COVID-19 vaccination strategy update March 2021

On 11 January we published our Vaccination Strategy for Wales. We published an update to the strategy on 26 February. Today I am publishing a further update – a reflection of the pace and progress of our programme.

We are nearing the end of phase 1 of our programme. We said that by the middle of April we will have offered a first dose of the vaccine to all those in the nine priority groups. More than 1.2 million people in Wales have now had their first dose of the vaccine, and more than 350,000 people are fully vaccinated having received both doses of the vaccine. We are quickly working our way through the current 9 priority groups. We have a 50% gateway in place for moving from one cohort to the next and expect to start inviting the under 50s for their first doses early in April.

It is worth reflecting on the fact that all of this has been achieved in just 15 weeks since the first jab was administered. This is remarkable and I am really proud of our vaccination teams, local partners and the many volunteers across the country for their incredible commitment.

Second doses are essential for longer term protection, so it’s really important that everyone comes forward for their full course when called.

The support of the Welsh public for our programme has been incredible. Vaccination really does provide us with hope for a brighter near future so it’s clear to see why such high-levels of the public have taken up their vaccine offer. The challenge for us now is maintaining this high-level of support and motivation as we move beyond the most vulnerable into groups of our population that are younger and generally healthier. 

Confidence is building around the effectiveness of the vaccines. Emerging evidence is clear on the impact of the vaccine in preventing severe disease and hospitalisation. The latest study coming from the USA just yesterday. That is now playing out in admissions to our hospitals, and thankfully, numbers of deaths from Coronavirus being reported. UK and EU regulators have also been very clear in the last week about the safety of the vaccines. The benefits of vaccination outweigh any possible risks. The vaccines are both safe and effective.

We are not out of the woods yet though.  All the evidence reminds us of the risks of a third wave. We only have to look to Europe to see this happening. It’s really important that we all continue to follow the rules and guidance in place to keep ourselves and our families safe. While we remove some restrictions on the way we live our lives as we move into the spring, the virus is still with us. So it’s important to continue to meet as few people as possible, wash our hands regularly, wear a face covering and keep our distance from others.

We published our national strategy on 11 January. We said in that that we would continue to keep it under review as our programme progresses. We published the first update to our strategy on 26 February. This update is the second and demonstrates the ongoing review of our approach and our desire to provide further information as it becomes available.

Since publishing the first update last month our programme has continued to go from strength to strength. We are currently vaccinating at a quicker pace than any other UK nation and more of our population has received their full vaccine course than England, Scotland or Northern Ireland.

We have said all along that vaccine supply is the limiting factor in our programme. The challenges around supply coming into the UK have become apparent again in the past week, with supply expected before mid-April now being delivered up to 4 weeks later than planned. This uncertainty and instability is likely to feature throughout the duration of the programme. 

When supply has been available the pace of our programme has been fantastic. With multi-partner teams across the country vaccinating around the rate of 1% of the population a day at points over recent weeks. When the supply has been available our infrastructure and capacity has expanded to match it. Vaccinations were administered from more than 600 locations across the country last week. The blended approach we have implemented – with a combination of mass centres, GP practices, hospital sites and mobile units – has allowed us to flex capacity to adapt to vaccine supply levels.  

We are continuing to frequently publish a range of information to keep everyone informed on developments and progress with the programme. More details are provided later on this.

Since publication of our last strategy update in February we have:

