Migration, Vaccination and COVID-19

Question 1

How can migration be an issue for our generation?

Answer 1

Migration is a defining issue of our generation

How the world addresses human mobility will determine public health and social cohesion for decades ahead

Question 2

What % of children globally are vaccinated for measles?

Answer 2

Around 80% of children have been vaccinated against measles (1st dose of measles) 70% of children have recieved their second dose of measles vaccine (MMR)

Along with other vaccinations (like rubella, polio, pneumococcal disease etc), these equate to around 23 million children last year (2021) not getting basic vaccinations. Around 60% of this figure live in 10 countries.

To acheicve and maintain elimination, WHO recommends 95% uptake with two doses of the MMR vaccine by 5 years of age

We need to acheive herd immunity threshold (HIT) targets in a given population to present disease from persisting

Question 3

How does herd immunity work?

Answer 3

• If only some get vaccinated, then the virus spreads easily
• If most get vaccinated, then the virus is contained

Question 4

What is happening with Uk vaccination coverage?

Answer 4

• UK vaccination coverage is declining for all routine vaccinations
• Considerable regional variations: London has a low measles coverage (83%)
• PHE data show there are inequities in vaccine uptake by ethnic and deprivation scores, but no data on migrants despite increases in migration to the UK in recent years
  
  • Under immunisation has resulted in a large sustained outbreak of measles in recent months, involving 17+ countries
  • 55% cases in adolescents/adults 15+ years; including adult labour migrants from Eastern Europe alongside other underimmunised groups
  • UK lost its WHO elimination status for measles in 2019
• We need to know what extent migrants are an under-immunised group so that we can better target catch-up vaccination campaigns

Question 5

Are migrants an underimmunised group?

Answer 5

• Migrants are an under-immunised groups involved in multiple outbreaks of vaccine-preventable diseases in Europe
• 19 (40%) of outbreaks were reported in temporary refugee camps or shelters
• Outbreaks often associated with adult migrants
• ‘a better understanding of vaccine access and intent in migrant groups is needed…with direct implications for COVID-19 vaccine delivery

Question 6

To what extent are migrants an underimmunised group?

Answer 6

2126 recently arrived asylum-seeking children and adolescents:

• 33% not immunised according to Danish national schedule
• 22% not immunised for MMR
• Afghan children and Eritrean least likely to be vaccinated
• 48% of those aged 12-17 years were vaccinated/status unknown

Question 7

Describe a systematic review of serology studies that pertain to migrant vaccination?

Answer 7

There was a systematic review conducted to observe the serology studies over the last decade

Measurement of antibodies in vaccine-preventable diseases

80 000 migrants (large study)

Study included 56 studies from 14 european countries

Metaanalysis included 37 studies (80 185 migrants) reporting on: measles, mumps, rubella, diptheria, tetanus, and polio

Question 8

What is the measles coverge in the meta-analysis ?

Answer 8

Aiming for approx. 92-95% coverage of measles immunity in migrant populations

Under hit target= 85.5%

Question 9

What is the mumps coverage in the metaanalysis?

Answer 9

• Below the HIT target
• Mumps coverage= 68.5%
• HIT target= 75-86%

Question 10

What is the diptheria coverage in the metaanalysis?

Answer 10

Below the HIT target

Diptheria coverage: 55%

HIT target= 83-86%

Question 11

What is the Rubella coverage in the metaanalysis?

Answer 11

Just below the HIT target however, it is very close

Rubella coverage: 82.8%

HIT target is 83-86%

In 2019, over 95% of rubella cases in pregnancy in the UK were in migrant women

Question 12

What is the polio coverage in the metaanalysis?

Answer 12

Polio coverage is higher than HIT targets (80-86%).

Type 1= 94.5%

Type 2= 96.4

Type 3: 87.3%

Question 13

How do people perform an analysis of UK bound refugee datasets?

Answer 13

= Study in the international organisation for migration: analysis of UK bound refugee datasets

They look at vaccine history, update vaccines, health updates, health check, TB screening before they come into the UK

Question 14

What did a study of UK immunisation say about migrants?

