Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

How is the Covid-19 lockdown impacting the mental health of parents of school-age children?

The Covid-19 pandemic has affected educational systems worldwide, leading to the near-total closures of educational institutions in the UK. As of 6 May 2020, schools were suspended in 177 countries affecting over 1.3 billion learners worldwide, and in many cases closures have resulted in the universal cancellation of examinations. UNICEF estimated that almost 4 months of education will be lost as a result of the first lockdown.

School closures have far-reaching economic and societal consequences, including the disruption of everyday behaviours and routines. In the UK, over 2 million workers have already lost their jobs, and although the long-term impact of the pandemic on education is not yet clear, the pre-existing attainment gap between the poorest and richest children7 may widen significantly as a result of COVID-19. Children and young people make up 21% of the population of England,10 and by the time they returned to school after the summer break, some would have been out of education for nearly 6 months.

In a paper published in the journal BMJ Open, we explored how the lockdown affected the mental health of parents of school-age children, and in particular to assess the impact of an extended period of school closures on feelings of social isolation and loneliness.

We collected data for 6 weeks during the first 100 days of lockdown in the UK and found that female gender, lower levels of physical activity, parenting a child with special needs, lower levels of education, unemployment, reduced access to technology, not having a dedicated space where the child can study and the disruption of the child’s sleep patterns during the lockdown are the main factors associated with a significantly higher odds of parents reporting feelings of loneliness.

We concluded that school closures and social distancing measures implemented during the first 100 days of the COVID-19 lockdown significantly impacted the daily routines of many people and influenced various aspects of government policy. Policy prescriptions and public health messaging should encourage the sustained adoption of good health-seeking self-care behaviours including increased levels of physical activity and the maintenance of good sleep hygiene practices to help prevent or reduce the risk of social isolation and loneliness, and this applies in particular where there is a single parent. Policymakers need to balance the impact of school closures on children and their families, and any future risk mitigation strategies should ideally not be a further disadvantage to the most vulnerable groups in society.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-043397

Lancet Commission on the Future of the UK’s NHS

I would like to thank the Lancet for giving me the opportunity to contribute to their Commission on the Future of the NHS. I fully support the recommendation for a strong and sustained increase in NHS funding to address the current weaknesses in the NHS. For me, the most striking data in the Lancet Commission on the Future of the NHS was this figure, taken from Securing a sustainable and fit-for-purpose UK health and care workforce, showing the changes in the number of NHS GPs and consultants per 1,000 people between 2008-18. Note the decline in GP numbers compared to the increase in consultant numbers. Although we hear a lot from NHS managers and politicians about the need to shift the focus of the NHS to the community, staffing statistics do not support this. The reality is that NHS primary care funding and workload need to reflect staff levels, not meaningless rhetoric.

Figure: Numbers of GPs and hospital consultants across the UK per 1000 people, 2008–18

Assessing the long-term safety and efficacy of COVID-19 vaccines

In an article published in the Journal of the Royal Society of Medicine, myself, Professor Marisa Papaluca and Dr Mariam Molokhia discuss how health systems can assess the long-term safety and efficacy of COVID-19 vaccines. Vaccines for COVID-19 were eagerly awaited, and their rapid development, testing, approval and implementation are a tremendous achievement by all: scientists, pharmaceutical companies, drugs regulators, politicians and healthcare professionals; and by the patients who have received them.

Because these vaccines are new, we lack long-term data on their safety and efficacy. In surveys of people who define themselves as ‘vaccine hesitant’, this lack of long-term data is one of the main reasons given for their beliefs. Hence, providing this information is a public health priority and could help reassure vaccine-hesitant people that receiving a COVID-19 vaccine is the right choice for them. Emerging data from the UK and elsewhere are confirming the benefits of COVID-19 vaccines and this is one of the factors that is leading to a reduction in vaccine hesitancy in the UK population.

As long-term data on the safety and efficacy build globally, these can address many of the concerns that vaccine-hesitant people have about COVID-19 vaccines, thereby creating a positive environment that encourages higher uptake of vaccination. These data will also guide national public health policies, such as how frequently to provide booster doses of vaccine and whether limits should be placed on the use of a specific vaccine.

Vaccination remains the best way to control the COVID-19 pandemic, and countries globally should work together to generate the information needed to provide long-term data on safety and outcomes. Because of the very rare nature of some side effects, this will require international collaboration so that data from countries can be pooled to allow more precise estimates of risk to be calculated. This will include using data from low- and middle-income countries once vaccination programmes are established there, as well as from marginalised groups in higher-income countries, to ensure that the data are fully representative of the global population.

