COVID-19 vaccination coverage for half a million non-EU migrants … – Nature.com

We present findings on COVID-19 vaccination delays and overdue or missed doses for almost half a million non-EU migrants and resettled refugees compared with the general population in England between 8 December 2020 and 20 April 2022. Refugees and migrants with non-white ethnicity were more likely to have a delayed second or third COVID-19 dose. Refugees and older migrants were more likely to not have received a second or third dose. These data hold immediate relevance to strengthening COVID-19 vaccination for migrants and identify important variability in uptake by age, visa type, and ethnicity.

Our findings highlight more overdue second and third doses (that is, not receiving a subsequent dose) in older migrants compared with their counterparts in England. Slower uptake could have been driven by greater language barriers, limited health literacy, digital exclusion or fear of side effects in older migrants18,19,20. Similar findings were found in a large cross-sectional study in Canada21. Decisions to not receive a second or third dose could also be associated with differences in perceived vulnerability to severe COVID-19 outcomes due to lower levels of underlying health issues in migrants compared with the general population in England22. Patterns in greater overdue second and third doses for older migrants remained even after the follow-up period was shortened to account for potential emigration or embarkations out of England once international travel resumed. In-depth qualitative exploration on the reasons behind older migrants lower uptake is needed especially given the importance of subsequent doses for protection against new variants.

Individuals on work visas were less likely to be overdue for a second or third dose than the England cohort. This may be due to firstly significant proportions of migrants working in health and social care23,24 who were initially prioritized for vaccination and eventually included in the United Kingdom government enforced vaccine mandate, and secondly, more stringent work visa sponsorship requirements may favour the entry of migrants with higher socio-economic status, which has been associated with lower vaccine hesitancy25,26. Conversely, refugees were more likely to be overdue for both second and third doses than the England cohort and were almost two times more likely to be delayed for their second or third dose, which is consistent with studies on low vaccine intent and under-immunization in other forced migrants12,27. Reasons for delays include access barriers, lack of accessible information in appropriate language, fear of vaccine side effects, or lack of familiarity/trust in the health system12,13,28. However, these estimates are probably an underestimation of true inequalities among other forced migrants as the refugee participants in this study are resettled refugees who received government support to facilitate early integration with appropriate health and social care services prior to their arrival.

Migrants with non-white ethnicities were more likely to be delayed for their second dose than migrants with a white ethnicity. This could reflect the unique challenges that being both a migrant and an ethnic minority have on vaccine access as a result of healthcare entitlement, language, literacy and other communication barriers2,29. As some ethnic minority communities experienced higher severe acute respiratory syndrome coronavirus 2 exposure and subsequent COVID-19 infection, second dose delays could have also influenced by following official guidance to wait at least 4weeks after an infection before receiving the next dose30,31. However, those differences disappeared for the third dose, perhaps due to the rapid roll-out of the booster (third dose) programme or more targeted vaccination campaigns. With evidence clearly demonstrating the disproportionate impact of COVID-19 on ethnic minority groups in England, there was a commitment from the United Kingdom government to support bespoke vaccination campaigns targeting ethnic minority communities to increase vaccine and booster uptake32. Still older migrants across all ethnic groups were less likely to return for their third dose than their counterparts within the same ethnic group in the England cohort. Conversely, another study found migrants arriving before 2011 from Black African, South Asian and Other ethnicities had a higher total first dose uptake than their United Kingdom-born counterparts15. Further research is needed in exploring predictors of vaccine uptake such as migration status (for example, migrants and non-migrants), visa type within ethnic groups, and socio-economic status.

Strengths of this study include a large study population with information on migration history linked to vaccination records that cover the primary course of COVID-19 vaccination and the initial booster (third dose) campaign recommended for adults in England. Our comparison dataset OpenSAFELY has been found to be largely representative of the general population in England across age, sex, deprivation level, and region33.

