Category: Coronavirus

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

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.

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

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.

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.

Staying safe at the beach and the park

With the weather improving and people in England now allowed to meet with others outdoors, we will be heading to the beaches and parks. Being outdoors and getting exercise are essential for our physical and mental health but also comes with some risks because of the Covid-19 pandemic. Here are some steps you can take to protect yourself and others from the risk of infection.

Travelling safely. If you are travelling by car, try to travel with people from your household or support bubble. If using public transport, make sure you wear a face mask. The best way to travel is by foot or bicycle but this won’t be practical for more distant locations.

Follow Covid-19 rules on how many people can meet. In England, you can currently meet with a maximum of five other people if they are from more than two other households. Make sure your total group size does not exceed six people if this is the case. If there are people from just two households meeting, then your group can be bigger than six people.

Keep your distance from other people. There will be many other people also out and about. Try to keep at least two metres away from others who are not in your group if they will be near you for a prolonged period. The virus that causes Covid-19 spreads from person to person by droplets or through an aerosol. Outdoors, the virus will disperse quickly and the risk of infection is very low if you are not near other people.

Don’t share food and drink. You should use separate cups, plates and utensils for each person present and not share them as sharing will increase the risk of infection. You should also avoid sharing food because this has been shown to increase the risk of infection.

Be aware of the greater risks in indoor spaces such as toilets. At some point, you may have to use to use a public toilet. The risk of infection is substantially higher in indoor spaces – particularly if they are crowded, used by lots of people and are poorly ventilated. Avoid coming into close contact with others while indoors. You should also wear a face mask or face covering, and wash or sanitise your hands before entering. After using the toilet, wash your hands thoroughly and go back outside immediately once you finish.

Avoid touching surfaces. Surfaces such as hand rails will have been touched by many other people and will be contaminated. If you do touch a surface that many people have been in contact with, wash or sanitize your hands as soon as possible.

Wash your hands or use hand sanitizer regularly. This will remove any virus that you may have inadvertently picked up from a surface or from someone else, and help to protect yourself and protect others.

Don’t drink too much alcohol. People are far more likely to engage in behaviour that increases their risk of infection if they have been drinking heavily. Ensure you maintain your self-control and remain aware of the people around you.

Don’t go out if you are unwell or are self-isolating. Don’t go out if you feel unwell, have symptoms of a possible Covid-19 infection, or if you are self-isolating because you have been in contact with someone else with Covid-19. If you break these rules, you are putting others at risk.

Avoid mixing indoors afterwards. It may be very tempting for your group to go back to a friend’s house for a drink or get together after your day out but this is a breach of the current Covid-19 regulations on people from different households mixing. The risk of infection is far higher indoors than outdoors, which is why the government prohibits indoor mixing.

Most importantly, get vaccinated. The UK’s Covid-19 vaccination programme is now well underway. If you are eligible for a vaccination, please book your appointment. If you have not yet been invited, please do attend for your vaccination when you are invited. Vaccination protects you and protects others, creating a safer environment for everyone and provides a route to a return to a more normal way of living.

Questions and answers about England’s new Covid-19 rules

Can I have a BBQ on the front of my house with others from my street?

Under the Rule of Six, you can only meet with a group of more than six if they are from your household and one other household (a maximum of two households). For example, if there were four people in your household and four in another household, the eight of you could meet for a BBQ as you are from two households. If your group is from more than two households, then a maximum of six people can meet, so you could not hold a BBQ for your entire street.

 

Can I use my friend’s toilet?

You are allowed to use your friend’s toilet if this is necessary. You should though avoid interacting or coming into close contact with anyone from your friend’s house while you are indoors as this is where the risk of infection is greatest. You should also wear a face mask or face covering whilst indoors, wash or sanitise your hands when entering the house, and spend the minimum time indoors. After using the toilet, wash your hands thoroughly, ideally using a separate towel or disposable hand towels, and go back outside immediately once you finish.

 

Can I meet with five mums and their kids in a park?