DOI: https://doi.org/10.1177/01410768211013437

Using the NHS App as a Covid-19 vaccine passport

The UK transport minister, Grant Shapps, announced on 28 April 2021 that the UK government plans to use the existing NHS App to provide proof of covid-19 vaccination status for international travel. For many years, proof of smallpox, polio, and yellow fever vaccinations have been an entry requirement for many countries. The World Health Organization “yellow card” scheme has been in place since 1969, and proof of ACWJ meningococcal vaccine is required for Hajj to Saudi Arabia.

So while discussions on “vaccine passports” are old, the scale of the covid-19 pandemic will require a large number of global travellers to use a vaccine passport, which is an unprecedented development; and the technological options are far more advanced than for the previous paper-based certificates used for other vaccines. There are arguments for and against vaccine passports. We are facing a global pandemic, with huge variations in disease prevalence and vaccine mobilisation between countries. And while we watch the tragic scenes from India, many people in the UK are preparing for their first opportunity this year to visit oversees relatives or take an international holiday.

In a statement on 5 February 2021, the World Health Organization (WHO) laid down their reasons (at that time) for not supporting the idea of vaccine certificates; based on ethical, legal, scientific, and technological reasons. WHO recommends that people who are vaccinated should continue to comply with other risk-reduction measures when travelling. WHO also stated that their recommendations will evolve as vaccine supply expands and as evidence about the efficacy of existing and new covid-19 vaccines increases. This however has not deterred some countries—notably Israel—pushing ahead with their digital “Green Pass” scheme, with the USA also exploring options for vaccine certification.

Should the UK government decide to proceed with a vaccine passport policy, what method would we use? General practitioners, who are already struggling to meet unprecedented demands, while delivering around 75% of covid-19 vaccines thus far, cannot be expected to provide proof of vaccinations. There are digital solutions available such as the NHS App, or possibly the NHS Covid-App. Many UK patients nationwide already use their NHS App for a range of services including to seek medical advice, view their GP records, make appointments, submit secure electronic enquiries to their GP, and to order repeat prescriptions. It is also possible for people to use the App to view their covid-19 vaccination record. This area of the existing NHS App, already used by millions of patients, is clearly a safe and obvious place to use as a digital “vaccine passport.” Increased downloads and use of the NHS App by those using it as their “vaccine passport” could have additional long term benefits for patients and the NHS through encouraging use of other digital NHS services.

However, detailed medical record access—currently required to view vaccination records—is not enabled by default when you register with the NHS App. Proof of covid-19 vaccination status would therefore need to be separate from the rest of the medical record so that it can be enabled by default for everyone without the need for individual permissions from general practices. The covid-19 vaccination record can also sometimes appear in the acute medication section of the NHS App, but not usually with all details (such as vaccine batch number). This needs to be rectified so that the vaccination details are always in the same place in the NHS App. We would expect NHS Digital to rectify these issues before the NHS App is enabled as a covid-19 vaccine passport.

Covid-19 vaccination is recorded using the national PharmaOutcomes (also known as Pinnacle) IT system. NHS England decided to use this rather than recording directly into GP patient record systems because data can be entered using a web browser, and thus the system can be used across all vaccine sites, including those that have no access to GP medical record systems such as EMIS or SystmOne. However, some people have reported that the information on their vaccination is not always transferred to their GP medical record, and indeed GP Teams have also noted other discrepancies.

When inaccuracies are noted, covid-19 vaccination data must then be entered manually by the GP practice. This is not an ideal solution as errors and omissions in data recording can then occur, in addition to creating extra work for hard-pressed primary care teams. If the NHS App is to be used to confirm vaccination status, it is essential that all IT issues are resolved promptly to ensure the NHS App contains an accurate record of people’s vaccination status and extra work is not created for primary care teams.

An editorial in The BMJ discusses some of the wider practical and ethical issues in the implementation and use of vaccine passports; such as the need to ensure they do not further exacerbate current health inequalities. For example, many people in the UK do not own a modern smartphone capable of running the NHS App, a feature of the “digital divide.” This may be because they either cannot afford a smartphone or because they lack the technical proficiency to use one. This will affect older people and those from poorer sections of society; groups that already have lower levels of vaccine uptake, and higher levels of illness and poor health. The UK government’s proposal of using the NHS App may work for the majority of the population, but we must consider alternative options for those without access to suitable technology so they are not prevented from overseas travel.

