Vaccination strategy for Wales: update February 2021

On 11 January we published our Vaccination Strategy for Wales. Whilst less than 2 months ago, a huge amount has happened since then. We are now over half way to protecting all those in priority groups 1-9, and have vaccinated over one-third of all those age 16 and over in Wales. Our vaccination programme has gone from strength to strength and I am publishing this update to both reflect on progress and provide some further detail on our current and upcoming priorities.

More than 890,000 people in Wales – most of whom are amongst the most vulnerable to poor outcomes should they become infected with Coronavirus – have now received their first dose of the vaccine. Second doses, which are important for longer term protection, are also beginning to be rolled out with almost 70,000 people having had theirs already. By following the JCVI’s advice on a longer interval between doses, we have been able to protect more people with first doses and provide good short and longer term protection for as many people as possible as quickly as possible.  This is an incredible effort in the national interest. My deepest thanks goes to all those involved – from NHS Wales, public and private sector partners, and the many volunteers that have stepped up.

My thanks also go to the many hundreds of thousands of you that have taken-up your offer of the vaccine. You have played your part in our national mission to keep Wales safe – thank you.

The situation in Wales as we enter spring 2021 remains serious. Cases of the virus are still high and a new, more infectious variant of coronavirus has emerged across the UK, and is now the dominant variant in all parts of Wales. As a result, we are all continuing to stay at home to keep Wales safe. But the impressive start to our vaccine programme has brought with it hope for all of us, and vaccines remain effective against this new variant.

The evidence is still emerging but confidence is building that the vaccine programme is a critical factor in our journey out of lockdown and to a brighter near future. 

In the meantime, we all need to continue to follow the rules and guidance in place to keep ourselves and our families safe. This means meeting as few people as possible, washing our hands regularly, wearing a face covering and keeping our distance from others.

We published our national strategy on 11 January.  It built upon the plans already in place within each of our seven health boards and trusts and provided more detail about our programme. We said in the strategy that it would be reviewed regularly – so that it reflected the latest clinical, scientific and other evidence. This update represents the first of those reviews.

Since publishing the strategy we have achieved our first milestone and are already making good progress towards the second.  Some greater certainty is also beginning to emerge in relation to the third milestone. This update will provide more information on the current and future priorities.   

It is important to be clear about the ongoing supply challenges. While supply into the UK is forecast to pick-up and stabilise from March; uncertainty and instability remains and is likely to be a feature throughout the duration of the programme.  

Our infrastructure and capacity has continued to grow since the publication of our strategy last month. We prioritised building strong foundations at the outset and this has paid off as we’ve progressed into the programme. At points, and when supply has allowed, vaccines have been administered from almost 500 locations across Wales at a combination of mass centres, GP practices, hospital sites and via mobile units. We have seen the role of primary care expand considerably over recent weeks and expect this to grow and adapt into the next stages, including with a greater role for community pharmacy.

Since publishing our strategy, the amount and types of information we routinely publish has increased.  We are committed to providing information to keep everyone informed. More details are provided later on this.

Where are we now?

Since commencement of the vaccine programme in early December we have:

• achieved the first milestone in our strategy. That is to have offered the vaccine to everyone in the first 4 priority groups:
  • Everyone over 70
  • All frontline health and social care workers
  • Everyone living or working in older people’s care homes
  • Everyone who is clinically extremely vulnerable
     
• as a consequence of completing priority groups 1–4 we have sought to protect 88% of those most at risk of dying from coronavirus
   
• seen incredible uptake from those groups that have been offered the vaccine. With uptake in excess of 80% in these groups, and exceeding 90% in some groups
   
• made significant progress in building our vaccination infrastructure in all parts of Wales, with vaccines being administered from close to 500 locations some weeks
   
• increasing capacity by bringing on board a flexible and multi-professional workforce which has enabled us to administer almost 180,000 doses of the vaccine some weeks
   
• reached out to and engaged with a wide range of communities, partners and stakeholders to seek to ensure a fair and equitable approach, which instils confidence, community and personal responsibility, and also ensure no one is left behind
   
• administered a first dose of the vaccine to over 850,000 people in Wales in less than 3 months.

Our priority list of people to receive the vaccine has been agreed by endorsing the UK’s independent Joint Committee on Vaccination and Immunisation (JCVI). The same priority list is being followed by all four nations in the UK and has the support of all 4 Chief Medical Officers within the UK.

It is on this priority list that we based the 3 milestones in our strategy.

Milestone 1

We achieved milestone 1 on 12 February. Eligible groups have been actively identified and called. Uptake has been extremely high with almost 9 in 10 in groups 1-4 accepting vaccination. It’s never too late to be vaccinated. In recognition of the fact that there will be reasons why some people in the first 4 groups have not yet been offered or taken up their vaccine – we have implemented a no one left behind approach.  