Answer 14

Under-immunisation of UK bound refugees

• Resettled refugees are arriving in the UK under-immunised
• More than one in 10 arrive in the UK with no doses of polio-containing vaccine and almost one in five with no doses of measles-containing vaccine
• Large majority had no recorded doses of diptheria, tetanus and pertussis (DTP) vaccine

Question 15

What are the barriers to vaccination?

Use a case study to highlight your point

Answer 15

Nigeria

• Poor functioning vaccine and health systems, lack of vaccines: measles coverage is currently 41.8%
• 1996 ‘Trovan trial’:Pfizer’s illegal trial of an unregistered drug that resulted in child deaths and an extreme lack of trust in western organisations and vaccine initiatives, and led to a polio vaccine boycott
• Vaccine hesitancy/ anti vaccination in Muslim communities in Northern Nigeria

Question 16

What are the barriers facing migrants on arrival in the UK, in terms of vaccination?

Answer 16

• Limited data on the perspectives of migrants: one recent study in Polish and Romanians
• Overall acceptance of vaccination/not vaccine hesitant, but several barriers to getting vaccinated
  
  • Difficulties navigating and trusting the NHS
  • Language barriers and challenges in accessing credible/translated vaccine information
  • Problems communicating their previous vaccine histories

Question 17

What are the differnces between access barriers and acceptance barriers with regards to vaccination?

Answer 17

Access

• Language, literacy and communication
• Practical, legal and service barriers

Acceptance

• Eastern European and Muslin migrants
• HPV, measles and influenza vaccines
• Being African or E European was associated with being under-immunised
• No apparent or strong association with gender or age

Question 18

What is vaccine hesitancy?

Answer 18

• Vaccine hesitancy: the delay in acceptance or refusal of vaccination services despite the availability of vaccination services
• It is complex and context specific varying across time place and vaccines

Question 19

Describe the increasing vaccination model

Answer 19

Like the COVID-19 VACCINE

• Practical coverage of COVID vaccine-> failure of global health
• If someone is working a lot-> may not access vaccine on time

Question 20

What are the health system barriers to catch migrants up on their vaccines?

Answer 20

• Focus is very much on migrant children for catch-up vaccinations on arrival to align them with the national schedule: assumption made by clinicians that they are vaccinated as children
• Less than half of all reporting countries in Europe offered DTP (16 of 31 countries), polio (12 of 32), MMR (12 of 32) to adults
• UK primary care: no systems in place
• 10 out of 32 countries charge adult migrants for routine vaccines
• Cheap routine vaccines that have been made inaccessible

Question 21

What are the social factors that may influence the vaccination of migrants?

Answer 21

Lack of trust:

• Both trust in vacicne itself, but also health system and wider governance system if host country
• Lack of trust in government messaging

Personal confidence

• Concerns around vaccine safety and side-effects, concerns about low efficacy
• Feas that the COVID-19 vaccine not well enough tested on minority groups

Low awareness and access to information

• Plenty of evidence showing lack of accessible robust information as a key driver of under-immunisation

Risk-perception

• Low percieved need
• preference for ‘natural options’
• Other life/health issues are a priority

Question 22

What are some of the social processes that may negatively influence motivation to vaccinate in migrants?

Answer 22

• Cultural or religious expectations
  
  • Religious norms or expectations are key social processes that may influence migrants motivations to vaccinate
  • Concern over vaccines being anti-islamic
• Influence of home country.dispora media
  
  • Lack of trust in vaccines and/or lack of percieved need to have one due to influence from factors in home country and dispora media
• Historical and structural racism in host country
  
  • Distrust in healthcare providers based on past experiences of discrimination or fears of being charged fees
  • In Africa, fears that there are ‘hidden agendas in the West’ for vaccination campaigns
• Lack of resources or awareness among Healthcare workers (HCWs)
  
  • Low knowledge of migrant needs among healthcare workers
  • Low proactivity in healthcare system to reach marginalised groups
  • Resource constraints: lack of access to interpreters and advocates, lack of information
• Circulating misinformation
  
  • Social media based communication negatively influencing motivation to vaccinate
  • Multiple conflicting information sources and migrants are not clear which ones to trust

Question 23

Vaccines and social media

Answer 23

• Social media is a communication platform
• Shares high levels of misinformation about vaccines
• Evidence suggests some ethnic minorities/migrant groups are potentially more at risk of recieving misinformation on social media
  
