Implementation of covid-19 vaccination in the United Kingdom
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj-2022-070344 (Published 29 September 2022) Cite this as: BMJ 2022;378:e070344Read our Covid Inquiry series
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Dear Editor,
I thank Elizabeth Cannon for her response to our article.[1] She describes the role that social media played in the USA in promoting misinformation about vaccines. As she states, vaccine hesitancy is not new but social media has increased the reach of misinformation about vaccines and the speed at which this information will spread. More positively, public health organisations such as CDC and WHO are countering this misinformation by promoting reliable, evidence-based information about vaccines. I agree with her final points about trying to depoliticise the debate around Covid-19 vaccines (which is a particularly prominent issue in the USA and in some other countries) and building credibility among the public in official sources of information on vaccines.
Reference
1. Majeed A, Pollock K, Hodes S, Papaluca M. Implementation of covid-19 vaccination in the United Kingdom BMJ 2022; 378 :e070344 doi:10.1136/bmj-2022-070344
Competing interests: No competing interests
Dear Editor,
I thank Kajl Ahmad for their response to our article and for their contribution to the UK’s Covid-19 vaccination programme.[1] Volunteers such as Kajl Ahmad played an important role in the implementation of Covid-19 vaccination in the UK. Kajl Ahmad highlights the key issue of vaccine hesitancy in the UK, particularly in people from ethnic minority backgrounds, and how misinformation on social media drove this.[2] Addressing vaccine hesitancy requires a multi-faceted approach. Directly countering misinformation and showing examples of reliable information– as done by Kajl Ahmad – can help address vaccine hesitancy and improve vaccine uptake. Everyone involved in our vaccination programme – government, the NHS, public health bodies, health and care professionals, and vaccine recipients – has a role to play in overcoming vaccine hesitancy but they do need support from the print and broadcast media as well from social media companies.
References
1. Majeed A, Pollock K, Hodes S, Papaluca M. Implementation of covid-19 vaccination in the United Kingdom BMJ 2022; 378 :e070344 doi:10.1136/bmj-2022-070344
3. Razai M S, Chaudhry U A R, Doerholt K, Bauld L, Majeed A. Covid-19 vaccination hesitancy BMJ 2021; 373 :n1138 doi:10.1136/bmj.n1138
Competing interests: No competing interests
Dear Editor,
I thank Linwei Li for their response to our article.[1] Linwei Li describes methods to address vaccine hesitancy and improve Covid-19 vaccine uptake in China. Concern about side effects is a key factor and as more data on safety becomes available globally, this should help address this issue.[2] Using community-based interventions is important to improve vaccine uptake and similar approaches have been used in many other countries, including the UK. Using material incentives is more controversial and has not been widely adopted. The use of incentives to encourage vaccine uptake does require careful evaluation, including of the ethical aspects.
References
1. Majeed A, Pollock K, Hodes S, Papaluca M. Implementation of covid-19 vaccination in the United Kingdom BMJ 2022; 378 :e070344 doi:10.1136/bmj-2022-070344
2. Majeed A, Papaluca M, Molokhia M. Assessing the long-term safety and efficacy of COVID-19 vaccines. Journal of the Royal Society of Medicine. 2021;114(7):337-340. doi:10.1177/01410768211013437
Competing interests: No competing interests
Dear Editor,
I thank Run Yuan for their response to our article.[1] Run Yuan describes the stricter rules about vaccination and entry to public areas such as cinemas and restaurants in China. The use of vaccination in this way (sometimes referred to as “vaccine passports”) is controversial and has largely fallen out of favour in European countries as they move to a “living with Covid-19 strategy”.[2] As in the UK, older and clinically vulnerable people were prioritised for vaccination. The use of incentives to encourage vaccine uptake is an interesting idea but is something that is not used in the UK. As Run Yuan describes, concerns about side effects remain a key issue and is one of the factors that underlies vaccine hesitancy in China and elsewhere.[3]
References
1. Majeed A, Pollock K, Hodes S, Papaluca M. Implementation of covid-19 vaccination in the United Kingdom BMJ 2022; 378 :e070344 doi:10.1136/bmj-2022-070344
2. Osama T, Razai M S, Majeed A. Covid-19 vaccine passports: access, equity, and ethics BMJ 2021; 373 :n861 doi:10.1136/bmj.n861
3. Razai M S, Chaudhry U A R, Doerholt K, Bauld L, Majeed A. Covid-19 vaccination hesitancy BMJ 2021; 373 :n1138 doi:10.1136/bmj.n1138
Competing interests: No competing interests
Dear Editor
The implementation of the Covid-19 vaccination program in Jordan
The COVID-19 vaccine is one of the most effective tools against severe illness, hospitalization, and death resulting from the infection of different strains of SARS-CoV-2.
