/61 967 781 (28.1%) individuals in England were recorded as vaccinated in the National Immunisation Management System with a first dose and a second dose of a COVID-19 vaccine, respectively.

INTERVENTIONS

Vaccination status with COVID-19 vaccinations.

MAIN OUTCOME MEASURES

Proportion, adjusted ORs and mean prevalence margins for individuals not vaccinated with dose 1 among those aged 50-69 years and dose 1 and 2 among those aged 70 years and above.

RESULTS

Of individuals aged 50 years and above, black/African/Caribbean ethnic group was the least likely of all ethnic groups to be vaccinated with dose 1 of the COVID-19 vaccine. However, of those aged 70 years and above, the odds of not having dose 2 was 5.53 (95% CI 5.42 to 5.63) and 5.36 (95% CI 5.29 to 5.43) greater among Pakistani and black/African/Caribbean compared with white British ethnicity, respectively. The odds of not receiving dose 2 was 1.18 (95% CI 1.16 to 1.20) higher among individuals who lived in a care home compared with those who did not. This was the opposite to that observed for dose 1, where the odds of being unvaccinated was significantly higher among those not living in a care home (0.89 (95% CI 0.87 to 0.91)).

CONCLUSIONS

We found that there are characteristics associated with low COVID-19 vaccine coverage. Inequalities, such as ethnicity are a major contributor to suboptimal coverage and tailored interventions are required to improve coverage and protect the population from SARS-CoV-2.

Trends and clinical characteristics of COVID-19 vaccine recipients: a federated analysis of 57.9 million patients’ primary care records in situ using OpenSAFELY

BACKGROUND

On 8 December 2020 NHS England administered the first COVID-19 vaccination.

AIM

To describe trends and variation in vaccine coverage in different clinical and demographic groups in the first 100 days of the vaccine rollout.

DESIGN AND SETTING

With the approval of NHS England, a cohort study was conducted of 57.9 million patient records in general practice in England, in situ and within the infrastructure of the electronic health record software vendors EMIS and TPP using OpenSAFELY.

METHOD

Vaccine coverage across various subgroups of Joint Committee on Vaccination and Immunisation (JCVI) priority cohorts is described.

RESULTS

A total of 20 852 692 patients (36.0%) received a vaccine between 8 December 2020 and 17 March 2021. Of patients aged ≥80 years not in a care home (JCVI group 2) 94.7% received a vaccine, but with substantial variation by ethnicity (White 96.2%, Black 68.3%) and deprivation (least deprived 96.6%, most deprived 90.7%). Patients with pre-existing medical conditions were more likely to be vaccinated with two exceptions: severe mental illness (89.5%) and learning disability (91.4%). There were 275 205 vaccine recipients who were identified as care home residents (JCVI group 1; 91.2% coverage). By 17 March, 1 257 914 (6.0%) recipients had a second dose.

CONCLUSION

The NHS rapidly delivered mass vaccination. In this study a data-monitoring framework was deployed using publicly auditable methods and a secure in situ processing model, using linked but pseudonymised patient-level NHS data for 57.9 million patients. Targeted activity may be needed to address lower vaccination coverage observed among certain key groups.

Older adults' vaccine hesitancy: Psychosocial factors associated with influenza, pneumococcal, and shingles vaccine uptake

Influenza, pneumococcal disease, and shingles (herpes zoster) are more prevalent in older people. These illnesses are preventable via vaccination, but uptake is low and decreasing. Little research has focused on understanding the psychosocial reasons behind older adults' hesitancy towards different vaccines. A cross-sectional survey with 372 UK-based adults aged 65-92 years (M = 70.5) assessed awareness and uptake of the influenza, pneumococcal, and shingles vaccines. Participants provided health and socio-demographic data and completed two scales measuring the psychosocial factors associated with vaccination behaviour. Self-reported daily functioning, cognitive difficulties, and social support were also assessed. Participants were additionally given the opportunity to provide free text responses outlining up to three main reasons for their vaccination decisions. We found that considerably more participants had received the influenza vaccine in the last 12 months (83.6%), relative to having ever received the pneumococcal (60.2%) and shingles vaccines (58.9%). Participants were more aware of their eligibility for the influenza vaccine, and were more likely to have been offered it. Multivariate logistic regression analyses showed that a lower sense of collective responsibility independently predicted lack of uptake of all three vaccines. Greater calculation of disease and vaccination risk, and preference for natural immunity, also predicted not getting the influenza vaccine. For both the pneumococcal and shingles vaccines, concerns about profiteering further predicted lack of uptake. Analysis of the qualitative responses highlighted that participants vaccinated to protect their own health and that of others. Our findings suggest that interventions targeted towards older adults would benefit from being vaccine-specific and that they should emphasise disease risks and vaccine benefits for the individual, as well as the benefits of vaccination for the wider community. These findings can help inform intervention development aimed at increasing vaccination uptake in future.

