COVID-19 vaccination uptake for half a million non-EU migrants and refugees in England: a linked retrospective population-based cohort study.

BACKGROUND: COVID-19 has highlighted severe health inequities experienced by certain migrants. Despite evidence suggesting that migrants are at risk of under-immunisation, data are limited for migrants' COVID-19 vaccine uptake in England. METHODS: We did a retrospective population-based cohort study on COVID-19 vaccination uptake in England. We linked the Million Migrant cohort (which includes non-EU migrants and resettled refugees) to the national COVID-19 vaccination dataset, using a stepwise deterministic matching procedure adapted from NHS Digital, and compared migrants with the general population. For migrants who linked to at least one vaccination record, we estimate temporal trends in first dose uptake and differences in second and third dose uptake and consequent delays between Dec 8, 2020, and April 20, 2022, by age, visa type, and ethnicity. FINDINGS: Of the 465 470 migrants who linked to one or more vaccination record, 427 073 (91·8%) received a second dose and 238 721 (51·3%) received a third. Migrants (>30 years) reached 75% first-dose coverage between 1 and 2 weeks after the general population in England, with the gap widening to 6 weeks for younger migrants (16-29 years). Refugees specifically had a higher risk of a delayed second dose (odds ratio 1·75 [95 CI% 1·62-1·88]) and third dose (1·41 [1·31-1·53]). Older migrants (>65 years) were at least four times more likely to have not received their second or third dose compared with those of the same age in England. INTERPRETATION: Uptake of the first dose was slower across all age groups for migrants compared with the general population. Refugees and older migrants were more likely to have delayed uptake of COVID-19 vaccines and to not have received their second or third dose. Policymakers, researchers, and practitioners should consider how to best drive uptake of COVID-19 and other routine vaccine doses and understand and address personal and structural barriers to vaccination systems for diverse migrant populations. FUNDING: Wellcome Trust and UK Research and Innovation.

Making the invisible visible: using national surveillance data to identify people experiencing homelessness in England with COVID-19.

Persons experiencing homelessness (PEH) or rough sleeping are a vulnerable population, likely to be disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 infection on this population is yet to be fully described in England. We present a novel method to identify COVID-19 cases in this population and describe its findings. A phenotype was developed and validated to identify PEH or rough sleeping in a national surveillance system. Confirmed COVID-19 cases in England from March 2020 to March 2022 were address-matched to known homelessness accommodations and shelters. Further cases were identified using address-based indicators, such as NHS pseudo postcodes. In total, 1835 cases were identified by the phenotype. Most were <39 years of age (66.8%) and male (62.8%). The proportion of cases was highest in London (29.8%). The proportion of cases of a minority ethnic background and deaths were disproportionality greater in this population, compared to all COVID-19 cases in England. This methodology provides an approach to track the impact of COVID-19 on a subset of this population and will be relevant to policy making. Future surveillance systems and studies may benefit from this approach to further investigate the impact of COVID-19 and other diseases on select populations.

A systematic review of the international evidence on the effectiveness of COVID-19 mitigation measures in communal rough sleeping accommodation.

BACKGROUND: Accommodations with shared washing facilities increase the risks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for people experiencing rough sleeping and evidence on what interventions are effective in reducing these risks needs to be understood. METHODS: Systematic review, search date 6 December 2022 with methods published a priori. Electronic searches were conducted in MEDLINE, PubMed, Cochrane Library, CINAHL and the World Health Organization (WHO) COVID-19 Database and supplemented with grey literature searches, hand searches of reference lists and publication lists of known experts. Observational, interventional and modelling studies were included; screening, data extraction and risk of bias assessment were done in duplicate and narrative analyses were conducted. RESULTS: Fourteen studies from five countries (USA, England, France, Singapore and Canada) were included. Ten studies were surveillance reports, one was an uncontrolled pilot intervention, and three were modelling studies. Only two studies were longitudinal. All studies described the effectiveness of different individual or packages of mitigation measures. CONCLUSIONS: Despite a weak evidence base, the research suggests that combined mitigation measures can help to reduce SARS-CoV-2 transmission but are unlikely to prevent outbreaks entirely. Evidence suggests that community prevalence may modify the effectiveness of mitigation measures. More longitudinal research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021292803.