Like many other countries, Jordan, a country located in the Eastern Mediterranean Region (EMR) with a population of 10,316,562, was not an exception to being impacted by the COVID-19 pandemic (1). Being a middle-income country (MIC) with limited resources in an unstable zone of the Middle East added more challenges to dealing efficiently with the pandemic (2). However, the efficient coordination between the different sectors and the appropriate decision-making contributed to Jordan’s successful experience in the vaccine rollout and achieved vaccine equity among the various populations within the country.
In Jordan, four types of COVID-19 vaccines have been approved by Jordan Food & Drug Administration (JFDA), These vaccines are Pfizer/BioNTech (BNT162b2), Oxford/AstraZeneca (AZD1222), Gamaleya (Sputnik V) and Sinopharm (Beijing) BBIBP-CorV (Vero Cells) (3).
Jordan has received sufficient quantities of COVID-19 vaccines through the COVAX program, which is co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance, and the WHO, alongside key delivery partner UNICEF. COVAX aims to speed up the development and production of COVID- 19 vaccines while also ensuring fair and equal access for all countries throughout the world (4).
As of July 2022, Jordan has administered around 10,007,983 doses of COVID-19 vaccines, which accounts for nearly 49.5% of the whole population being vaccinated with two doses (3).
Jordan has developed its national immunization plan for the COVID-19 roll-out. Registration through the ministry of health website started in late 2020 and the vaccination rollout was in January 2021. As Jordan is a country that hosts a high number of refugees from neighboring countries, vaccination programs included all of them. Remarkably, the COVID-19 vaccination data system was established on a strong electronic system, unlike the childhood immunization program, which is still a paper-based vaccination system today (6).
Like in the UK, there was coordination between the Ministry of Health (MoH) and the National Center for Security and Crisis Management (NCSCM). The technical implementation was driven by the MoH, whereas the NCSCM led the logistical and cooperation duties. The NCSCM has given the political aspect to the vaccine's roll-out process, which was a bit new to the population. However, it added a lot of high commitment to monitor the operations very effectively. All populations have been targeted, starting with the most vulnerable patients such as elderly and immunocompromised patients, healthcare professionals, and highly exposed people to COVID-19. These groups were regularly viewed and updated by the National Coordination Committee, which is part of the NCSCM (6).
Vaccination centres were distributed throughout the country. It was run by the MoH, university hospitals, Royal Medical Services, and the United Nations Relief and Work Agency (UNRWA). Also, a mobile vaccination service was available for those who couldn’t reach the vaccination centres.
High vaccine hesitancy rates were observed among the population during the early months of rolling out the COVID-19 vaccine, COVID-19 misinformation; spreading rumors through social media platforms, and the lack of trust in governmental actions. All these were reasons to hold back from receiving the jab. The government, healthcare professionals, and private and public institutions needed to run big campaigns to re-correct the misconceptions about the disease and the vaccine (7).
References: 1.
2. Ala'a B, Tarhini Z, Akour A. A swaying between successive pandemic waves and pandemic fatigue: Where does Jordan stand?
4. Gavi.org. 2021. COVAX Facility. [online] Available at: https://www.gavi.org/covax-facility#what
5. Bhatia G, Dutta PK, McClure J. Jordan: The Latest Coronavirus Counts, charts and maps [Internet]. Reuters. Thomson Reuters; 2022 [cited 2022Oct23]. Available from: https://graphics.reuters.com/world-coronavirus-tracker-and-maps/countrie...