There is debate for and against vaccine passports, which are being implemented by several countries already, but are not currently recommended by the WHO. The UK government’s proposal to use the NHS App to provide proof of covid-19 vaccination status is a practical and pragmatic solution for most UK citizens. However, we suggest that IT issues need to be addressed before we can rely on the NHS App as a “covid-19 vaccination passport,” to prevent extra bottlenecks and delays in airports. GP teams, who are already struggling for time, need to be protected from a tsunami of requests for certification to travel; and solutions also need to be found in case of technology failure, and for those unable or unwilling to use the NHS App.

Simon Hodes, GP Partner, Watford, UK

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK

This article was first published by BMJ Opinion.

High quality primary care and achievement of key quality targets lowers the risk of amputations in people with type 2 diabetes

Amputations are an important and largely preventable complication of type 2 diabetes mellitus that impact considerably on the life expectancy and quality of life of those affected. In England, more than 9000 diabetes-related amputations are performed each year, with decreasing rates but higher absolute numbers of major amputations, and the annual direct healthcare costs of diabetic foot ulceration and amputation are approximately £1 billion.

In an article published in BMJ Open Diabetes Research & Care, we investigated the associations between attainment of primary care quality clinical indicators, completion of National Diabetes Audit care processes, and non-traumatic lower limb amputations among people with type 2 diabetes. We observed that minor or major, as well as major-only, amputation rates were 26%–51% and 3%–51%, respectively, lower among those who met the HbA1c indicator and 14%–47% lower among those who met the cholesterol indicator for our primary outcome.

Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.

DOI: http://dx.doi.org/10.1136/bmjdrc-2020-002069

Safe management of full-capacity live events in the era of Covid-19

In an article published in the Journal of the Royal Society of Medicine, we discuss the safe management of full-capacity live events in the era of Covid-19. The importance of the live events industry to the UK economy is significant, with the creative industries1 alone contributing £117bn to the UK economy in 2018. However, the public health response to COVID-19 led to an unprecedented fall in theatrical sales of 93%, with the entertainment industry estimated to lose £110 m per month of full closure.

Several high-profile live music events have been cancelled. There has been limited experience of the reopening of live events in other countries; however, this has only been possible due to effective public health interventions to reduce community transmission to near zero levels. The sustainability of stringent border control measures to virus transmission is much debated; however, it is clear that the ability for the UK to achieve and then sustain low community transmission levels will require rigorously monitored borders and quarantine measures for inbound travellers.

Widespread population immunity through vaccination (and from previous infection) will help the UK to reach low transmission levels; however, the success of the vaccine programme will largely depend on convergent evolution of the virus but this remains unknown. Additional measures to stringent social distancing, isolating at home and high uptake of the vaccination programme to achieve herd immunity to existing and emergent mutant strains of coronavirus will all be required to maintain low transmission levels in the UK. However, because of vaccine hesitancy among some groups, there may be areas of the UK where COVID-19 outbreaks continue.

DOI: https://doi.org/10.1177/01410768211007759

Association between attainment of primary care quality indicators and diabetic retinopathy

Nearly three million people in England have type 2 diabetes. Diabetic retinopathy is a common complication, affecting nearly a third of patients with type 2 diabetes with considerable impacts on visual acuity and quality of life. In a paper published in the journal BMC Medicine, we examined the associations between attainment of primary care indicators and incident diabetic retinopathy among people with type 2 diabetes in England.

We found that that attainment of primary care HbA1c and BP indicators is associated with lower incidence of diabetic retinopathy in patients with type 2 diabetes. There is scope to enhance coverage of HbA1c and BP indicator attainment, and thus to potentially limit the incidence of diabetic retinopathy in England, through appropriate community-based measures. Further research is required to examine whether tighter glycaemic and/or BP control could achieve greater reductions in diabetic retinopathy.

What is behind the low covid-19 vaccine take-up in some ethnic minorities?

The latest data from the Office for National Statistics confirms that ethnic minorities in England are considerably less likely to receive a covid-19 vaccine than their White counterparts. While 90.2% of those aged 70 years and over living in England had received at least one dose of vaccine by 11 March 2021, uptake rates were 58.8% and 68.7% in Black African and Black Caribbean groups, respectively. [2] This was followed by Bangladeshi (72.7%) and Pakistani (74.0%) populations, with the most pronounced differences seen in those living in the most deprived areas of England.