• continued to protect the most vulnerable in our communities – over 95% of older person care home residents have now received their first dose and over half have received their full course of the vaccine
• reached our targets of delivering 1 million doses and vaccinating 1 million people. More than 1.5 million doses in total have now been administered
• made strong progress in delivering against the second milestone in our strategy for priority groups 5-9.  Over 70% of the clinically at risk have now received their first dose of the vaccine and over 60% of people aged 50-69. The trajectory for the coming weeks is clear and we are confident that we will achieve this milestone by our mid-April target date
• continued to see incredible take up from those in priority groups 1-9, with take up in some groups exceeding 95% for first doses
• moved forward at pace with our second dose programme.  With over 70% of health care staff having already received theirs
• further increased our capacity and expanded our infrastructure to ensure that every vaccine received into Wales is administered as soon as possible
• published guidance to provide clarity on the eligibility of and support for a number of key priority groups, including unpaid carers, those with a learning disability and those who are experiencing homelessness
• reached into communities to ensure equality and equity of access – including using faith buildings as vaccination centres and vaccination teams vaccinating at a Traveller site
• reached out to and engaged with a wide range of communities, partners and stakeholders to ensure a fair and equitable approach, which instils confidence, community and personal responsibility, and also ensures no one is left behind
• published weekly data on vaccination stocks and wastage, in order to provide transparency on vaccine supplies in Wales

Our current priority list of people to receive the vaccine has been agreed by endorsing the UK’s independent expert Joint Committee on Vaccination and Immunisation (JCVI). The same priority list is being followed by all 4 nations in the UK and has the support of all 4 Chief Medical Officers within the UK. The JCVI has published its interim advice on the prioritisation approach for the rest of the adult population in phase 2 of the programme (our milestone 3). In line with the phase 1 approach, all 4 Governments of the UK have agreed to follow the advice of the JCVI for phase 2.  More information on this is included below under milestone 3.

We have based the 3 milestones in our strategy on the JCVI’s prioritisation advice.

Milestone 1

We achieved milestone 1 on 12 February. The strategy update we published in February set out further information on this. We have implemented a no one left behind approach. No one in those first four priority groups who wants a vaccine will be missed or left behind. This approach is something that we will continue to see throughout the vaccine programme.

Milestone 2

With less than one month until the deadline we have set ourselves for achieving milestone 2 we are making strong progress.  

We have said that by the middle of April we aim to have offered a first dose of the vaccine to all those in priority groups 5-9. This includes:

• everyone aged 50 to 69
• everyone aged over 16 with an underlying health condition, which puts them at increased clinical risk of serious illness with COVID-19 – including some people with learning disabilities and with severe mental illness and those experiencing homelessness
• many invaluable unpaid carers who provide care for someone who is clinically vulnerable to COVID-19

Over 90% of those in group 5 – those aged 65-69 – have now received their first dose of the vaccine as have more than two-thirds of the clinically at risk group, and over half of people aged 50-64. We are confident, therefore, we will meet our aim of achieving 75% uptake amongst groups 5-9. However, we will be aiming higher than 75%. We want take-up to be as high as possible, and ideally much closer to 100% than 75%. With ‘no one left behind’, the offer of a vaccine will always be there for anyone who wants it. Every vaccine administered counts – it is important for individual protection and also contributes to indirect protection for the community. Together, these benefits can provide a credible route towards a future that looks more like normal. 

The trajectory for the coming weeks is clear and we are confident that, based on our current planning assumptions, we will achieve milestone 2 within the timeframe we have set ourselves.

NHS Wales has proved it can deliver on our national vaccination targets and we have every confidence this will continue.

That is, of course, assuming there are no further changes to our projected vaccine supply. The reductions in supply that have become apparent in the past week do place a squeeze on our supply and demand margins. However, at this point, we remain confident in delivering against the milestone.

Achieving milestone 2 will represent a fundamental point in our strategy. Everyone in Wales considered to be at a higher risk of poor outcomes were they to contract Coronavirus will have been offered the vaccine. The JCVI estimates that around 99% of deaths from COVID-19 have come from these groups. This is hugely significant, but there is more to do. 

Milestone 3

Milestone 3 represents the second phase of our programme. We have said that our aim is to have offered a first dose of the vaccine to the rest of the eligible adult population by the end of July. We have a 50% gateway in place for moving from one cohort to the next and expect to start inviting the under 50s for their first doses early in April.

Vaccine supply is the limiting factor in achieving this and the events of the past week demonstrate that we need to be cautious and careful. If the supply is available and timely, NHS Wales and its partners will step-up and deliver.

We have confirmed, as have the other 3 Governments of the UK, that we will continue to follow the prioritisation advice of the JCVI for phase 2. The JCVI issued its interim advice on phase 2 on 26 February. Final advice is expected shortly. 