The impact of NHS charging regulations on healthcare access and utilisation among migrants in England: a systematic review.

BACKGROUND: The NHS Charges to Overseas Visitors Regulations 2015 outline when healthcare costs should be recuperated from overseas visitors in England. National and global stakeholders have expressed concerns that charging may exacerbate health inequalities and undermine public health efforts especially among vulnerable migrant groups. This review aims to systematically describe the evidence regarding the impact of NHS charging regulations on healthcare access and utilisation and health outcomes for migrants in England. METHODS: A systematic search of scientific databases and grey literature sources was performed. Quantitative and qualitative studies, case studies and grey literature published between 1 January 2014 and 1 April 2021 were included. Screening, data extraction and quality appraisal were carried out in accordance with PRISMA guidelines. RESULTS: From the 1,459 identified studies, 10 were selected for inclusion. 6 were qualitative, 3 were mixed methods and 1 was quantitative. The evidence is lacking but suggests that fears of charging and data sharing can deter some migrants from accessing healthcare. There is also evidence to suggest a lack of knowledge of the charging regulations among patients and healthcare professionals is contributing to this deterrence. CONCLUSIONS: Further independent research supported by strengthening of data collection is required to better understand the effects of charging on healthcare and health outcomes among vulnerable migrants. Our findings support improved training and communication about NHS Charging Regulations for patients and professionals.

A comparison of COVID-19 incidence rates across six European countries in 2021.

International comparisons of COVID-19 incidence rates have helped gain insights into the characteristics of the disease, benchmark disease impact, shape public health measures and inform potential travel restrictions and border control measures. However, these comparisons may be biased by differences in COVID-19 surveillance systems and approaches to reporting in each country. To better understand these differences and their impact on incidence comparisons, we collected data on surveillance systems from six European countries: Belgium, England, France, Italy, Romania and Sweden. Data collected included: target testing populations, access to testing, case definitions, data entry and management and statistical approaches to incidence calculation. Average testing, incidence and contextual data were also collected. Data represented the surveillance systems as they were in mid-May 2021. Overall, important differences between surveillance systems were detected. Results showed wide variations in testing rates, access to free testing and the types of tests recorded in national databases, which may substantially limit incidence comparability. By systematically including testing information when comparing incidence rates, these comparisons may be greatly improved. New indicators incorporating testing or existing indicators such as death or hospitalisation will be important to improving international comparisons.

Differential impact of quarantine policies for recovered COVID-19 cases in England: a case cohort study of surveillance data, June to December 2020.

BACKGROUND: From 12th March 2020, individuals in England were advised to quarantine in their home if a household member tested positive for SARS-CoV-2. A mandatory isolation period of 10 days was introduced on 28th September 2020 and applied to all individuals with COVID-19. We assessed the frequency, timing, and characteristics of recovered COVID-19 cases requiring subsequent quarantine episodes due to household re-exposure. METHODS: In this case cohort study, all laboratory-confirmed COVID-19 cases notified in England (29th June to 28th December 2020) were analysed to identify consecutive household case(s). Multivariable logistic regression was used to determine associations between case characteristics and need to quarantine following recent infection (within 28 days of diagnosis). RESULTS: Among 1,651,550 cases resident in private dwellings and Houses of Multiple Occupancy (HMOs), 744,548 (45.1%) were the only case in their home and 56,179 (3.4%) were succeeded by further household cases diagnosed within 11-28 days of their diagnosis. Of 1,641,412 cases arising in private homes, the likelihood of further household cases was highest for Bangladeshi (aOR = 2.20, 95% CI = 2.10-2.31) and Pakistani (aOR = 2.15, 95% CI = 2.08-2.22) individuals compared to White British, as well as among young people (17-24y vs. 25-64y; aOR = 1.19, 95% CI = 1.16-1.22), men (vs. women; aOR = 1.06, 95% CI = 1.04-1.08), London residents (vs. Yorkshire and Humber; aOR = 1.57, 95% CI = 1.52-1.63) and areas of high deprivation (IMD 1 vs. 10; aOR = 1.13, 95% CI = 1.09-1.19). CONCLUSION: Policies requiring quarantine on re-exposure differentially impact some of the most disadvantaged populations. Quarantine exemption for recently recovered individuals could mitigate the socioeconomic impact of responses to COVID-19 or similar infectious disease outbreaks.