If, for example, a person has changed their mind about vaccination, missed their appointment because they were unwell, were not given an appointment because they were not listed as a frontline health or social care worker or live or work in an older person’s care home that has had cases of the virus recently, they have not missed their chance. Every health board is actively encouraging those in groups 1-4 that have not yet had their vaccine and all have published contact numbers and email addresses for those in the first 4 groups to get in touch.

The no one left behind approach is something that we will continue to see throughout the vaccine programme. As we move through the priority groups, NHS Wales will continue to check back to ensure that all those who are eligible and want the vaccine get it and that those who have not made up their minds continue to have opportunities. 

Milestone 2

Having achieved milestone 1 we are now pursuing milestone 2. That is to offer the vaccine to everyone in priority groups 5-9. That 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
• many invaluable unpaid carers who provide care for someone who is clinically vulnerable to COVID-19

Our strategy said that our aim was to offer the vaccine to these groups by the spring, and we subsequently confirmed our intention to do this by the end of April.  We are now aiming to bring this forward to the middle of April.  This is following commitments made by the UK Government to bring forward some of Wales’ supply allocation to enable an earlier delivery timescale.  We have always been clear that we had the capacity to go quicker were the supply available.  However, this earlier allocation of supply comes with challenges because of the type of supply and the timing of its delivery.  Therefore, while we are clear that we have the capacity to deliver to this timescale, supply is very much the limiting factor. 

By targeting the priority groups in milestones 1 and 2, it is estimated that around 99% of deaths from Covid-19 will be prevented. That is significant; giving us confidence and presenting opportunities as we navigate the virus through the months ahead.

Uptake of the vaccine has been exceptionally high within groups 1-4.  As the vaccine programme moves into the younger and healthier groups, we will continue to work to protect as many people as possible, however it is possible that uptake levels may drop off slightly. The vaccines are very safe, with evidence from over 17 million doses given in the UK and weekly reports published by the Medicines Regulator.  We will continue to pursue very high levels of uptake and use all levers available to us to do this – including our communications channels and opportunities through our infrastructure arrangements. Our aim for groups 5-9 is to achieve at least 75% uptake. 

With the strong progress we have seen in terms of both infrastructure and capacity, supply permitted, we expect to achieve the following during milestone 2:

• 1 million vaccine doses administered by 7 March 
• 1 million first doses administered by 14 March 
• to administer over 1.5 million doses during milestone 2

As of week commencing 15 February, NHS Wales has effectively begun operating two sets of arrangements alongside each other – that’s a first dose system and a second dose system.

This brings with it operational challenges, for example around scheduling and appointments. It also brings with it challenges around vaccine stock management and in terms of capacity.  

We all want to see the continued high-pace that we have seen over recent weeks with first doses.  But second doses are essential for longer term protection and, as a consequence, there is a need for a balance between the deployment of both doses. Completing the first 4 priority groups means that the most vulnerable in our communities have a high level of protection against the virus. This gives us the confidence and assurance to start deploying second doses.

Over the coming weeks and months we will continue to see NHS Wales administer thousands of vaccines each week, but these will be a mix of first and second doses, so the numbers of new people called for appointments may not be as high as they have been over recent weeks.

That said, we do not believe that NHS Wales has peaked yet in terms of capacity. To-date, the highest weekly number of vaccines administered has been around 180,000 vaccines. Subject to the availability of supply, we are confident we have the capacity to exceed 200,000 doses in a week.

There will be weeks where there are reduced levels of supply across the UK.  These dips in supply will be planned and expected and as a result we will flex our infrastructure and capacity accordingly. We have the flexibility within our model to pop-up and pop-down vaccine locations as needed. This means NHS Wales will need to prioritise the vaccine programme alongside its other essential work.

Priority group 6 is a large and complex group and merits explanation.

JCVI priority group 6 includes ‘all individuals aged 16 years to 65 years with underlying health conditions which put them at higher risk of serious disease and mortality’. It also includes some unpaid carers. 

We have published separate guidance on the prioritisation of unpaid carers for vaccination. We will also publish separate guidance on the prioritisation of those with learning disabilities and severe mental illness.

Priority group 6 is further defined in the Green Book Chapter 14a as ‘Adults aged 16 to 65 years in an at-risk group’. The list of at-risk conditions can be further subdivided into three main sub-groups:

• Adults aged 16 to 65 years in an at-risk group which includes:
  • Chronic respiratory disease
  • Chronic heart disease and vascular disease
  • Chronic kidney disease
  • Chronic liver disease
  • Chronic neurological disease, including severe or profound learning disability (which the separate guidance we will publish will explain)
  • Diabetes mellitus
  • Immunosuppression
  • Asplenia or dysfunction of the spleen
  • Morbid obesity
  • Severe mental illness (which the separate guidance we have published explains)

Individuals in an at risk group being treated by their GP will be known to the NHS and will be contacted automatically for their vaccine appointment.

