COVID-19 vaccination programme: a central role for primary care

Anthony Harnden; Wei Shen Lim; Andrew Earnshaw

doi:10.3399/bjgp21X714929

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The central role of primary care in the COVID-19 vaccination programme: is there any moral obligation to vaccination for healthcare workers?
Emanuele Castagno, Giancarlo Mercurio and Barbara De Vito

Published on: 11 September 2021
The COVID-19 vaccination programme in primary care
Mohamed Guled, Asif Khapedi, Yousef El-tawil and Erni Hoti

Published on: 22 August 2021
COVID-19 vaccination programme: a central role for primary care
Laura R Skeldon and Mihari N. DeSoysa

Published on: 22 February 2021

Published on: (11 September 2021)
Page navigation anchor for The central role of primary care in the COVID-19 vaccination programme: is there any moral obligation to vaccination for healthcare workers?
The central role of primary care in the COVID-19 vaccination programme: is there any moral obligation to vaccination for healthcare workers?
Emanuele Castagno, Emergency pediatrician, Department of Pediatric Emergency, Regina Margherita Children’s Hospital, Turin, Italy
Other Contributors:
Giancarlo Mercurio, Teaching nurse, Department of Public Health and Pediatric Sciences - School of Medicine, University of Turin, Turin, Italy

Barbara De Vito, Emergency pediatrician, Department of Pediatric Emergency, Regina Margherita Children’s Hospital, Turin, Italy
The authors underline the strategic importance of offering early vaccination to healthcare professionals, but part of them is still showing hesitancy worldwide. Thus, moral and legal duty to vaccination against COVID-19 for healthcare workers is a matter of discussion. Some countries have imposed it by law, while in others informed consent has been preferred to obligation.^1,2

The choice whether to be vaccinated or not is a deontological and ethical issue dealing both with self-determination and professional commitment. Some believe that compulsion to vaccination violates their individual right to refuse any treatment. But which is the limit of a state in the power to require an individual citizen committed to promote health to receive a medication for the protection of the community?

The right to refuse vaccination is not absolute and is overshadowed by the right of the whole population to be protected. Vaccine-induced herd immunity to COVID-19 can be considered one of the most important public goods, and everyone is expected to fairly contribute to its achievement, even if he/she would not receive any direct individual benefit.³ Indeed, the right of the most vulnerable patients to be protected is added to moral and deontological commitment of healthcare professionals to promote health.⁴ Although professionals have the same constitutional individual rights of autonomy and freedom of contract as all the other citizens, the co...
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The authors underline the strategic importance of offering early vaccination to healthcare professionals, but part of them is still showing hesitancy worldwide. Thus, moral and legal duty to vaccination against COVID-19 for healthcare workers is a matter of discussion. Some countries have imposed it by law, while in others informed consent has been preferred to obligation.^1,2

The choice whether to be vaccinated or not is a deontological and ethical issue dealing both with self-determination and professional commitment. Some believe that compulsion to vaccination violates their individual right to refuse any treatment. But which is the limit of a state in the power to require an individual citizen committed to promote health to receive a medication for the protection of the community?

The right to refuse vaccination is not absolute and is overshadowed by the right of the whole population to be protected. Vaccine-induced herd immunity to COVID-19 can be considered one of the most important public goods, and everyone is expected to fairly contribute to its achievement, even if he/she would not receive any direct individual benefit.³ Indeed, the right of the most vulnerable patients to be protected is added to moral and deontological commitment of healthcare professionals to promote health.⁴ Although professionals have the same constitutional individual rights of autonomy and freedom of contract as all the other citizens, the common rights of public health and safety should prevail, thus allowing a limitation of individual rights.⁵

In this view, conscientious objection to vaccination could be hardly admitted. COVID-19 is highly severe and contagious and has been producing a huge impact on global health and economy. On the other hand, anti-vaccine arguments are weak: any obligation to get vaccinated derives from the best interest of the population, while merely hypothetical unproven future damage cannot prevail over the current proven harm deriving from lack of vaccination in the key category of healthcare workers.