Epidemiology of Confirmed COVID-19 Deaths in Adults, England, March-December 2020.

Of the 58,186 coronavirus deaths among adults in England during March-December 2020, 77% occurred in hospitals, 93% were in patients >60 years, and 91% occurred within 28 days of positive specimen. Cumulative mortality rates were highest among persons of Black, Asian, other, or mixed ethnicities and in socioeconomically deprived areas.

What do primary care staff know and do about blood borne virus testing and care for migrant patients? A national survey.

BACKGROUND: UK migrants born in intermediate to high prevalence areas for blood borne viruses (BBV) including hepatitis B, hepatitis C and HIV are at increased risk of these infections. National guidance from Public Health England (PHE) and National Institute for Health and Care Excellence (NICE) recommends primary care test this population to increase diagnoses and treatment. We aimed to investigate primary care professionals' knowledge of entitlements, and perceptions of barriers, for migrants accessing healthcare, and their policies, and reported practices and influences on provision of BBV testing in migrants. METHODS: A pre-piloted questionnaire was distributed between October 2017 and January 2018 to primary care professionals attending the Royal College of General Practitioners and Best Practice in Primary Care conferences, via a link in PHE Vaccine Updates and through professional networks. Survey results were analysed to give descriptive statistics, and responses by respondent characteristics: profession, region, practice size, and frequency of seeing migrant patients. Responses were considered on a per question basis with response rates for each question presented with the results. RESULTS: Four hundred fourteen questionnaires were returned with responses varying by question, representing an estimated 5.7% of English GP practices overall. Only 14% of respondents' practices systematically identified migrant patients for testing. Universal opt-out testing was offered to newly registering migrant patients by 18% of respondents for hepatitis B, 17% for hepatitis C and 21% for HIV. Knowledge of healthcare entitlements varied; fewer clinical staff knew that general practice consultations were free to all migrants (76%) than for urgent care (88%). Performance payment structure (76%) had the greatest reported influence on testing, followed by PHE and Clinical Commissioning Group recommendations (73% each). Language and culture were perceived to be the biggest barriers to accessing care. CONCLUSIONS: BBV testing for migrant patients in primary care is usually ad hoc, which is likely to lead to testing opportunities being missed. Knowledge of migrants' entitlements to healthcare varies and could affect access to care. Interventions to improve professional awareness and identification of migrant patients requiring BBV testing are needed to reduce the undiagnosed and untreated burden of BBVs in this vulnerable population.

Shifting determinants of health inequalities in unstable times: Portugal as a case study.

Background: We explore how health inequalities (HI) changed in Portugal over the last decade, considering it is one of the most unequal European countries and has gone through major economic changes. We describe how inequalities in limitations changed considering different socioeconomic determinants, in order to understand what drove changes in HI. Methods: We used cross-sectional waves from the European Survey on Income and Living Conditions database to determine how inequalities in health limitations changed between 2004 and 2014 in Portugal in residents aged 16 years and over. We calculated prevalence estimates of limitations and differences between income terciles, the concentration index for each year and its decomposition and multiple logistic regressions to estimate the association between socioeconomic determinants and limitations. Results: The prevalence of health limitations increased in Portugal since 2004, especially after 2010, from 35 to 47%. But the difference between top and bottom income terciles decreased from 23 to 10 percentage points, as richer people experienced a steeper increase. This was driven by an increase in prevalence among economically active people, who, from 2011 onwards, had more limitations (OR and 95% CI were 2.42 [2.13-2.75] in 2004 and 0.71 [0.65-0.78] in 2014). Conclusion: These results suggest worsening health in Portugal in the last decade, possibly connected to periods of economic instability. However, absolute HI decreased considerably in the same period. We discuss the possible role of diverse adaptation capacity of socioeconomic groups, and of high emigration rates of young, healthier people, reflecting another side of the 'migrant health effect'.

