Covid-19: GPs raise workload concerns as government extends flu vaccination programmeBMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2990 (Published 24 July 2020) Cite this as: BMJ 2020;370:m2990
All rapid responses
Your news coverage that "GPs raise workload concerns as government extends flu vaccination programme" highlights the importance of prioritisation when resources are limited, and potentially adverse effects of poor targetting. In this context the lack of focus on social care staff in the extended programme is particularly shocking. Adding in extra groups when resources, including vaccine supplies, are constrained can decrease the coverage amogn those not prioritised.
COVID-19, has affected those living care homes particularly. The most vulnerable in society clustered together are vulnerable to outbreaks and COVID-19 is far from the first example of this [1,2]. Shared facilities and necessary close contact and personal assistance facilitate transmission. Raised vulnerability with increasing age has been particularly marked for COVID-19 . Mortality data highlights the resulting human cost internationally with the percentage of COVID-related deaths falling among care homes residents ranging from 19% in Hungary to 62% in Canada . The pandemic has also highlighted lack of resilience across the poorly funded care home sector, compounded by high reported rates of COVID-19 linked staff sickness and absenteeism . Looking forward, COVID-19 may become endemic with recurrent wintertime increases and outbreaks . Reducing the challenge of co-circulating influenza has motivated a radical extension of the NHS influenza vaccination programme to wider age groups . The World Health Organization recommends annual vaccination of social care residents and staff . As well as protecting employees, their vaccination may reduce transmission of influenza to and among residents .
Internationally, policy is inconsistent on social care staff flu vaccination. US state laws surrounding care home worker vaccination are variable ; care home staff vaccination rates lag behind hospital staff . In Australia, the onus is on care homes to arrange and fund flu vaccination for staff . Canada provides publically-funded flu vaccination for social care workers in almost all states [13,14], achieving 69.2% coverage among those working or volunteering in care settings . UK policy is a fudge. It advises vaccination for frontline health and social care workers by their employers  but also permits NHS delivered vaccine to social care workers “to complement but not replace the duty of their employer” . In contrast to healthcare workers among whom coverage has been rising in recent years , coverage among social care staff is poorly monitored, variable, and on average very low . Cost, communication and convenience difficulties influence social care worker uptake, and monitoring is essential to guide effective programme delivery . However effective policy is foundering due to conflicting principles: that employers are responsible for employee occupational health, but that the health service supports and optimises population public health interventions. UK policy, prioritising the former but with a nod to the latter, has not worked  and should change. We have not been able to find evidence from other countries that anything approaching universal coverage among social workers can be achieved without an optimized programme fully addressing funding, staff convenience, information and education, monitoring, and oversight. This should be prioritized over concerns for who should pay. The UK annual policy letter maintained the status quo but noted that amendments are being considered in the light of COVID-19 21. The substantial extension announced on 24 July, incredibly, left this critical and poorly performing part of the programme unchanged. In the UK and elsewhere we strongly propose full integration of social care staff into a nationally-funded programme, to protect them, protect the vulnerable and decrease pressure on healthcare.
1. Loeb M, McGeer A, McArthur M, Peeling RW, Petric M, Simor AE. Surveillance for outbreaks of respiratory tract infections in nursing homes. CMAJ. 2000;162(8):1133-7.
2. Inns T, Clough HE, Harris JP, Vivancos R, Adams N, O'Brien SJ. Estimating the burden of care home gastroenteritis outbreaks in England, 2014-2016. BMC Infect Dis. 2019;19(1):12.
3. Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, Cuomo-Dannenburg G, Thompson H, Walker PGT, Fu H, Dighe A, Griffin JT, Baguelin M, Bhatia S, Boonyasiri A, Cori A, Cucunubá Z, FitzJohn R, Gaythorpe K, Green W, Hamlet A, Hinsley W, Laydon D, Nedjati-Gilani G, Riley S, van Elsland S, Volz E, Wang H, Wang Y, Xi X, Donnelly CA, Ghani AC, Ferguson NM. Estimates of the severity of coronavirus disease 2019: a model-based analysis. The Lancet Infectious Diseases. 2020;30:S1473-3099(20)30243-7.
4. Comas-Herrera A, Zalakaín J, Litwin C, Hsu AT, Lane N and Fernández J-L (2020) Mortality associated with COVID19 outbreaks in care homes: early international evidence.
5. Plimmer, G. and Staton, B., 2020. Coronavirus pushes Britain’s care homes to the brink. Financial Times, [online].
6. S. M. Kissler, C. Tedijanto, E. Goldstein, Y. H. Grad, M. Lipsitch, Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science , eabb5793 (2020).
7. Department of Health and Social Care. Most comprehensive flu programme in UK history will be rolled out this winter. 24 July 2020. https://www.gov.uk/government/news/most-comprehensive-flu-programme-in-u... .
8. World Health Organization, Regional Office for Europe. Recommendation on influenza vaccination during the 2019-2020 winter season. October 2019.
9. Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD005187.
10. Centers for Disease Control and Prevention. Menu of State Long-term Care Facility Influenza Vaccination Laws. 28 February 2018.
11. Centers for Disease Control and Prevention. The Influenza Vaccination Coverage in Long-Term Care Settings. 31 October 2018.
12. Australian Government Department of Health. Responsibilities of residential aged care providers. 24 April 2020.
13. National Advisory Committee on Immunization (NACI). Statement on Seasonal Influenza Vaccine for 2011-2012: An Advisory Committee Statement (ACS). Can Commun Dis Rep. 2011;37(ACS-5):1‐55. Oct 14 2011.
14. Government of Canada. Public Funding of Influenza Vaccination by Province/ Territory. September 2019.
15. Government of Canada. Vaccine uptake in Canadian adults: results from the 2014 adult National Immunization Coverage Survey. 24 February 2016.
16. Department of Health and Social Care. National flu immunisation programme 2019 to 2020 letter. London. March 2019. PHE publications gateway number: 2018767
17. NHS England and NHS Improvement. Direct Enhanced Service Specification: Seasonal influenza and pneumococcal polysaccharide vaccination programme 2020/21. April 2020.
18. UK Government. Public Health England. Seasonal flu vaccine uptake: figures. January 2020.
19. Public Health England. Evidence to the Science and Technology Committee. UK Parliament: Flu vaccination programme in England. 18 October 2018.
20. Department of Health and Social Care. National flu immunisation programme 2020 to 2021 letter. London. 14 May 2020. PHE publications gateway number: GW-1266. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
Competing interests: No competing interests