Informed consent and compromise are the best options when different rights conflict one against the other. The common good should prevail, and mandatory vaccination should be considered as extreme option if insufficient vaccination rate was reached among healthcare workers.

References

1. Paterlini M. COVID-19: Italy makes vaccination mandatory for healthcare workers. BMJ 2021;373:n905.
2. Wise J. COVID-19: France and Greece make vaccination mandatory for healthcare workers. BMJ 2021; 374:n1797.
3. Giubilini A. Vaccination ethics. Br Med Bull 2021; 137:4-12.
4. Maki DG, Hennekens GH. Healthcare workers need COVID-19 vaccination: clinical, public health and ethical considerations. Am J Med 2021; doi.org/10.1016/j.amjmed.2021.06.030.
5. Stewart AM. Mandatory vaccination of health care workers. N Engl J Med 2009; 361:2015-7.
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Competing Interests: None declared.
Published on: (22 August 2021)
Page navigation anchor for The COVID-19 vaccination programme in primary care
The COVID-19 vaccination programme in primary care
Mohamed Guled, Medical Student, King's College London
Other Contributors:
Asif Khapedi, Medical Student, King's College London

Yousef El-tawil, Medical Student, King's College London

Erni Hoti, Medical Student, King's College London
We read this article with great interest. As final year medical students and vaccinators in primary and secondary care, we have experience to draw upon and can provide a fresh perspective after months of involvement in the programme.

In mass-vaccination centres, a proportion of patients ask if they could have more time to discuss the vaccine with their GP and have it done that practice instead. Harnden et al.¹ place value in this, stating that patients' relationship with their GPs will improve vaccine uptake. During our GP rotation, GP’s often called their unvaccinated patients upon seeing a notification on EMIS (EMIS Web is the most widely used clinical system for primary care in the UK). GP’s would then have a conversation with the patient regarding their reasons for not having been vaccinated yet and explain the benefits of the vaccine on a more personal level, inviting the patient to attend for the vaccine. This highlights the importance of primary care to the vaccine rollout. The increased trust which patients have in taking the vaccine from their GP is supported by the literature. One particular study²gathered data from 1.5 million patient surveys where a ‘substantial majority’ of respondents ‘expressed definite confidence and trust in their GP’.

The logistical difficulties of vaccinating in primary care was briefly touched upon. Nevertheless, we feel more could have been covere...
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We read this article with great interest. As final year medical students and vaccinators in primary and secondary care, we have experience to draw upon and can provide a fresh perspective after months of involvement in the programme.

In mass-vaccination centres, a proportion of patients ask if they could have more time to discuss the vaccine with their GP and have it done that practice instead. Harnden et al.¹ place value in this, stating that patients' relationship with their GPs will improve vaccine uptake. During our GP rotation, GP’s often called their unvaccinated patients upon seeing a notification on EMIS (EMIS Web is the most widely used clinical system for primary care in the UK). GP’s would then have a conversation with the patient regarding their reasons for not having been vaccinated yet and explain the benefits of the vaccine on a more personal level, inviting the patient to attend for the vaccine. This highlights the importance of primary care to the vaccine rollout. The increased trust which patients have in taking the vaccine from their GP is supported by the literature. One particular study²gathered data from 1.5 million patient surveys where a ‘substantial majority’ of respondents ‘expressed definite confidence and trust in their GP’.

The logistical difficulties of vaccinating in primary care was briefly touched upon. Nevertheless, we feel more could have been covered regarding these obstacles. In particular, at a London GP placement, clinics were held for a few half days per week and were on a walk-in basis. Therefore, patient flow was more difficult to control for vaccinators than it is in appointment-based mass-vaccination centres. Further, the varying number of patient’s attending for their vaccination on a given day, coupled with the lower proportion of regular vaccination staff in comparison to hospital hubs means that it is difficult to appropriately staff many of these GP centres to be able to operate smoothly and manage the workload. We feel this article could be further improved with more mention of the hurdles that vaccinating in primary care can bring.