6. Worldometers.info. 2021. Jordan Population (2021) - Worldometer. [online] Available at: https://www.worldometers.info/world-population/jordan-population/
3. Covid19.trackvaccines.org. 2021. Vaccines – COVID19 Vaccine Tracker. [online] Available at: https://covid19.trackvaccines.org/vaccines/approved/
Muthu N, Aidyralieva C, Profili MC, Bellizzi S. COVID-19 vaccine roll-out in middle-income countries: Lessons learned from the Jordan experience. Vaccine. 2021 Aug 8;39(34):4769.
7. Abdel-Qader DH, Hayajneh W, Albassam A, Obeidat NM, Belbeisi AM, Al Mazrouei N, Ala'a F, Nusair KE, Al Meslamani AZ, El-Shara AA, El Sharu H. Pharmacists-physicians collaborative intervention to reduce vaccine hesitancy and resistance: A randomized controlled trial. Vaccine: X. 2022 Apr 1;10:100135.
Competing interests: No competing interests
Dear Editor,
During my junior year of college, the vaccine roll out began in the United States. As access to vaccines increased so did the digital content surrounding them. For me, it was hard to gain perspective of the pros and cons when you did not know what information was exaggerated, accurate, or flat out wrong. Personally, I received the Johnson and Johnson single dose vaccine. If that happened to come up in conversation, I would be bombarded by opinions from peers I too had seen on social media: J & J leads to infertility, J & J causes blood clots, or J & J is dangerous. The lack of professional education about vaccinations led to uncertainty. This uncertainty led people to cling onto any information presented to them.
While vaccine hesitancy is not a new phenomena, it is important to realize how significant social media and mainstream media has become in spreading news, and how easily the public is willing to believe it. Studies found a significant relationship between not only social media and public hesitation, but also between foreign disinformation campaigns and decreased mean vaccine coverage. The World Health Organization (WHO) even listed vaccine hesitancy as a top 10 threat to world health in 2019. So, the question we must ask is how do we start taking advantage of the social marketing opportunity we have in front of us?
We need to step back and ask ourselves 2 main questions:
What kind of information do people need?
Why would they say no or be hesitant about it?
What kind of information do people need:
Right now, we need information without political bias. By browsing the WHO and CDC website and social media pages, I see simplified facts and creative digital content. This informational marketing will work well for generations who are mainly on social media. The association between health organizations and the government is what causes the blurry vision between the ability to differentiate fact and fiction.
Hesitancy and rejection:
With politically unjust times, we have reached a time where the public trust in the government has reached a historic low. Listening to government officials and the news about the importance of vaccination may cause individuals to question the motives behind the information told to them. At the end of the day, as public health officials we need to find a way to dissociate vaccine coverage with political gain. We need to find a way to market with good intention and limit political bias/association. I believe this is the only way we can overcome vaccine hesitancy from creeping up the ladder of the WHO’s list of top threats to public health. This is something which needs to be implemented ASAP in order to not only improve conditions with COVID-19, but also to increase trust in the future of public health as we continue to run into global issues.
Sources:
https://www.pewresearch.org/politics/2022/06/06/public-trust-in-governme...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8650625/
https://gh.bmj.com/content/5/10/e004206
Competing interests: No competing interests
Dear Editor,
I would like to share examples of work to address vaccine hesitancy in China.
China released the first edition of the technical guidelines for covid-19 vaccination in March 2021, which call for increasing the vaccination rates following the principle of "informed, voluntary, and free". According to the National Health Commission, the coverage rate of the first dose of the covid-19 vaccine in mainland China was 92.1%, the full vaccination rate was 89.7% and the booster vaccination rate was 71.7% by July 2022 (Source: news.cn xinhua news 2022 July 23). However, in the early stages of the introduction of China's domestically produced inactivated vaccine in September 2020, there was a degree of vaccine hesitancy among the population due to questions about the effectiveness and safety of the vaccine. In response, China has adopted a territorial approach to vaccination, with vaccination being introduced on a community basis.
