Father and daughters walking to school wearing masks

The dangers of flu and the risks of hospitalisation and being admitted to intensive care due to severe complications are not well-publicised. Nor are they as clearly understood as they are for COVID-19. 

Flu is often used as a misnomer for a common cold, trivialised and not taken seriously. If the risks of flu complications were more fully recognised, vaccination uptake in the eligible population might significantly increase.  

The World Health Organisation estimates that seasonal influenza kills between 290,000 and 650,000 people around the world every year. Yet since January 2020, very few articles have been published across the world with specific mention of flu without mention of COVID-19.  

What’s in a name?

The outbreak of the COVID-19 virus in early 2020 has been much more prominent in media coverage worldwide than recent epidemics including Ebola, which while far less transmissible has a 50% mortality rate. 

The extensive media coverage of the current pandemic has frequently used emotive, fear-inducing language such as reference to the ‘killer virus’, language rarely used in relation to the reporting of flu. Whilst there is no desire to promote fear in the general public, increased awareness through media reporting of the dangers of flu might in itself lead to improvements in uptake of the vaccination each year.  

A significantly higher uptake rate for COVID-19 vaccines

Analysis of current vaccination uptake data for flu and COVID-19 in the Midlands, UK, shows the significantly higher uptake rates achieved by individual CCGs in relation to COVID-19 vaccination compared to flu. 

The current first dose vaccination uptake rate for COVID-19 in the Midlands stands at 69% across all cohorts eligible for the vaccination (as at 02/06/21), compared to an end of flu vaccination season uptake rate of 58%. 

Many CCGs with complex demographic issues relating to diverse ethnicity mix and high levels of social deprivation struggle to achieve high flu vaccination uptakes but have made significant achievements in relation to the COVID-19 vaccination programme. 

As an example, Dudley CCG in the Black Country has achieved a 73% uptake rate to date (as at 02/06/21) compared to 49% for flu. Conversely, the difference between the COVID-19 and flu vaccination uptake is much less significant in CCGs who year on year achieve high flu vaccination uptake rates. 

Challenge #1 – overcoming lack of trust and confidence

There are clearly lessons to be learnt from the COVID-19 vaccination programme that can be applied to the flu vaccination programme in the future to target pockets of the population where there are high levels of deep-seated mistrust in vaccinations. 

The National Immunisation Management System (NIMS) and SCW regional team have played a major role in identifying areas of low vaccination uptake which need to be targeted. 

Across the Midlands and in particular, in parts of Birmingham and the Black Country, there are high levels of ethnic diversity and deprivation affecting local populations. It is recognised that there is an inherent lack of trust and confidence in vaccinations within a number of ethnic populations particularly prominent but not limited to Black African and Black Caribbean communities. 

A whole system collaboration

It is clear from the success of the COVID-19 vaccination programme that a whole-system collaborative approach is essential to achieving high vaccination uptake. 

The introduction of STPs and subsequently ICSs (Integrated Care Systems) provides a greater opportunity for effective collaboration between partners across the NHS, Local Authorities and the voluntary sector in relation to the whole agenda around health improvement and wellbeing with increased focus upon preventative services, including vaccination programmes, to keep local populations well. 

Sustainability and Transformation Partnerships (STPs) in the Midlands developed plans to address vaccine inequalities and improve COVID-19 vaccination uptake in their local populations which recognised the importance of partnership working to tackle the barriers that some communities face in taking up the offer of a vaccine. From the outset, it was clear that partnership working involving a whole range of statutory and non-statutory organisations including local faith leaders and community leaders was essential to plan and implement local and targeted initiatives moving away from traditional vaccination centre settings.    

Engaging with trusted local leaders

Effective communication is required with different communities to break down inherent mistrust and vaccine hesitancy manifested in slower vaccination uptake. 

Meaningful conversations with local people are key but must be undertaken by trusted members of the local community. Community and faith leaders need to be communicating in the appropriate language and setting in order to be effective and break down communication barriers, improve understanding, address particular concerns and dispel myths. 

Improved uptake needs to be encouraged over time and may require numerous conversations and extensive communication to break down deep-seated concerns and fears across different ethnic communities.  

A range of targeted interventions to facilitate conversations and communication channels have been introduced across the Black Country including for a contact centre established by Wolverhampton City Council to follow up unvaccinated people and in neighbouring Walsall, door-to-door contact is being made to hold these conversations. Health coaching has been introduced in Dudley to train GP practice staff to hold richer and more meaningful conversations with patients to encourage them to book a vaccination appointment.