• Younger adults in long-stay in-patient nursing and residential care
• Adult carers, which the separate guidance we have published explains

Priority group 6 is similar to the flu at risk groups, but with some important differences. In particular, for Covid-19 compared with flu:

• The age range is limited to adults with the exception of some children with severe neurodisabilities
   
• Those with severe asthma are at increased risk and included. Severe asthma is defined by the JCVI as requiring regular use of oral corticosteroids or previously requiring hospital admission. Individuals with mild to moderate asthma are not at increased risk and not recommended for vaccination by JCVI

• Those with ‘severe and profound’ learning disability are included (and this will be explained further in separate guidance, including the inclusion of an element of clinical discretion in our approach to reflect that this is not recognised language in Wales)

Milestone 3

Milestone 3 is essentially the second phase of our vaccine programme. In our strategy we state that our aim is to have offered the vaccine to the rest of the adult population by autumn. The UK Government has suggested vaccine supply could be brought forward to enable this milestone to be achieved by the end of July.  As with bringing forward the target date for milestone 2, NHS Wales has the capacity to deliver to this earlier timescale, but vaccine supply needs to be the right supply and deliveries need to be timely so that effective deployment plans can be made.  We will continue to work with the UK Government on this.

Our strategy also says that delivery of milestone 3 is subject to further advice from the JCVI on prioritisation.

The JCVI has today issued interim advice on phase 2 prioritisation. It has recommended the continuation of an age-based approach for prioritisation. This is with the aim of continuing to focus on mortality, morbidity and hospitalisations while also continuing vaccine roll-out at pace – organising the programme by age is the most straightforward approach that allows everyone to be offered a vaccination as quickly as possible. A more complex system would require the setting up of new systems and arrangements which would take time and potentially slow down deployment. Other important factors – specifically ethnicity and socio-economic status – are also featured. We will build these considerations, as well as broader equalities considerations, in our wider communications and deployment arrangements, allowing for local operational flexibility where appropriate.

The 4 Chief Medical Officers agree with the JCVI advice and the 4 nations of the UK have subscribed to implementation of the advice. That was our clear approach for the milestones 1 and 2 and will be maintained for the next phase.

What is clear already in terms of phase 2 is that it will require us to keep under close review our infrastructure and capacity. Around 2 million doses of vaccine will need to be administered over the summer and into the autumn. We need to ensure we have the right infrastructure for this – including a greater role for community pharmacies and more in-reach into communities – both to ensure equity of access across all areas of Wales and to maintain the current high-levels of up-take. We will also say more about this soon.

As we proceed with the vaccination programme we are learning more about how effective vaccines are and there has been some recent positive news on this:

• This week, research by Public Health Scotland suggests the vaccination programme is having a significant impact on preventing serious illness. The research found that four weeks after the first dose, hospital admissions were reduced by 85% and 94% for the Pfizer and AstraZeneca vaccines respectively.  Also, among the over 80s, there was an overall reduction of 81% in the numbers admitted to hospital.
   
• Public Health England has also published research this week showing that protection against infection from a single dose of the Pfizer vaccine was 72%, corresponding with similar data from Israel that suggested 75% protection.
   
• The independent Medicines and Healthcare products Regulatory Authority recently released research demonstrating the vaccines are extremely safe, the vast majority of side effects are mild and short lasting reflecting the normal and expected response, including some individuals who experience a day or two of flu-like symptoms requiring rest.
   
• A study on the Oxford Astra-Zeneca vaccine suggests that it could lead to a substantial fall in the transmission of the virus (up to 67%), and that protection remained at 76% during the first three months after the first dose, and rose to 82% after the second dose.
   
• The World Health Organisation’s department of immunisation has said that even if the efficacy against developing new symptoms with new variants of the virus dropped to a low level, the vaccine will still stop severe disease and death.

This is incredibly positive. However, there is more we need to learn about the impact of vaccination and there is a risk from variants and mutations – both those we know about and those that could emerge. That is why it is so important that, even after vaccination, people continue to follow the rules to keep themselves and their loved ones safe. 

To combat this potential risk, we may need to build on the current vaccine deployment plan with a booster programme in the autumn. The need for this should become clearer over the coming months and will be factored into future planning if considered necessary.

There is much to be hopeful about due to the success of the roll-out of vaccines.  But cause for concern and risks to our health and care systems remain. The role of the vaccine programme in releasing restrictions and coming out of lockdown is explored further in our Coronavirus Control Plan: Update. We are on the road to recovery, but it will take time.

Since publishing our national strategy in early January we have expanded the ways in which we are communicating information about the vaccine programme.

Public Health Wales in 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.

From this month, Public Health Wales will also publish monthly surveillance reports on equity of coverage between ethnic groups and level of socioeconomic deprivation. Over time, this will be expanded to look at coverage at a geographical level too.

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.

More broadly, a national communications and stakeholder engagement plan is in place, which includes the prioritisation of communications with marginalised or hard to reach groups. During February, for example, the Minister for Health and Social Services hosted a roundtable event with community leaders from Black and Minority Ethnic communities; and a webinar was held in relation to the prioritisation of unpaid carers. Public Health Wales has also published accessible information resources.