The community is the basic unit of social life and grassroots management for Chinese residents, usually consisting of party branches, neighbourhood committees, neighbourhood centres and other departments. In the covid-19 vaccination programme, the vaccination rate is allocated to the community as a political task and target, and the community is responsible for mobilisation and organisation. Firstly, at the community level, extensive initiatives are carried out to spread vaccine-related knowledge and encourage vaccination throughout the community using posters, news and broadcasts. Secondly, at the individual level, community workers visit and persuade residents who decline vaccination. In short, the vaccination programme has become part of the regular work of the community and is carried out as a political task. With dedicated efforts and close contact between the community and residents, vaccination coverage has increased significantly.
While making the vaccination programme as a political task and requiring communities to be responsible for it is an efficient and direct solution to vaccine hesitancy, it has also led to several problems. Prominent among these are the irrational and unscientific means used by some communities to achieve vaccination coverage targets. For example, material rewards are a common incentive for vaccination, and the rewards of food and daily necessities can be effective in attracting the elderly and poor to vaccination. However, a few communities have resorted to direct cash handouts to attract more residents to be vaccinated, which results in a waste of public property. It can also lead to resentment among those who received vaccinations early but did not receive material rewards.
Competing interests: No competing interests
Dear Editor
The Covid-19 pandemic started, in the UK, 2020.By September 2021, I was employed as a covid-19 vaccination operations manager. The general belief in the London population was that the two individuals who were infected by the disease, did not enter the capital city and were quickly admitted to the Infectious Disease Unit at Castle Hill Hospital. [1]. However, by June 2020, Covid-19 was declared the third most frequent underlying cause of death by the Office for National Statistics, in England [2]. Although the government introduced the first lockdown by 8/06/2020, people went against the government guidelines and broke lockdown rules. The Serco Institute nationally representative poll revealed 57% of people say they know someone who broke lockdown rules [3]. Therefore, the statistics revealed that the pressure for the introduction of a Covid-19 vaccination rollout in the United Kingdom was growing.
The UK administered the first fully clinically trialled and tested Covid-19 vaccine on 8/12/2020 and was ahead of every European Union (EU country) in the Covid-19 vaccination roll-out programme. Initially, Covid-19 vaccines were administered in clinical settings by healthcare workers. However, soon the increasing demand for the Covid-19 vaccine in younger age groups in the population meant that the government was behind the target to offer every adult a Covid-19 vaccine by 19/06/2021 [4]. Therefore, the NHS partnered with St John Ambulance to train individuals to administer the vaccine. UK residents, including myself, stepped forward trained as volunteers.
I volunteered in a local pharmacy in Southall, London, and was able to see the vaccine hesitancy amongst the population in a deprived area. Southall is considered to be home to a large South Asian low-income population. As I began to volunteer more frequently and was later employed as a vaccinator, I witnessed the negative impacts of the spread of misinformation around the Covid-19 vaccine. Patients were refusing the Covid-19 vaccine on the basis that it would cause infertility. Often the patients who refused the Covid-19 vaccine, would present a WhatsApp message on which issued a warning that the Pfizer vaccine would make them infertile. In order to help minimise the spread of misinformation associated with the Covid-19 vaccine; I would provide them with the official Public Health England Covid-19 Vaccination leaflet. However, vaccine hesitancy increased at an alarming rate in deprived London areas with posters causing fear amongst the low-income population. According to an Ofcom survey, it was concluded that 28% of 2000 respondents had been exposed to misinformation surrounding Covid-19, March 2021 [5]. Although the government and social media platforms partnered up to moderate vaccine information on social media platforms, Covid-19 vaccine misinformation was still a major Public Health threat amongst low income societies.
The negative information of the Covid-19 vaccine was still a cause of concern more than a year later. After being employed as a Covid-19 vaccination operations manager of a mass vaccination site, leaflets were left at the entrance of the Covid-19 vaccination site, January 2022.
Research carried out by The Royal Society and The British Academy concluded that vaccine uptake has always been lower amongst ethnic minority groups, despite being the most successful way in curbing the spread of disease [6]. Therefore, in conclusion it is vital to understand where vaccine hesitancy stems from amongst low-income groups, historically and put more emphasis in helping lower-income communities understand the benefits of vaccine uptake.