In Sandwell and Birmingham, the collaborative approach including local Muslim, Sikh and Hindu Faith Groups has been key to increasing vaccination uptake. Mobile vaccination units or pop-up clinics in places of worship have played a major role in terms of addressing the issues experienced by particular ethnic minority groups. 

Birmingham was the first city to set up a vaccination clinic in a mosque – a model which has been replicated across other parts of the country. 

Spiritual leaders are well-placed to discuss with communities their personal responsibility for taking up the vaccination which has contributed to improved uptake. 

Local communities have experienced an increased level of security and safety through receiving their vaccination at their regular place of worship alongside familiar and respected members of the local community. 

Challenge #2 - Reaching everyone

Often the reluctance to take up the vaccination stems from practical problems around how they can travel to an unfamiliar vaccination centre and concerns around what they will find when they arrive there, rather than specific fears or concerns about the vaccines themselves. 

In Lincoln, part of a predominantly rural county covering a very large geographical footprint with a predominantly White British population, there is a high rate of homelessness and rough sleepers. 

Taking a proactive and agile approach

The collaborative effort of health and social care organisations to support vaccination of homeless and rough sleepers has been a shining example of multi-agency working. Building on existing trusted relationships and networks including the Homeless Team, District Council, YMCA, Nomad, Rough Sleeper Team, Intervention Team, Primary Care networks and Faith network, a proactive and agile approach has been taken to set up a roving model locally with pop up clinics also offering wider health and social care support. 

Similar roving models have been introduced in other city centres across the Midlands to provide pop-up clinics in shelters, churches and city centre GP practices and in Derby city centre a vaccination clinic has been set up for asylum seekers as they arrive in the city.

Further examples of collaborative approaches have been developed in the rural county of Herefordshire to support vaccination uptake through joint working of PCNs, the County Council and local employers. The potential risk of infection outbreaks was identified in fruit packing houses where seasonal workers have arrived from countries with high levels of COVID-19 infection and low vaccination uptake. 

Welcome Packs were introduced for circa 25,000 seasonal workers arriving from Eastern European countries where there is evidence of limited confidence and mistrust in vaccines accompanied by low vaccination uptake. The Welcome Packs included essential items such as soap and toothbrushes as well as translated information about infection control, self-isolation and vaccination in a number of languages. 

In terms of targeted interventions, a vaccination roving model was agreed with local employers including farmers to enable workers to be vaccinated at their workplace from a mobile vaccination bus. This model has been effective in terms of improving vaccination uptake amongst communities with a high degree of vaccine hesitancy, unlikely to attend traditional clinic settings such as local GP surgeries or vaccination centres. 

Similar roving models have been introduced across other rural areas of the Midlands. 

Collaborative engagement and outreach

In Derbyshire, the vaccination bus has attended supported housing sites across the county as part of a collaborative approach combining local shared resources and expertise across the NHS, public health, district councils and the voluntary sector and has also been used to support homeless and traveller populations supported with link workers with whom they have trusted relationships. people.

Strong pre-engagement is critical to building confidence and support attendance and taking the bus to familiar settings supported by known and trusted staff is more effective than approaches that seek to encourage homeless people to attend traditional vaccination centre settings. The engagement and outreach model facilitated by this roving model has also enabled a number of rough sleepers not engaged with homeless settings to be vaccinated. 

Challenge #3 – sharing the full picture

Significant success has been achieved in the COVID-19 vaccination programme in the Midlands to date and there are undoubtedly valuable lessons to be learned and adopted for the forthcoming flu vaccination programme. 

Access to real-time quality data

NIMS and the regional support team have played a major role in identifying areas of low vaccination uptake requiring attention through the provision of quantitative and qualitative data analysis on a regional basis.  

Joined-up working

Improving the COVID-19 vaccination uptake has not been easy and has required significant and sustained collaborative investment of effort and resources. There is no ‘one size fits all’ approach that can be adopted. 

The success of the programme to date is entirely attributable to the collaborative efforts of a full range of statutory and non-statutory organisations working together at pace, to engage and communicate with local communities, address local needs, encourage vaccination uptake where required, and move vaccination clinics outside traditional clinic settings. 

More information about the Immunisation Management Service 

More information about the Improving Immunisation Uptake Team 

 

Regional Head for the NHS Immunisation Management Service

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