Vaccine take-up also varied by religious affiliation with Muslims (72.3%) and Buddhists (78.1%) having the lowest rates, despite Pfizer-BioNTech, AstraZeneca and Moderna confirming that their vaccines do not contain animal products, and despite endorsement of the vaccines by the British Islamic Medical Association, the Dalai Lama, the Hindu Council UK and the Board of Deputies of British Jews. Vaccination rates were also lower among disabled people (86.6%), who are more likely to live in poverty and account for a large proportion of covid-19 deaths. After accounting for geography, underlying health conditions and some socioeconomic inequalities, these stark differences in vaccine uptake persisted.

Despite the considerable obstacles, there is an opportunity to improve the historically low vaccine uptake rates in ethnic minorities. With new data continuing to emerge on the relationship between the AstraZeneca/Oxford vaccine and a very rare risk of specific types of blood clots, such as cerebral venous sinus thrombosis (sometimes associated with low platelet counts), the Medicines and Healthcare products Regulatory Agency (MHRA) and the European Medicines Agency (EMA) have stated, once again, on 7 April 2021 that the benefits of covid-19 vaccines considerably outweigh the possible risks. Some anti-vaccination advocacy groups may try to take advantage of this association to further their own agenda, but clinicians and public health specialists need to reaffirm the safety of covid-19 vaccination, and also the high risk of serious illness, long-term complications, and death in people who are not vaccinated.

Vaccine safety and effectiveness concerns are, however, not our only challenges; effective vaccine allocation strategies can alleviate other barriers, including vaccine-related access and convenience of appointments. Reaching communities, through culturally-sensitive communication, remains even more crucial in light of the Joint Committee on Vaccination and Immunisation resisting calls to prioritise ethnic minorities across the different phases of the vaccination programme or through larger allocations of vaccines to areas with the highest rates of covid-19.

The origins of vaccine hesitancy and vulnerability are rooted in everyday life, requiring intersectoral approaches and mitigation efforts from outside the health sector to transform the social determinants of health. The legacies and current practices of racial exclusion, disinvestment, discrimination, and violence that continue to enable health inequalities provide conditions for covid-19 to persist in ethnic minorities even when life-saving vaccines are available. A refusal to address the root causes of these ingrained societal inequalities may lead covid-19 to become, like many other infectious diseases, a “disease of poverty.” The recent government report, denying the reality and consequences of structural racism—despite overwhelming evidence—will make it extremely difficult to establish trust and overcome justifiable anger and mistrust in some ethnic minorities.

One of the core aims of health policy is maximising overall population health while achieving equitable health distributions. Tensions between efficiency and equity often lead to positive and negative impacts of health policies and interventions being distributed unequally within populations, as observed during the covid-19 response. For public health interventions to be considered effective, and not only efficient, those at highest risk must be targeted, protected, and supported, thereby ensuring that health outcomes are improved.

Social justice is the moral foundation of public health. However, the pandemic response demonstrates that it is not always central to government policy. Unless we mitigate the consequences of past and ongoing wrongs, and unless vulnerable populations feel seen, heard and advocated for, the low uptake rates seen across older people from ethnic minorities will become even more pronounced when the vaccination programme starts to target younger people, among whom vaccine hesitancy and distrust is highest.

Tasnime Osama, Honorary Clinical Research Fellow in Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London, London, UK

Mohammad S Razai, Academic Clinical Fellow in Primary Care, Population Health Research Institute, St George’s University of London, London, UK

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London, London, UK

This article was first published by BMJ Opinion.

Attainment of primary care quality of care indicators and emergency hospital admissions in people with type 2 diabetes

England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. In a study published in the Journal of the Royal Society of Medicine, we aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.

Diabetes, cardiovascular and all-cause unplanned hospital admission rates were 7%–12% lower among those who met the Quality and Outcomes Framework HbA1c indicator, and 8%–14% lower among those who met the cholesterol indicator. By contrast, univariate analyses demonstrated that blood pressure indicator attainment was associated with higher rates of all types of unplanned admission. However, this association only persisted for diabetes-related admissions in multivariate analyses, and blood pressure attainment was associated with a significantly lower rate of cardiovascular-related unplanned admissions after adjustment for confounders.

Longer latency to diabetes, cardiovascular and all-cause unplanned admissions was also observed among those who met the HbA1c or cholesterol indicators, and again an association was not observed for the blood pressure indicator. Completing 7–9 National Diabetes Audit processes was associated with lower rates of all types of unplanned admissions, and meeting all nine National Diabetes Audit care processes was linked to 22%–26% lower rates for all types of unplanned admissions.