1. Lillie, P.J., Samson, A., Li, A., Adams, K., Capstick, R., Barlow, G.D., Easom, N., Hamilton, E., Moss, P.J., Evans, A., Ivan, M., PHE Incident Team, Taha, Y., Duncan, C.J.A., Schmid, M.L. and the Airborne HCID Network (2020). Novel coronavirus disease (Covid-19): The first two patients in the UK with person to person transmission. Journal of Infection, 80(5). doi:10.1016/j.jinf.2020.02.020.
2. Campbell, D.A. and Caul, S. (2020). Deaths involving COVID-19, England and Wales - Office for National Statistics. [online] www.ons.gov.uk. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarri....
3. Serco Institute. (2020). Poll: Nearly 60% of UK know someone who broke lockdown rules & majority sceptical of Sue Gray investigation outcomes ahead of publication. [online] Available at: https://www.sercoinstitute.com/news/2022/poll-nearly-60-of-the-uk-public....
4. GOV.UK. (2020). Every adult in UK offered COVID-19 vaccine. [online] Available at: https://www.gov.uk/government/news/every-adult-in-uk-offered-covid-19-va....
5. Ofcom (2020). Covid-19 news and information: consumption and attitudes. [online] Ofcom. Available at: https://www.ofcom.org.uk/research-and-data/tv-radio-and-on-demand/news-m....
6. The British Academy, The Royal Society (2020), COVID-19 vaccine deployment: Behaviour, ethics, misinformation and policy strategies. [Online] Available at: https://royalsociety.org/-/media/policy/projects/set-c/set-c-vaccine-dep...
Competing interests: No competing interests
Dear Editor,
I would like to talk about vaccination implementation in China.
Firstly policies towards injection in China are more compulsory, if the residents are not vaccinated, they might be refused entry to most of the public areas, such as cinemas, restaurants and so on. Senior citizens and populations with chronic disease are prioritised among all the citizens, children under 18 are the second prioritised. In order to encourage more people to get vaccinated, governments give out basic necessities such as tissue paper, eggs etc. right after you get vaccinated to motivate people. But due to some political issues general vaccination did not replace other restrictions in China. People's lives are still being hugely affected. Most of the population in big and more developed cities have been vaccinated with three doses which includes booster. However Leukemia cases associated with vaccination raised moral hazard problems among the population. Citizens started to lose trust in vaccination due to these cases. There are also some articles mentioning the same issues in the UK. Further analyses are needed to address the effectiveness of vaccination.
Sincerely,
R
Competing interests: No competing interests
Re: Implementation of covid-19 vaccination in the United Kingdom: Response to Response to Mahmoud Mohammad Al Ammouri
Dear Editor,
I thank Mahmoud Mohammad Al Ammouri for his response to our article.[1] As a middle-income country, Jordan was very reliant on the COVAX programme, showing its importance in trying to achieve global equity in the supply of Covid-19 vaccines.[2] Jordan faced the additional challenge of a large refugee population and it is very commendable that this group was also targeted for vaccination as they can sometimes be overlooked in national vaccination programmes.[3] As in other countries, Jordan used factors such as age, clinical status and occupation to prioritise groups for vaccination. It also established an electronic population register to support the implementation of its Covid-19 vaccine programme. Vaccine hesitancy remains a challenge and much more needs to be done globally to address this and counter misinformation about vaccines.
References
1. Majeed A, Pollock K, Hodes S, Papaluca M. Implementation of covid-19 vaccination in the United Kingdom BMJ 2022; 378 :e070344 doi:10.1136/bmj-2022-070344
2. Osama T, Chowdhury M, Majeed A. Prioritising the global response to curb the spread of COVID-19 in the fragile settings of the Global South. Journal of the Royal Society of Medicine. 2021;114(1):15-18. doi:10.1177/0141076820974994
3. Crawshaw AF, Farah Y, Deal A, Rustage K, Hayward SE, Carter J, Knights F, Goldsmith LP, Campos-Matos I, Wurie F, Majeed A, Bedford H, Forster AS, Hargreaves S. Defining the determinants of vaccine uptake and undervaccination in migrant populations in Europe to improve routine and COVID-19 vaccine uptake: a systematic review. Lancet Infect Dis. 2022 Sep;22(9):e254-e266. doi: 10.1016/S1473-3099(22)00066-4.
Competing interests: No competing interests