  • Study on approx 400 Syrian refugee mothers in jordan found that the main sources of public health info were via Facebook (Approx 90%) and WhatsApp (Approx 70%)
• Greater considertiokn must be given to influence of social media-based communciation as a major source of vaccine misinformation
  
  • You cannot control private messages, therefore you must mobilise community response​

Question 24

What are the current policies in Europe for vaccinating migrants

Answer 24

• Identify who has been missed out in the past & reach them with the vaccines they need
• All groups have equitable access to vaccination services and that these are convenient
• UK recommends MMR, Td/IPV (Tetanus, diptheria and polio), MenACWY (aged 10-25) to be readministered to all adult migrants with uncertain vaccination status
  *

Question 25

What is the WHO immunisation campaigns

Answer 25

• Trgeting excluded and marginalised groups
• Greater focused placed on vaccination across the life-course and try to seek every oppertunity to ‘catch up’ individuals for missed vaccines, missed doses, boosters
• Aligning with the universal health coverage agensa
  
  • A world where everyone, everywhere at every age fully benefits from vaccines for good health and wellbeing

Question 26

What is the UK approach to maintaining targeting migrants and ethnic minorities?

Answer 26

• Catch up vaccines MMR, Td/IPV/MenACWY, HPV
• Facilitates creening & vaccination for many health needs->the first routine data collection on health of migrants
• Prompts GPs and nurses if a patient is under immunised, or eligible for screening for key conditions s (based on NICE and PHE guidelines)
• Highly targeted, and generates information in one pop-up which will summarise blood tests and vaccines
• Requires coding country of origin, ethnicity, BMI, age/sex and time in UK
• Facilitates data collection on screening uptake, screening outcomes, prevalence of infection/conditions etc
• Challenges: cost, workload, incentivation, availability of some screening tests

Question 27

What are some of the approaches and solutions along the pathway to accepting or refusing COVID-19 vaccination?

Answer 27

Question 28

What is the link between cases, hospitalisations and deaths attrbuted to COVID-19 in migrant populations?

Answer 28

• Cases
  
  • Some migrant groups are at increased risk of COVID-19 infection and are disproportionately represented in cases
• Hospitalisations
  
  • Some evidence that migrants are at greater risk of hospitalisation and ICU admission due to COVID-19
• Deaths
  
  • Migrant groups experience higher all-cause mortality during the pandemic and potentially COVID-19 specific mortality
• More taxi cab drivers had the most deaths attributed to COVID-19 than any other group.

Question 29

Name a study where it shows a lower intent to vaccinate and lower uptake of COVID-19 vaccines in migrants

Answer 29

Lower intent to vaccinate

• E.g. Syrian refugees in Lebanon reported that 29% would not vaccinate
• In US study, 25% of migrants said they would be unlikely to go out and get a vaccine
• Migrants in deprived areas of Greece, 38% said no to vaccinating

Uptake data: norway

• Highest uptake in people born in Norway, Sweden and Denmark (over 90%)
• Similar findings when exploring uptake among migrant healthcare workers

Uptake data: Sweden

• In ages 65-79 (to May 2021): Uptake in Swedish Born 92%, EU migrants 70&, North Africa 61% and Other Africa 52%

Question 30

What is the relationship between socioeconomic deprivation/religion and vaccine rollout?

Answer 30

Age 50-54: coverage is 75% in most deprived areas vs 90% in least deprived areas

Religion:

• People of Muslim religion have vaccination rates of 72% versus Christian/jewish religion of 90%

Question 31

What are the implications of vaccine rollout in the UK to BAME?

Answer 31

• Only 57% of people from black, Asian and minority (BAME) backgrounds would have the COVID-19 vaccine if advised to by their GP, compared to 79% of white respondents

What are some barriers to COVID-19 vaccines for migrants in theUK?

• Non access to primary care

Question 32

What are the COVID-19 vaccine uptake in migrants in Greece?

Answer 32

No system in place to deliver vaccines to irregular migranst with no papers

Very slow and low levels of vaccine rollout so far with coverage in host Greek populations; 84% of Greek adult populaiton has received a COVID-19 vaccine only 45% among asulym seekers and refugees in these camps

56 000 asylum seekers and refugees