References

1. Harnden, A., Lim, W. and Earnshaw, A. COVID-19 vaccination programme: a central role for primary care. Br J Gen Pract 2021: 71(703): 52-53.

2. Croker, J., Swancutt, D., Roberts, M., Abel, G., Roland, M. and Campbell, J.Factors affecting patients’ trust and confidence in GPs: evidence from the English national GP patient survey. BMJ Open 2013; 3(5): e002762.

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Competing Interests: None declared.
Published on: (22 February 2021)
Page navigation anchor for COVID-19 vaccination programme: a central role for primary care
COVID-19 vaccination programme: a central role for primary care
Laura R Skeldon, Medical student, University of Warwick
Other Contributors:
Mihari N. DeSoysa, Medical Student, University of Warwick
The article by Harden et al highlighted to us the important and admirable role that primary care is playing in the COVID-19 vaccine rollout. The authors mentioned the importance of targeting vulnerable groups, such as BAME communities, however we noted that individuals with learning disabilities were overlooked.

Whilst the impact of the pandemic has been devastating to the general population, individuals with learning disabilities have been among those hardest hit. A report by Public Health England identified that people with learning disabilities have a death rate 6.3 times higher than the general population. Additionally, the death rate for people aged 18-34 with learning disabilities was 30 times higher compared to their peers without learning disabilities.¹ These statistics confirm our own experiences of working on COVID positive wards and caring for a high number of patients with learning disabilities.

Under the current vaccine roll out, care home residents and their carer’s are the highest priority group. Those with underlying health conditions were also identified as high risk, and therefore to receive the vaccine early. This group included individuals with Down’s syndrome and those with severe and profound learning disabilities.² Whilst it is important that these group receive the vaccine quickly, this approach has been criticized as it overlooks many people with learning disabilities, who are also at...
Show More

The article by Harden et al highlighted to us the important and admirable role that primary care is playing in the COVID-19 vaccine rollout. The authors mentioned the importance of targeting vulnerable groups, such as BAME communities, however we noted that individuals with learning disabilities were overlooked.

Whilst the impact of the pandemic has been devastating to the general population, individuals with learning disabilities have been among those hardest hit. A report by Public Health England identified that people with learning disabilities have a death rate 6.3 times higher than the general population. Additionally, the death rate for people aged 18-34 with learning disabilities was 30 times higher compared to their peers without learning disabilities.¹ These statistics confirm our own experiences of working on COVID positive wards and caring for a high number of patients with learning disabilities.

Under the current vaccine roll out, care home residents and their carer’s are the highest priority group. Those with underlying health conditions were also identified as high risk, and therefore to receive the vaccine early. This group included individuals with Down’s syndrome and those with severe and profound learning disabilities.² Whilst it is important that these group receive the vaccine quickly, this approach has been criticized as it overlooks many people with learning disabilities, who are also at a greater risk

Prior to the pandemic, individuals with learning disabilities already faced barriers to accessing primary care, which has only been exacerbated in the last year.³ Primary care services have little influence over deciding who should receive the vaccine. However, it is vital that primary care services are accessible and inclusive to ensure that when the time comes, all those who are vulnerable will be able to receive it. These services could become more welcoming to individuals with learning disabilities by increasing staff training, providing longer appointments and accessible information.³

References
1. Public Health England (2020). Deaths of peoples identified as having learning disabilities with COVID-19 in England in spring of 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933612/COVID-19__learning_disabilities_mortality_report.pdf (Accessed 15th February 2021).
2. Joint Committee on Vaccination and Immunisation (2021). Department of Health and Social Care (2021). Joint Committee on Vaccination and Immunisation: advice on priority groups for COVID-19 vaccination, 30 December 2020. www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020/joint-committee-on-vaccination-and-immunisation-advice-on-priority-groups-for-covid-19-vaccination-30-december-2020 (Accessed 15 February 2021).
3. Doherty AJ, Atherton H, Boland P et al. Barriers and facilitators to primary health care for people with intellectual disabilities and/or autism: an integrative review. BJGP Open 2020 25;4(3).

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Competing Interests: None declared.