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News Q&A

Covid-19: How is the UK’s vaccine booster programme faring?

BMJ 2021; 375 doi: (Published 05 November 2021) Cite this as: BMJ 2021;375:n2702
  1. Gareth Iacobucci
  1. The BMJ

After a successful vaccination campaign for the first and second doses, the UK’s booster programme has stuttered. Gareth Iacobucci examines why

Who is eligible for a booster vaccine?

The NHS website says that booster doses are available for people most at risk of serious illness from covid-19 (box 1) who had their second dose at least six months ago.1 This means around 30 million people across the UK. On 29 October the government updated its information for public health professionals on immunisation, the “Green Book,”2 to allow extra flexibility for certain groups of vulnerable people, such as care home residents or housebound patients, who can now be given booster doses a minimum of five months after their second dose where this makes “operational sense.”

Box 1

Who can have a covid-19 booster dose

  • All adults aged 50 or over

  • People living and working in care homes

  • Frontline health and social care workers (those involved in direct care, together with non-clinical staff in secondary, primary, and community health settings and laboratory and pathology staff)

  • Anyone aged 16-49 years with a health condition that puts them at high risk of becoming seriously ill from covid-19, and their adult carers. This includes people with chronic respiratory heart, kidney, liver, or neurological disease, diabetes mellitus, immunosuppression, asplenia or dysfunction of the spleen, obesity, and severe mental illness

  • Adults under 50 in long stay care settings

  • People aged 16 or over who live with immunosuppressed individuals


Has there been confusion over eligibility?

Yes. Some of this stems from the fact that booster doses and primary third doses,3 which are two separate vaccination programmes, were introduced at the same time, and some sources, including the NHS website, have been using the terms interchangeably. For example, the NHS booster vaccine site links to a list of “high risk” patients that it says are those eligible for a “booster.” Closer inspection shows this is a list of people who are eligible for a third primary dose, including those who have targeted cancer treatments that can affect the immune system; people with blood or bone marrow cancer such as leukaemia, lymphoma, or myeloma; adults having dialysis or who have long term kidney disease; and people who have undergone transplantations.4 While this may seem like a question of semantics, the mixing of vaccine terminology may have confused some patients about whether they are eligible.

Who is delivering booster shots?

As with the initial vaccination programme, the booster programme is being delivered by a combination of large civic vaccine sites, local GP led centres, and pharmacies. But many general practices in England that previously signed up to participate through their local primary care networks have opted out of delivering the booster programme, because of workload and workforce pressures and a policy directive from NHS England not to allow GPs to offer booster vaccines at practice level in the same way they do with flu vaccines.5

Azeem Majeed, a GP in west London and professor of primary care and public health at Imperial College London, told The BMJ that his practice had opted out this time. “There are fewer sites [for people to get vaccinated] because fewer GPs are involved,” he said. “My practice has dropped out, as have a lot of other practices in my area. To be honest, there was no great encouragement from NHS England to carry on with the programme, which is another factor in deciding not to get involved.”

What does the current uptake look like?

The pace of the booster rollout has been far slower than the initial vaccination programme that began last winter. As of 1 November the government reported that 8.1 million people in the UK had received their booster jab. On the same day, John Roberts from the Covid-19 Actuaries Response Group, which has been tracking the vaccine rollout, reported that roughly 5.8 million people who qualify have not yet had a booster.6 This is up from 2.8 million a month ago and too slow to give everyone a booster this winter, he projects. There has been a recent uptick, with NHS England reporting that 1.7 million booster doses were delivered last week (25 to 31 October). A further 1.6 million invitations are being sent this week, and the NHS is also opening hundreds of walk-in sites to improve access.

When will all those who are eligible have had their boosters?

In an interview with the BBC on 3 November England’s deputy chief medical officer Jonathan Van-Tam was asked to comment on reports that it will be February at the earliest before the booster programme is completed.7 “I would like to wake up tomorrow morning and everybody who needed a booster has had one,” he said. “But I know that that is not possible. I know that the capacity of the NHS to get through boosters is finite. It is really important that we stick to the order of boosting the most vulnerable first, which are also the people who had their primary doses the greatest time ago.”

Majeed said he was concerned that the programme was progressing too slowly to avert a winter crisis. “I suspect at the current rates it will probably be [continuing] well into next year, and I think the rates probably will slow down as we vaccinate the people who are keenest,” he said. “Many people won’t have their booster before the new year or even at all, so there will be an increased risk of serious illness and death.”

Why has uptake been slower this time around?

A lack of urgency among some members of the public and government complacency over the rollout have been cited as possible reasons. Majeed points to the confusing fragmentation of the current programmes (boosters, third primary doses, first doses for children), and the reduction in GPs’ involvement as detrimental to uptake. He argues that it was a mistake not to equip general practices to run the programme, because they are best placed to reach people who are reluctant to get vaccinated at larger sites further from their home. “In the end you have to recognise that if you want a sustainable vaccine programme which really gets high uptake quickly, you’ve got to work with GPs,” said Majeed. “That means providing them with the management support, the personnel, and the funding, rather than just having relations which are quite antagonistic and constantly flogging GPs for not doing enough face-to-face consultations.”

He added, “We’ve got a patchwork system with different sites: pharmacies, hospital sites, some GP led sites, and schools. The government needs to work with GPs to develop a system that is integrated, where they are supported to deliver vaccines that can really target people who aren’t coming forward for their vaccination.”

Who’s in charge of delivering the programme?

Maggie Throup is now the UK’s vaccines minister, having replaced Nadhim Zahawi in September. But unlike her predecessor she has lacked visibility in the media, leading to some criticism, given the slow take up of boosters.8

Which vaccines are being used for booster shots?

Most people are being offered a booster dose of the Pfizer-BioNTech or the Moderna vaccine, meaning it may be different from the vaccines they had for their first and second doses.1 Van-Tam said this decision was based on robust but as yet unpublished data from the Com-Cov study,9 which he hoped, he said, would be in the public domain “within a matter of weeks.” He said, “I am very, very confident, having seen the data, that the JCVI’s [UK Joint Committee on Vaccination and Immunisation’s] advice to use a messenger RNA vaccine as the booster, irrespective of whether you’ve had AstraZeneca first or Pfizer first, is really the right thing to do.” The NHS said there may be exceptions for some people, who may be offered a booster dose of the Oxford-AstraZeneca vaccine if they can’t have the Pfizer or Moderna vaccine.

What’s the evidence on the effectiveness of boosters?

Early data from Israel, the first country to offer booster doses, showed that at least 12 days after the booster jab the rate of confirmed infection was lower in the booster group than in the non-booster group by a factor of 11.3 (95% confidence interval 10.4 to 12.3).10 The rate of severe illness was lower in the booster group by a factor of 19.5 (12.9 to 29.5). The absolute difference between the groups in the rate of severe illness was 7.5 cases per 100 000 person days. But it is not yet known how long that effect lasts. When more data are published, from the UK and beyond, a clearer picture will emerge of how long extra protection lasts and whether an annual covid vaccine might be recommended, in the same way that the flu vaccine is.

What’s the schedule for people who need four doses?

People at high risk of serious illness who will require four doses of covid vaccine will not require their fourth dose until at least six months after their third, possibly longer. Van-Tam said it wasn’t possible to be more precise at this stage. “I think, on first principles, it’s quite likely that the third dose that you get is likely to last a bit longer than the protection that we had from the first two doses, which is now starting to wane,” he said. But he added, “We are still learning about how long these vaccines will last after the third dose, and we have to wait for those data before we can give absolutely emphatic answers.”

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