The JCVI has recommended that vaccine deployment continues on the basis of age. This is because age remains the most significant risk factor. The JCVI has also recommended that, within an age based model, particular focus should be placed on achieving high take up amongst males, those from minority ethnic groups and those experiencing socio-economic deprivation. In recommending this approach, the JCVI noted the importance of continuing vaccine roll-out at pace, saying that age is a straightforward approach for the NHS allowing the current pace of deployment to be maintained.

Given this, when our programme moves from phase 1 into phase 2, the first people after groups 1-9 to be invited for their first dose of the vaccine will be those aged 40-49. We expect this group to begin to be called for appointments early in April. 

The age range for phase 2 is 18-49. Our preference would be a starting age of 16. This would be in line with the children and young people’s rights approach we have within Wales. We also believe there would be a sound basis from a virus transmission point of view given younger people often mix with others to a greater degree than some older groups of the population. The JCVI has been asked to consider this further and we’re assured that this consideration is ongoing. 

Our milestone 3 approach

We said in our update in February that milestone 3 would require us to look closely at our approach and delivery model. This next phase will see our programme seek to target younger people and parts of our population that are generally healthier. This will present challenges in maintaining high levels of take up for a wide range of reasons. It will also require us to build on our approach in terms of equity and fairness so that we are reaching further into communities. We will also need to look closely at the resilience of our model from a capacity and infrastructure perspective, including in the context of society beginning to open up.

As such, our strategy for milestone 3 will be based on the following key considerations:

Maintaining a high level of take up

Maintaining support and motivation for vaccination is absolutely critical if the programme is to continue to be a path out of lockdown. We know that the main variant of Coronavirus now circulating in Wales is more transmissible that the original variant. This means we need to achieve exceptionally high levels of immunity in order to continue to reduce restrictions on people’s lives and try to prevent or minimise further waves of the disease.

We know that the vaccines are safe and effective. The update we published in February set out some of the real world evidence on efficiency and this evidence continues to grow (a study from the USA was published on 22 March, for example). We also know that the vaccines are safe – on 18 March the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) and European Medicines Agency confirmed that the vaccines are “safe and effective to protect citizens against COVID-19” and the benefits outweigh any possible risks. They also confirmed that the vaccines are not associated with an increase in the overall risk of thromboembolic events or blood clots.
Whilst support for vaccination across the age ranges remains high (at over 85% according to the latest survey by Public Health Wales), there is a risk that motivation for vaccination will level off in the younger age groups because they are less at risk of poor outcomes. We are also aware of a range of hesitancy concerns that are likely to be more prevalent in the younger population, for example fertility concerns amongst younger females.

We will implement a robust approach to take up:

• using all communications and engagement channels available to us nationally and locally
• ensuring our delivery model offers the best possible and convenient access to vaccination, so that it is responsive to the needs of harder to reach and marginalised groups and communities, including those in the younger age ranges; and
• which incentivises vaccine take up, to ensure the personal and societal benefits of vaccination are clear

For milestone 2 we said our aim for uptake was 75%, whilst of course working towards as high uptake as possible. This was based on take up levels for other immunisation programmes, such as the annual influenza campaign. We will continue to aim for 75% in milestone 3 and strive for higher uptake. Whilst aware that this is likely to be challenging we will continue with our approach to reach every single citizen in Wales – every vaccine really does count and no one in Wales who wants the vaccine will be left behind.

Every person in Wales should have fair access to vaccination with a fair opportunity to receive their vaccination. That is why additional and tailored support will be put in place for harder to reach and under-served groups, who may otherwise be left behind, worsening existing health inequalities. 

Targeted action for these groups can be considered across three interlinked dimensions; people with protected characteristics under the Equality Act 2010, including people from ethnic minority backgrounds and disabled people; those at socio-economic disadvantage living in communities with high deprivation or social exclusion; and those within marginalised or under-served groups such as asylum or sanctuary seekers, people experiencing homelessness, people involved in the justice system, people suffering from poor mental health and people from Traveller communities who do not regularly access traditional healthcare services. However, our approach will also look wider, beyond traditionally marginalised groups, reflecting on the experiences of groups and communities during the pandemic to ensure a genuine ‘no one left behind’ approach.