Herpes zoster in older adults in Ontario, 2002-2016: Investigating incidence and exploring equity

Older adults are at increased risk of herpes zoster (HZ) and post-herpetic neuralgia (PHN) and HZ vaccines are available to help prevent infection. The objective of our study was to provide updated data on incidence of HZ and PHN related to clinical and demographic factors in older adults to inform immunization practices. We conducted a population-based, retrospective cohort study and included all cases of HZ seen in outpatient, emergency department, and hospital settings for adults aged 65 years and over between April 1, 2002 to August 31, 2016 in Ontario, Canada. We calculated the incidence of HZ and PHN, and estimated the proportion within each subgroup that developed PHN. We also assessed incidence by neighbourhood-level income quintile before and after the availability of vaccine for private purchase. The average annual incidence of HZ in any setting was 59.0 per 10,000 older adults, with higher incidence in outpatient as opposed to hospital settings. Incidence was higher in the oldest age groups, females, and those classified as immunocompromised or frail. Relative to the pre-vaccine era, the disparities in incidence of HZ by neighbourhood-level income increased, with higher rates of HZ and PHN seen in those residing in lower income quintiles. Additional prevention efforts should be targeted toward adults who are immunocompromised, frail, and those living in lower socioeconomic quintiles. Future work should assess the impact of the zoster vaccine program with a particular focus on equity in the publicly-funded era.

Determinants of shingles vaccine acceptance in the United Kingdom

BACKGROUND

The United Kingdom (UK) was the first European country to introduce a national immunisation program for shingles (2013-2014). That year, vaccination coverage ranged from 50 to 64% across the UK, but uptake has declined ever since. This study explored determinants of the acceptance of the shingles vaccine in the UK.

METHODS

Vaccinated and unvaccinated individuals, who were eligible for the last catch-up cohort of the 2014-2015 shingles vaccination campaign, were identified using the Clinical Practice Research Datalink (the National Health Service data research service) and invited to participate by their general practitioner (GP). An anonymised self-administered questionnaire was developed using the Health Belief Model as a theoretical framework, to collect data on demographic and socio-economic characteristics, health status, knowledge, influences, experiences and attitudes to shingles and the shingles vaccine. Multivariable logistic regression was used to identify the factors associated with vaccination. Physicians' views concerning perceived barriers to vaccination were also assessed.

RESULTS

Of the 2,530 questionnaires distributed, 536 were returned (21.2%) from 69 general practices throughout the UK. The majority of responders were female (58%), lived in care homes (56%) and had completed secondary or higher education (88%). There were no differences between vaccinated and unvaccinated responders. Being offered the shingles vaccine by a GP/nurse (odds ratio (OR) = 2.3), and self-efficacy (OR = 1.2) were associated with being vaccinated (p<0.05). In contrast, previous shingles history (OR = 0.4), perceived barriers to vaccination (OR = 0.7) and perceived control of the disease (OR = 0.7) were associated with not being vaccinated against shingles (p<0.05). Less than half (44.0%) of GPs were aware of the local communication campaigns regarding shingles and the shingles vaccine.

CONCLUSIONS

Socio-psychological factors largely influence shingles vaccination acceptance in this study. The results add to existing evidence that healthcare providers (HCPs) have a pivotal role against vaccine hesitancy. Campaigns focusing on GPs and accessible information offered to eligible members of the public can further enhance shingles vaccine uptake.

