Implementation of covid-19 vaccination in the United Kingdom

Our new paper in the British Medical Journal reviews the implementation of the UK’s Covid-19 vaccination programme. The programme is essential in keeping down the number of serious cases, hospitalisations and deaths from Covid-19 and allowing society to function more normally. 

Overall the programme performed well. But it’s important to address some common misconceptions about the programme. Firstly, the rapid implementation of the Covid-19 in vaccination in the UK was not due to Brexit. When the programme started, the UK had not finalised Brexit. Secondly, the vaccination programme was good and all those who supported the programme are to be congratulated for their efforts but it was not “world-leading” as some politicians have claimed. Many other countries have outperformed the UK in areas such as vaccine uptake. 

One limitation of current vaccines is that although they are very successful in reducing the number of serious cases of covid-19, they are less effective in preventing infection from SARS-CoV-2, which means that vaccinated people can still become infected and infect others. Early in the vaccination programme, this was often not communicated well to the public, leading to unrealistic expectations about how well vaccines would suppress the risk of infection, particularly with the emergence of new variants that reduced vaccine efficacy.

The UK became the first country in Europe to grant emergency use authorisation for a covid-19 vaccine when the MHRA gave approval for use of the Pfizer-BioNTech vaccine in adults on 2 December 2020. This decision took place when the UK was still operating under EU law.

Overall, the policy for prioritising people for vaccination was fair but was criticised for not including ethnic minority groups or key occupational groups other than health and care workers, such as people working in public transport or teaching. The pandemic had major effects on the education of children, for example, and it could be argued that staff working in schools should have been prioritised in the same way as NHS staff to reduce the disruption caused by the pandemic to children’s education.

Shortly after the start of the vaccination programme in the UK, the government decided to prioritise delivery of the first dose of vaccine over the second dose, based on advice from the JCVI. This meant a delay in giving the second dose of vaccine from 3-4 weeks after the first dose to 12 weeks. The immunisation programme was disrupted by this decision, with many people having their appointments for their second doses cancelled. A key question for the Covid-19 Inquiry is why the JCVI did not consider a delayed second dose policy before the programme started. The Inquiry also needs to look at what plans were in place for evaluating the effects of the delayed second dose on clinical outcomes such as infection, hospital admission and case fatality rates and on the delivery of the vaccine programme.

Although the UK was an early adopter of covid-19 vaccines for use in adults, it was slower than many other countries to implement vaccination for 16-17 year olds, then for 12-15 year olds, and finally for 5-11 year olds. This also needs careful review by the Covid-19 Inquiry. Additional problems arose after the decision to give some immunocompromised people a third primary dose of vaccine. The rationale was that immunocompromised people often had a poor response to two doses of vaccine and that a third dose would give improved protection. 

The third dose programme was rolled out with little central or local planning, resulting in considerable confusion among both the public and NHS staff and leading to delays in many eligible people getting their third primary vaccine dose. Key lessons from this component of the vaccination programme were the need to give the NHS adequate time to plan and to ensure that NHS staff are fully briefed in advance of any public announcement or media briefing about vaccination policy.

It’s also essential to look at the method of vaccine delivery. In England, there is now a very fragmented system. In the longer term, we need to look to integrate Covid-19 vaccination with other vaccine programmes in primary care and schools.

One area in which the UK excelled internationally was using data from the NHS, covid-19 testing, and national mortality records to monitor vaccine uptake, safety, and effectiveness. Congratulation to PHE and then to the UKHSA who set up this work.

The UK is currently very reliant on overseas manufactured vaccines. We must plan consider how we ensure that the UK can develop, test, and manufacture vaccines for the current and any future pandemics at the speed and quantity needed. 

The feedback on our article from patients emphasised the importance of clear, positive messages about vaccination for the public; and personalised support for people who were vaccine hesitant or who had concerns about vaccination to help increase vaccine uptake. 

Access to vaccination at a local site was also important, particularly for older people or those with limited mobility. Finally, there are many questions about vaccination that the UK’s Covid-19 Inquiry will need to consider. Some of these are summarised below.

Questions for the UK's Covid-19 Inquiry

1. What should we be doing to secure the legacy of the covid-19 vaccine research and delivery strategy for vaccine science, vaccine manufacturing, public health, and pandemic preparedness?
2. Why hasn’t the UK established a pipeline for the rapid development of RNA vaccines?
3. Why did the UK lag behind many other countries in recommending covid-19 vaccines for children?
4. How would we respond to a future pandemic causing high levels of morbidity and mortality in children?
5. Was sufficient attention paid to targeting groups who were likely to be vaccine hesitant?
6. What can be done to build on the JCVI’s communications and operations—particularly around public and patient involvement and engagement and its position on equality, diversity, and inclusion?
7. Why did the JCVI not recommend a delayed second dose strategy in its initial recommendations to the government in 2020? What impact did this have?
8. What is the best method of covid-19 vaccine delivery in the future?
9. Should staff working in schools also have been included in the initial occupational groups targeted for vaccination (such as health and care workers) reduce the effect of the pandemic on schools, given the many adverse effects of the pandemic on the education, social development, and the physical and mental health of children?
10. Did the UK government take the correct decisions about vaccine procurement? Was the UK correct to work alone on procurement or should there have been greater collaboration with the EU?
11. What impact did the over-procurement of vaccines by developed countries such as the UK have on vaccine equity and on the supply of vaccines for lower income countries early in the pandemic?

In a follow-up letter to our BMJ paper, we discuss the need for the JCVI to be given adequate administrative and financial support by the government, and aim to emulate the high standards set by the National Institute for Health and Care Excellence (NICE).