Reaching into communities has been an important feature throughout the programme. We have put in place specific arrangements for some marginalised groups, including those experiencing homelessness or caring for others. Local approaches have also been implemented to take the vaccine to communities, for example to some Traveller sites and faith centres. This will continue and be built upon in the next phase.

To sit under our national strategy we are publishing a Vaccine Equity Strategy, to set out more detail on our thinking and plans. A new Vaccine Equities Committee has been formed to guide this work. It will monitor and review data, intelligence and research on inequities in uptake of vaccination and advise on appropriate interventions and communication to reduce vaccine inequity in the programme. It will follow a community led approach so local concerns can be raised and specific barriers acknowledged and addressed through tailored support as the programme moves into its next phase.

A comprehensive communications and engagement plan has also been developed using behavioural insights to explore and understand perceptions around vaccination, including the motivations for and barriers to vaccine uptake.

The pressure NHS Wales has operated under for over a year now has been unprecedented and immense. We are incredibly proud of and grateful to our NHS, primary care and social care staff for working tirelessly to keep us safe during the pandemic, and now for protecting us from future harm through our vaccination programme. The partnership approach we have seen to deliver the essential vaccination programme has been incredible – it shows just what can be achieved through joint endeavours and partnership.

But it is essential that we take stock as we move into a new phase of our programme to safeguard the resilience of our delivery model, consider the wider context – for example, non-COVID harms that may be exacerbated as a consequence of such a focus of resources on our vaccination programme – and ensure our model is fit for purpose in terms of the target population during this next phase. This will include increasing our use of other key resources, such as community pharmacy, to provide another route of delivery moving forward. Reassessing the use of existing venues will also be important as society begins to open up and some buildings, such as leisure centres, will need to be returned to the intended purpose.

A ground-up approach is needed to plan the next phase effectively, and this work is already well progressed. The following overarching expectations will frame local delivery approaches:

• a particular focus on groups that may be less likely to take up the vaccine – in terms of communications and engagement and decisions on infrastructure
• specific consideration of community venues, such as faith buildings or community centres, as vaccination centres – with a direct aim of targeting those communities regardless of the wider local options
• use of local data, evidence and intelligence gathered from engagement to develop local plans
• intelligent use of local capacity, with decision-making taking into account wider and future considerations – including minimising non-Covid harms, ensuring resilience of the workforce, particularly in the context of a potential autumn booster programme and potential ongoing annual programme, and the possible return of some venues

Effective communications will be critical to the success of our approach to milestone 3. Our target audience is a younger and healthier population who will likely feel less at risk and potentially also have increased hesitancy, for example due to concerns around fertility or the vaccine ingredients including meat products. Our communications will be targeted and evidence based and will make full use of public and trusted figures to maintain support and motivation for vaccination.

Whilst there is little doubt about the success of the vaccination programme, and the emerging evidence is really positive both in terms of the efficiency of vaccines in preventing severe disease and in reducing transmission, we are not out of the woods. More information on our wider approach to the pandemic is contained in our revised Coronavirus Control Plan.

As we approach autumn and winter this year, we need to reflect carefully on the potential COVID vaccine booster programme, particularly among the priority groups. The JCVI is currently considering the evidence and will give advice on what is required. This will include a consideration of the options for alignment with the traditional winter flu vaccine. We will provide a further update later in the spring.

We are continuing to frequently publish information about the vaccine programme.

Public Health Wales is publishing daily and weekly surveillance data, which provides information on how many vaccinations have been administered, including daily breakdowns by priority groups, and weekly breakdowns by health board.  Monthly surveillance reports on equity of coverage between ethnic groups and level of socioeconomic deprivation are also now being published.

Welsh Government statisticians are publishing some of the more operational statistics attached to the programme each week.

We are also publishing a weekly narrative to set out progress against our strategy.