What is the cost of delivering routine vaccinations at GP practices in England? A comparative time-driven activity-based costing analysis

Background: The expansion of available vaccines in recent years has increased the overall costs of the vaccine program and put pressure on providers responsible for vaccination. In England in 2016-17, GP practices responsible for vaccinating their local population were paid £227 million. However, the costs to general practice of delivering the program and the factors influencing these costs are unknown. Therefore, the aim of this study was to evaluate the costs of delivering the routine vaccination program at GP practices in England, to identify organizational factors impacting costs, and to compare these to the funding received.Methods: Time Driven Activity Based Costing was undertaken at a convenience sample of nine geographically and socio-economically diverse GP practices in 2017-2018. Cost data were gathered for the preceding year using a survey and clinical and administrative staff kept activity logs for a 2-week period.Results: The mean cost of delivering a childhood vaccination appointment was £18.20 (range £9.71-£25.97) and an adult appointment cost £14.05 (range £7.59-£20.88), of which 75% was for staff, 24% for facility costs and 1% for consumables. Organizational factors contributing to lower costs include: shorter length of allocated appointment; greater use of administrative and reception staff; lower working time for practice manager and practice nurse; and use of health-care assistants for adult vaccinations. The costs identified are lower than payments at all practices.Conclusions: Funding received for vaccination activities was higher than costs at included practices. Several organizational factors have been identified that impact on program delivery costs that could be modified.

Zoster vaccination inequalities: A population based cohort study using linked data from the UK Clinical Practice Research Datalink

OBJECTIVE

To quantify inequalities in zoster vaccine uptake by determining its association with socio-demographic factors: age, gender, ethnicity, immigration status, deprivation (at Lower-layer Super Output Area-level), care home residence and living arrangements.

METHOD

This population-based cohort study utilised anonymised primary care electronic health records from England (Clinical Practice Research Datalink) linked to deprivation and hospitalisation data. Data from 35,333 individuals from 277 general practices in England and eligible for zoster vaccination during the two-year period (2013-2015) after vaccine introduction were analysed. Logistic regression was used to obtain adjusted odds ratios (aOR) for the association of socio-demographic factors with zoster vaccine uptake for adults aged 70 years (main target group) and adults aged 79 years (catch-up group).

RESULTS

Amongst those eligible for vaccination, 52.4% (n = 18,499) received the vaccine. Socio-demographic factors independently associated with lower zoster vaccine uptake in multivariable analyses were: being older (catch-up group: aged 79 years) aOR = 0.89 (95% confidence interval (CI):0.85-0.93), care home residence (aOR = 0.64 (95%CI: 0.57-0.73)) and living alone (aOR = 0.85 (95%CI: 0.81-0.90)). Uptake decreased with increasing levels of deprivation (p-value for trend<0.0001; aOR most deprived versus least deprived areas = 0.69 (95%CI: 0.64-0.75)). Uptake was also lower amongst those of non-White ethnicities (for example, Black versus White ethnicity: aOR = 0.61 (95%CI: 0.49-0.75)) but was not lower among immigrants after adjusting for ethnicity. Lower uptake was also seen amongst females compared to men in the catch-up group.

CONCLUSIONS

Inequalities in zoster vaccine uptake exist in England; with lower uptake among those of non-White ethnicities, and among those living alone, in a care home and in more deprived areas. Tailored interventions to increase uptake in these social groups should assist in realising the aim of mitigating vaccination inequalities. As care home residents are also at higher risk of zoster, improving the uptake of zoster vaccination in this group will also mitigate inequalities in zoster burden.

A process evaluation of how the routine vaccination programme is implemented at GP practices in England

BACKGROUND

In recent years, the incidence of several pathogens of public health importance (measles, mumps, pertussis and rubella) has increased in Europe, leading to outbreaks. This has included England, where GP practices implement the vaccination programme based on government guidance. However, there has been no study of how implementation takes place, which makes it difficult to identify organisational variation and thus limits the ability to recommend interventions to improve coverage. The aim of this study is to undertake a comparative process evaluation of the implementation of the routine vaccination programme at GP practices in England.