Large parent and child groups can only take place outdoors if they are for the benefit of children aged under five and organised by a business, charity or public body. If this was an informal meeting, however, you would need to limit the group to a maximum of six people. So, if you had five mums, only one child could join because children count towards the size of the group

 

If I can meet up with a BBQ, what are the rules around cups, plates, utensils?

There are no specific rules around cups, plates, and utensils but you should practise good infection control measures at a BBQ. You should use separate cups, plates and utensils for each person present and not share them as sharing will increase the risk of infection. You should also avoid sharing food because this has been shown to increase the risk of infection. Hence, shared food such as bowls of nuts or buffet style food is best-avoided as handling food by many people will increase the risk of infection (not just for Covid-19 but also for gastroenteritis).

 

Can I now chat with other mums in the school playground?

The same rules apply while you are in the playground as in other outdoor settings so you could only chat to a maximum of five other mums. However, schools would not look favourably on large groups of parents mixing in their playgrounds as they know this would increase infection risks and so may discourage such groups meeting on their grounds.

 

Now I’m allowed to see my mum who lives in another county, can I stay overnight in a hotel so I can spend more time with her?

This is a grey area as overnight stays away from home are only allowed for specific purposes. If this was a social visit, an overnight stay away from home would generally not be allowed. However, the rules also state that you can stay away from home overnight if you are unable to return to your main residence the same day. So, if your mother lived too far away for you to visit and return the same day, an overnight stay may be permissible

 

Can two households and the people in both their support bubbles meet, even if there will be 15 people?

You can meet in a group of any size from up to two households, including members of any existing support bubble. So, a group of 15 can meet outdoors if they are from a maximum of two households and their respective support bubbles.

 

Now I’m allowed to go walking outside my local area, am I allowed to camp overnight?

You can go walking outside your local area but an overnight camp would not be allowed as this would be seen as being for a non-essential purpose.

 

Can 10 people meet up for a game of five-a-side football?

10 people could only meet for an informal game of five-a-side football outdoors if they are from a maximum of two households. If they are from more than two households, they would exceed the maximum number of six people who can get together. You can take part in formally organised outdoor sports with any number of people but this must be organised by a business, charity or public body, and the organiser must take the required infection control precautions,

 

Are we on track to open shops, theme parks and gyms on April 12? What might set it back?

We are on track to open a wider range of businesses on April 12 because Covid-19 case numbers, hospital admissions and deaths are all currently falling in England. If there was a rapid increase in the number of cases in the next 1-2 weeks, this might lead the government stop this re-opening of businesses but this looks unlikely to be the case.

 

Could a hairdresser come and cut my hair in my garden?

As your haircut is taking place outdoors and only two people are involved, this is permissible under the rules. Your haircut though can’t take place indoors or at the hairdresser’s premises for now.

 

Can I conduct my yoga class in my garden or a park?

If this is a formally organised event held by a qualified yoga instructor or by a yoga club, then you can conduct your class outdoors without limits on numbers. You can’t however meet for an informal yoga session with your friends if this breached the rules on the maximum number of people who can get together.

 

Will more people than just the designated person be able to visit my mum in the garden of her care home?

Care homes can offer visits to other friends or family members if these take place outdoors, such as in the garden of the care home. You need to be mindful though that care home residents have a very high risk of serious illness and death if they contract Covid-19, so good infection control measures must be followed. Ideally, the visitors should also have been vaccinated as should your mum.

 

Can I go to the beach?

Yes, you can visit a beach but overnight stays away from home would not be allowed for this purpose, so you would need to be able to go to the beach and return home the same day.

Questions and answers about Covid-19 vaccination in children

Why should children have the vaccine?

Children will usually have a mild or asymptomatic illness and are very unlikely to die if they contract Covid-19. But they can sometimes have a prolonged illness that can result in them being absent from school and which can also occasionally lead to serious long-term complications, such as Multisystem Inflammatory Syndrome. Children can also transmit infection to others at higher risk of serious illness and death, such as their parents and grandparents.

 

Will all under-18s get the jab or specific groups/age groups?