Key limitations of this study include that the Million Migrant-NIMS cohort is not representative of the entire migrant population in England, with a study population consisting of resettled refugees and migrants from non-EU countries who entered on longer-term visas and have an NHS number. Irregular migrants (for example, undocumented migrants, refused asylum seekers, visa overstayers, and children born to irregular migrant couples), migrants on a temporary visa, EU and European Economic Area migrants, non-EU migrants from low-incidence tuberculosis (TB) countries who do not require a pre-entry TB screening as part of visa application and non-EU migrants who emigrated before the start of either health screening programme were not captured. Importantly, some of these groups like irregular migrants could be in more vulnerable situations. Although only half of the Million Migrant cohort with NHS numbers linked to at least one NIMS COVID-19 record, the demographic profile between the two cohorts was broadly similar but the representativeness of our findings as a result could be limited.

There are several potential sources of bias in the linkage methodology that could impact the generalizability of our findings. An individual might not have linked in either the PDS or NIMS COVID-19 vaccination dataset if they never arrived in England, were resident in Scotland, Northern Ireland or Wales, they were never allocated an NHS number, or their linkage variables were recorded incorrectly or inconsistently. Linkage error due to missing or mis-recorded identifiers could result in a selection bias if the missed matches were not missing completely at random. Because the linkage to a NIMS COVID-19 vaccination record relied on having an NHS number, the cohort excluded migrants without any previous contact with health services and who may have been less likely to receive a vaccine. This selection criteria into the cohort probably overestimated vaccine coverage.

Although there is some certainty that individuals who receive an entry visa to the United Kingdom migrate, when and whether they leave after their visa expires is less certain34. Similarly for those with overdue or missed doses, lack of data on emigration during the study period could have led to an over-ascertainment of vaccination overdue. However, for individuals who were most likely to have remained in England for the duration of the study period such as those on refugee, settlement and dependent, and family visas, these estimates are broadly robust and can be helpful indicators of second and third dose uptake35. Importantly, the highest rate of vaccination overdue were found in these subgroups and older migrants, even after the study period was shortened and newly arrived migrants on short-term visas (for example, individuals on student, work, and working holiday visas arriving in the last 5years) were excluded to account for travel out of England.

Several determinants for COVID-19 vaccination coverage were included in this analysis, but no data were available on clinical vulnerability, accommodation (for example, living with someone with a clinical vulnerability or in a care home) or high-risk occupations, all of which were prioritized risk factors for early vaccination in England36. We had no information on death, contraindications, or emigration out of the country; all of which could artificially inflate our denominator for vaccination overdue. Our sensitivity analyses measuring the impact emigration (restricting the follow-up period and excluding shorter-term visa holders) showed minimal effect on our estimates. Lastly, we restricted our analyses to those over the age of 16 for first dose and over 18 for second and third doses, limiting the generalizability of our data to those under the age of 16.

Our findings hold immediate relevance to strengthening COVID-19 vaccination and other routine immunizations for migrants and identify important variability in uptake by age, visa type and ethnicity. Most migrants in our cohort, in particular older migrants and refugees, were more likely to be overdue for their second and third doses than Englands general population. These findings highlight slower vaccination uptake for some migrant groups and reinforce the importance of migrant-inclusive policies and services to ensure equitable access36. Box 1 summarizes key policy and practice areas of relevance to improve COVID-19 vaccination uptake in migrants in the United Kingdom and other European countries.

It remains important to better understand the drivers of low and delayed vaccine uptake in migrant populations and why refugees and older migrants are not returning to receive their second or third dose of the COVID-19 vaccination. The extent to which these are structural or personal barriers, the role of vaccine hesitancy and misinformation, and the impact of policies resulting in the exclusion of some migrant groups from accessing health and vaccination systems need to be further elucidated. As immunity wanes and new COVID-19 boosters are needed for emerging variants, understanding vaccination coverage for high-risk groups such as migrants will be essential for an adequate and equitable response.

Key policy and practice areas requiring action:

Co-design context and culturally appropriate vaccination campaigns and research with international, national, regional and local migrant community organizations to ensure accessibility and culturally appropriate services and to better understand barriers and facilitators to vaccination systems on arrival.

Explore opportunities with stakeholders to strengthen data collection around vaccination uptake and country of birth, visa category and time since arrival in the host country.

Improved consideration of migrant populations in the evaluation and delivery of vaccination programmes for COVID-19 and routine vaccinations.

Further research the causes of uptake variations, including differences between different types of migrants.

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COVID-19 vaccination coverage for half a million non-EU migrants ... - Nature.com