Covid-19 Vaccination for Inclusion Health Groups in Liverpool

This case study describes a two-day campaign to vaccinate inclusion health groups in Liverpool.

The campaign was carried out by Brownlow Homeless Team with support from Liverpool Central Primary Care Network.

We used an outreach approach visiting 22 hostels, two probation hostels, two hotels used for emergency accommodation and two drug and alcohol rehabilitation units. Three teams worked in different sites across the two days.  Each team was headed by a member of the homeless team (two outreach nurses and a GP), and had one nurse prescriber and three medical students.

The three teams were co-ordinated centrally by a further GP with a special interest in homelessness to ensure adequate supplies and movement of the teams. In most cases the vaccinations occurred in a room within the hostel with hostel staff bringing residents down to the vaccination point. Where uptake was poor, the vaccination team would go around rooms to collect people or vaccinate people in their room.

363 individuals experiencing homelessness or otherwise vulnerable individuals (with a drug and alcohol misuse background who were in rehabilitation) were vaccinated.  In addition, 84 hostel staff were vaccinated, and 30 additional people were offered the vaccine to minimise wasted vaccine.  This gave an overall number of 477 people vaccinated over the weekend.

The overall uptake rate was 58% with a range from 21% to 100%.  The best uptake was seen in smaller hostels, with lower uptake in larger hostels and hotels. We were actually disappointed with the uptake rate, and think this could be improved in other areas using learning from our experience:

• Larger hostels presented larger logistical challenges for hostel staff – extra staffing for a short period of time would increase up take.
• We attended larger hostels earlier in the morning – while this was useful to pick up those who used drugs and were out early to ‘score’, we struggled with engagement with others, especially those using alcohol.  Either starting later or a return visit would improve greater access and uptake.
• We found that hostels where support workers were encouraging of the vaccination programme had a much higher uptake.  Detailed communication with hostel workers before the programme would likely increase up take.
• Time required to vaccinate was over-estimated, and we were able to move on to new hostels quicker than expected.  This meant that we were early for times that had been advertised, and may have missed a group who would have returned for the vaccine (although it is not known how many would have returned).
• We were limited by our interpretation of the Standard Operating Procedure (SOP) for the AstraZeneca vaccine use in care homes.  We did not ‘move’ the vaccine across sites when opened – this meant that where numbers were low we did not attend, for fear of wasting vaccine.  This also limited offering the vaccine to the full number of residents in a large emergency accommodation hostel.  For the second jab phase we are interpreting the SOP to have more freedom with movement of vaccine while maintaining hygiene, temperature and preventing cross over of vaccines.
• The programme was limited to one weekend – we feel we will have further uptake by identifying those who missed out and we are arranging for them to be seen in our drop in clinics.

All individuals experiencing homelessness were included irrespective of their clinical risk stratification.  We feel this was appropriate given under-diagnosis, recognised frailty burden and risk in shared accommodation in this population.

There were a mix of reasons why people did not have the vaccine. The main one being they were not in the hostel at the time (using drugs, begging or for other reasons); others revealed mistrust / and engagement with conspiracy theories; some were worried about side effects (despite reassurances); others simply did not seem engaged with the concept and had other priorities at the time. Anecdotally, these reasons were reported to be less common when engaged support workers were involved.

We are very keen to share this experience with others, and have them share their experiences back. Our experiences have been fed to Professor Andrew Hayward who is currently lobbying the Joint Committee on Vaccination and Immunisation (JCVI) to give higher priority to inclusion health groups.

Dr Ryan Young (Homeless GP)

ryan.young@livgp.nhs.uk

Ian Harrison (Homelessness Nurse Coordinator)

ian.harrison@livgp.nhs.uk

Melanie Johnson (Homeless Outreach Nurse)

Dr Debbie Faint (Homeless GP)

www.brownlowhealth.co.uk