METHODS

We recruited a sample of geographically and demographically diverse GP practices through a national research network and collected quantitative and qualitative data as part of a Time-Driven Activity-Based Costing analysis between May 2017 and February 2018. We conducted semi-structured interviews with practice staff involved in vaccination, who then completed an activity log for 2 weeks. Interviews were transcribed and coded using a framework method.

RESULTS

Nine practices completed data collection from diverse geographic and socio-economic contexts, and 52 clinical and non-clinical staff participated in 26 interviews. Information relating to 372 vaccination appointments (233 childhood and 139 adult appointments) was captured using activity logs. We have defined a 14-stage care delivery value chain and detailed process map for vaccination. Areas of greatest variation include the method of reminder and recall activities, structure of vaccination appointments and task allocation between staff groups. For childhood vaccination, mean appointment length was 15.9 min (range 9.0-22.0 min) and 10.9 min for adults (range 6.8-14.1 min). Non-clinical administrative activities comprised 59.7% total activity (range 48.4-67.0%). Appointment length and total time were not related to coverage, whereas capacity in terms of appointments per eligible patient may improve coverage. Administrative tasks had lower fidelity of implementation.

CONCLUSIONS

There is variation in how GP practices in England implement the delivery of the routine vaccination programme. Further work is required to evaluate capacity factors in a wider range of practices, alongside other contextual factors, including the working culture within practices.

Evaluation of the effect of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study

BACKGROUND

In 2013, a herpes zoster vaccination programme was introduced in England for adults aged 70 years with a phased catch-up programme for those aged 71-79 years. We aimed to evaluate the effect of the first 3 years of the vaccination programme on incidence of herpes zoster and postherpetic neuralgia in this population.

METHODS

In this population-based study, we extracted data from the Royal College of General Practitioners sentinel primary care network on consultations with patients aged 60-89 years for herpes zoster and postherpetic neuralgia occurring between Oct 1, 2005, and Sept 30, 2016, obtaining data from 164 practices. We identified individual data on herpes zoster vaccinations administered and consultations for herpes zoster and postherpetic neuralgia, and aggregated these data to estimate vaccine coverage and incidence of herpes zoster and postherpetic neuralgia consultations. We defined age cohorts to identify participants targeted in each year of the programme, and as part of the routine or catch-up programme. We modelled incidence according to age, region, gender, time period, and vaccine eligibility using multivariable Poisson regression with an offset for person-years.

FINDINGS

Our analysis included 3·36 million person-years of data, corresponding to an average of 310 001 patients aged 60-89 years who were registered at an RCGP practice each year. By Aug 31, 2016, uptake of the vaccine varied between 58% for the recently targeted cohorts and 72% for the first routine cohort. Across the first 3 years of vaccination for the three routine cohorts, incidence of herpes zoster fell by 35% (incidence rate ratio 0·65 [95% 0·60-0·72]) and of postherpetic neuralgia fell by 50% (0·50 [0·38-0·67]). The equivalent reduction for the four catch-up cohorts was 33% for herpes zoster (incidence rate ratio 0·67 [0·61-0·74]) and 38% for postherpetic neuralgia (0·62 [0·50-0·79]). These reductions are consistent with a vaccine effectiveness of about 62% against herpes zoster and 70-88% against postherpetic neuralgia.

INTERPRETATION

The herpes zoster vaccination programme in England has had a population impact equivalent to about 17 000 fewer episodes of herpes zoster and 3300 fewer episodes of postherpetic neuralgia among 5·5 million eligible individuals in the first 3 years of the programme. Communication of the public health impact of this programme will be important to reverse the recent trend of declining vaccine coverage.

FUNDING

Public Health England.

Extracting general practice data for timely vaccine coverage estimates: The England experience

In England, primary care providers use standardised coding systems to record health events such as vaccination as well as patient characteristics. This information can be automatically extracted to estimate coverage for vaccine programmes delivered through primary care, in the general population as well as in specific geographical, ethnic, age or clinical groups. This system provides timely vaccine coverage estimates as well as the flexibility to extract tailored data in order to directly inform a continuously evolving national vaccine programme. It is however limited by the quality and completeness of clinical coding in primary care. A centralised, individual-level register would however improve data quality, completeness and reliability and remains the gold standard.