Covid-19 vaccines will only be made available to children once we have good evidence of their safety and efficacy, and they have been licensed for use in children in the UK by the MHRA. It’s likely that any vaccination programme for children will start with those old enough to attend secondary school (above the age of 11 years), with vaccinations for younger children starting later.

 

Will it be compulsory?

Childhood vaccinations are not compulsory in the UK and are only given with parental consent.

 

Does it have to be an injection?

All the Covid-19 vaccinations in use in the UK, or which are close to being approved, are given by injection. It will be sometime, perhaps years, before we have vaccines that can be given by other routes, such as the nasal influenza vaccine that is used in children.

 

Will babies get it when they get their other jabs?

The timing of vaccination will depend on the results of research studies and the conditions put in place by the MHRA and guidance from the JCVI. Hence, we cannot yet say if younger children will be able to get the vaccine at the same time as their other vaccinations. But if this was possible, this would make vaccination more straightforward for children, parents and the NHS.

 

Will children get it at school or elsewhere?

This has not been decided yet but if vaccines are given to school-age children, this would be easier to carry out in schools as we currently do for the influenza vaccine for children. However, the government may also decide to use the NHS Covid-19 vaccine centres because some vaccines – such as the Pfizer mRNA vaccine – are not very easy to transport.

 

Are children getting vaccines in other countries? What has happened?

There are trials underway in some countries, such as the USA and UK, to test the safety and efficacy of Covid-19 vaccines in children. Israel has started to use vaccines in 16-17 year olds. Some children aged 16-17 years old in the UK with serious medical problems are also being vaccinated. However, the use of Covid-19 vaccines in children is not yet widespread, even for older children.

 

Does it mean children who aren’t vaccinated won’t be able to travel abroad?

It’s likely that children will be excluded from the need to provide proof of vaccination to travel overseas as there are not yet any vaccines that are approved for use for them. They may though require a recent negative test for Covid-19 before they can travel. It’s also possible that some countries will change their rules once Covid-19 vaccination becomes common in children.

 

If every person in Britain is vaccinated, will Covid be eradicated?

Only one disease, smallpox, has been entirely eradicated through vaccination. Some people will refuse to be vaccinated and in those who are vaccinated, the vaccines are not 100% effective in preventing infection, although they are very effective at preventing serious illness and death. Hence, we will still see cases of Covid-19 in the UK but if we have very high vaccine uptake in our population, we are unlikely to see large outbreaks unless a new variant of virus appears that is resistant to current vaccines.

Covid-19 vaccine adverse events: balancing monitoring with confidence in vaccines

As the global covid-19 vaccine rollout continues, uncertainties regarding the association between thromboembolic events and the Oxford-AstraZeneca vaccine have dominated the news during March, leading 18 European countries to suspend its use whilst this association was investigated by the European Medicines Agency. This suspension of the vaccine will have serious implications for vaccine confidence in general and, in particular, for global vaccination programmes. It has already  heightened anxiety levels and affected vaccine uptake especially among vaccine-hesitant groups due to claims about side effects that are not supported by real world data or data from clinical trials.

Of all the covid-19 vaccines currently licensed or in development, the Oxford-AstraZeneca vaccine was considered the vaccination of choice by many countries because of its low cost and ease of storage compared to other vaccines. In the UK, more than 25 million people have had their first dose of covid-19 vaccine, comprising almost half of the adult population, with either the Oxford-AstraZeneca or Pfizer-BioNTech vaccines.

The UK Medicines and Healthcare products Regulatory Agency (MHRA) has monitored the safety of both vaccines through the Yellow Card scheme—a mechanism of reporting any possible vaccine side effects known as adverse drug reactions (ADRs). However, these reports do not mean there is causal link between the use of a vaccine and side effects. Data up to 7 March shows an estimated 11.7 million first doses of Oxford-AstraZeneca and 10.9 million doses of Pfizer-BioNTech vaccines were administered in the UK, resulting in 35,325 and 61,304 reports of possible side effects for Pfizer and AstraZeneca vaccines respectively, indicating a very low rate of reported side effects. The overwhelming majority of reports consist of injection-site reactions and symptoms secondary to the normal immune response such as “flu-like” illness, headaches, chills, and fatigue. All these are in line with the findings from clinical trials and from side effects reported with other routinely used vaccines.