DOI: https://doi.org/10.1177/01410768211005109

Covid-19 vaccine passports: access, equity, and ethics

In an editorial published in the British Medical Journal, Tasnime Osama, Mohammad Razai and I discuss the practical and ethical issues in the implementation and use of vaccine passports, and the need to ensure they do not exacerbate current societal or health inequalities.

With millions of people receiving covid-19 vaccines globally, some countries have already started planning the implementation of “vaccine passports”—accessible certificates confirming covid-19 vaccination linked to the identity of the holder. The purpose of vaccine passports, governments argue, is to allow people to travel, attend large gatherings, access public venues, and return to work without compromising personal safety and public health. There remain, however, considerable practical and ethical challenges to their implementation.

Vaccine passports are not only permissible under international health regulations, they already exist. The World Health Organization endorses certificates confirming vaccination against yellow fever for entry into certain countries. Contrary to immunity passports, which may, perversely, incentivise infection, vaccine passports incentivise vaccination, an international public good with many positive benefits4 including individual and population immunity.

The public health principle of least infringement states that to achieve a public health goal, policy makers should implement the option that least impairs individual liberties. While lockdowns may be required, the continued restriction of the civil liberties of those who are immune and pose minimal risk of spreading infection may be unethical, as lack of freedom of movement is one of the most common adverse impacts of the pandemic on people’s lives. Additionally, vaccine passports could help prevent other health and socioeconomic harms caused by lockdowns, thereby accruing individual and collective health, economic, and social benefits.

For vaccine passport holders to demonstrate protection from illness and lack of infectiousness, however, more evidence about the long term effectiveness of different types of vaccines and the duration of protection they confer is required, particularly with the regular emergence of new variants. The AstraZeneca vaccine may reduce transmission by up to 67% while the Pfizer BioNTech vaccine is 85% effective in preventing asymptomatic and symptomatic infections after the second dose, 78 generating indirect benefits that extend to unvaccinated individuals through a reduction of SARS-CoV-2 circulation. Given that there are currently more than 200 vaccine trials underway, however, establishing the characteristics of each vaccine for the purpose of passport renewal would be challenging.

Vaccine passports need to be internationally standardised and must have verifiable credentials that safeguard against problems such as forgery and loss of privacy. WHO does not currently endorse covid-19 vaccine or immunity passports because of these concerns. It has, however, initiated a Smart Vaccination Certificate Working Group to establish key specifications and standards for effective and interoperable digital solutions for covid-19 vaccination.

Ethical concerns remain about the societal divide that these passports could cause. The Nuffield Council on Bioethics states that such passports could enable coercive and stigmatising workplaces, thereby compounding current structural disadvantages. Vaccine passports must be available and accessible to all to prevent exacerbating existing societal inequalities and worsening the health divide. Vaccines are scarce and access remains unequal, both globally and within countries. Covid-19 vaccines are also contraindicated in some people with serious health conditions and allergies. People facing vaccination access problems will be unable to obtain vaccine passports. Pregnant women are at an increased risk of severe covid-19 illness; however, as clinical trials did not include pregnant women, the uncertain risk of vaccination during pregnancy may also lead to understandable hesitancy in this group. Ethnic minorities are also more likely to be vaccine hesitant.

With most vaccine doses delivered in high income countries, WHO warned that the world is on the brink of a catastrophic moral failure. Because of vaccine nationalism and insufficient efforts to support globally coordinated access to covid-19 vaccines, nearly 25% of the world’s population may not have access to a vaccine until at least 2022. This will widen the global north-south divide and create a situation where people from high income countries are able to travel, but not those from low income countries.

As vaccine passports would probably be digital and require access to private medical records, there are important questions around internet access, costs of acquiring and maintaining the passports, privacy, and data protection that must be tackled. Many consider adequate internet access a fundamental human right; as large numbers of people do not have smartphones or stable internet connections, their exclusion breaches their rights to equality, particularly for those in low and middle income countries. Whether it is legal for workplaces, airlines, and entertainment and leisure venues to access vaccination data remains controversial, as this can perpetuate a form of elitism. Furthermore, ensuring that patient sensitive data are not used for other purposes is essential.

While the merits of vaccine passports may be undeniable, implementation will require ethical justifications and practical solutions that do not discriminate against the poor, the less technically literate, and people from low and middle income countries. Without mitigation strategies and alternative solutions, the hardships experienced by marginalised and vulnerable groups will be intensified through the perpetuation of discrimination. If they are to be rolled out, the benefits of vaccine passports should not be dispersed unequally, and societies globally must strive to ensure that they are available to all.

DOI: https://doi.org/10.1136/bmj.n861

This article was first published in the BMJ.