Reports of severe allergic reactions to the Pfizer (223 reports) and AstraZeneca (234 reports) vaccines have been very rare. Available MHRA data do not suggest that venous thromboembolism is caused by the AstraZeneca vaccine. To date, there have been five reports of cerebral venous sinus thrombosis to MHRA, a rare type of blood clot in the cerebral veins, with no causal association with the vaccine. The temporal association between vaccination and death in mostly elderly patients with health conditions have also been reported in about 500 cases. However, there is no evidence to support that vaccination caused these deaths.

While the investigations of a potential link between AstraZeneca vaccine and thromboembolic events continue, the MHRA, the World Health Organization (WHO) and the European Medicines Agency (EMA) have ruled out the causal link and stated that the population benefits far outweigh the risks, thereby reaffirming the safety of the vaccine that over 17 million people in the UK and EU have so far received. Around 30 cases of thromboembolic events have been reported amongst five million vaccinated people in EU; this rate remains lower than that observed in the general population.

Receiving a covid-19 vaccine is a landmark and memorable event for people and this coupled with a heightened sense of awareness following vaccination may lead to more cases being picked up. Moreover, there will be more presentations and over-diagnoses of thromboembolic events as expected following a highly publicised safety scare such as this.

While routine monitoring of vaccines to avoid potential harms is necessary, pausing or delaying vaccines must be evidence-based. The speculative commentary, generated by the media, will have serious and unintended consequences including an increase in vaccine hesitancy and even refusal; across Ireland, 30,000 vaccination appointments were cancelled during the week starting 15 March. Safety signals occur often with vaccines, with the majority representing false signals; although well-intentioned, the misapplied precautionary principle will undermine public trust, and heighten covid-19 risk through amplification of misinformation and disinformation campaigns of the “anti-vaxxer” movement. Vaccine-hesitant individuals are concerned about side effects and health-related long-term effects; these reports will make it very challenging to overcome these concerns at a time when covid-19 cases are still increasing across many European countries, requiring optimal uptake of vaccines to limit the impact of the covid-19 pandemic on populations.

The risks and trade-offs of suspending a life-saving vaccine must be carefully weighed especially during a pandemic; covid-19 itself is associated with blood clotting disorders. Historical precedents show that widely publicised safety scares have profound and long-lasting influence on vaccine confidence. [1] In 2017, the announcement that the dengue vaccine, Denvaxia, posed a risk to those who had not previously been exposed to the virus caused a drop in vaccine confidence in the Philippines and Indonesia. The safety controversy around the human papillomavirus vaccine in Japan caused one of the sharpest declines in vaccine uptake (from approximately 74% in those born in 1994-1998 to approximately 0.6% for those born in 2000). [2] The shock of this still reverberating today with Japan ranking among the lowest in vaccine confidence in a worldwide study. [1] A decline in vaccine uptake was also observed in Indonesia following warnings by the country’s faith leaders. [3]

Covid-19 vaccines are the single most effective way to prevent severe illness and death from the disease and accelerate the re-opening of society following non-pharmacological interventions such as lockdowns. Furthermore, vaccines are safe and have contributed to saving millions of lives. We call for monitoring of vaccine safety to occur out of the media limelight as sensationalist and exaggerated reporting will do irreparable damage to vaccine confidence. This includes suggestions by some media outlets that the actions taken by European countries were driven by political reasons. Sensationalist media reporting will lead to increased vaccine hesitancy, further loss of lives and derail efforts to end the current pandemic. Governments responses must be led by independent evidence through established public health and regulatory bodies such as the WHO, EMA and MHRA.

Mohammad S Razai, Academic Clinical Fellow in Primary Care, St George’s University of London. 

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

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

This article was first published on BMJ Opinion