Connecting the dots on health inequalities--a systematic review on the social determinants of health in Portugal.

INTRODUCTION: Health inequalities are recognised as a public health issue worldwide, but only a few countries have developed national strategies to monitor and reduce them. Despite its considerable health inequalities, Portugal seems to lack a systematic strategy to tackle them, possibly due to the absence of organised evidence on the issue. We performed a systematic review that aimed to describe the available evidence on social inequalities in health in Portugal, in order to contribute towards a comprehensive and focused strategy to tackle them. METHODS: We followed the PRISMA guidelines and searched Scopus, Web of Science and PubMed for studies that looked at the association between a measure of socioeconomic status and a health outcome in the Portuguese resident population since the year 2000. We excluded health behaviours and healthcare use from our search. We performed a qualitative description of the results. RESULTS: Seventy-one publications were selected, all reporting observational analyses, most of them using cross-sectional data. These publications showed strong evidence for health inequalities related to education and gender, chiefly for obesity, self-rated health and mental health. CONCLUSIONS: Analysis of the eligible publications showed that current research does not seem to have consistently covered the link between health and key Portuguese social problems. A strategy focusing on the monitoring of most prevalent diseases, most determining socioeconomic factors and vulnerable populations would be crucial to guide academic research in a country in which health inequalities are so ubiquitous and deeply rooted. REGISTRATION: This systematic review is not registered.

The 'dark side' of social capital: trust and self-rated health in European countries.

BACKGROUND: Generalized interpersonal trust (as an indicator of social capital) has been linked to health status at both the individual and ecological level. We sought to examine how changes in contextual and individual trust are associated with changes in self-rated health in the European Social Surveys 2002-12. METHODS: A multilevel analysis using a variance components model was performed on 203 452 individuals nested within 145 country cohorts covering 35 countries. Conditional on sociodemographic covariates, we sought to examine the association between self-rated health and individual trust, country average trust and a cross-level interaction between the two. RESULTS: Although individual trust perceptions were significantly correlated with self-rated health [OR = 0.95, 95% confidence interval (0.94-0.96)], country-level trust was not associated [OR = 1.12, 95% confidence interval (0.95-1.32)]. There was, however, a strong crosslevel interaction between contextual and individual trust (P < 0.001), such that individuals with high interpersonal trust reported better health in contexts in which other individuals expressed high average interpersonal trust. Conversely, low trust individuals reported worse health in high trust contexts. CONCLUSION: Our findings suggest that contexts with increasing average trust can be harmful for low trust individuals, which might reflect the negative impact that social capital can have in certain groups. These findings suggest that contextual trust has a complex role in explaining health inequalities and individual self-rated health.

Linking migration and hospital data in England: linkage process and evaluation of bias.

Introduction: Difficulties ascertaining migrant status in national data sources such as hospital records have limited large-scale evaluation of migrant healthcare needs in many countries, including England. Linkage of immigration data for migrants and refugees, with National Health Service (NHS) hospital care data enables research into the relationship between migration and health for a large cohort of international migrants. Objectives: We aimed to describe the linkage process and compare linkage rates between migrant sub-groups to evaluate for potential bias for data on non-EU migrants and resettled refugees linked to Hospital Episode Statistics (HES) in England. Methods: We used stepwise deterministic linkage to match records from migrants and refugees to a unique healthcare identifier indicating interaction with the NHS (linkage stage 1 to NHS Personal Demographic Services, PDS), and then to hospital records (linkage stage 2 to HES). We calculated linkage rates and compared linked and unlinked migrant characteristics for each linkage stage. Results: Of the 1,799,307 unique migrant records, 1,134,007 (63%) linked to PDS and 451,689 (25%) linked to at least one hospital record between 01/01/2005 and 23/03/2020. Individuals on work, student, or working holiday visas were less likely to link to a hospital record than those on settlement and dependent visas and refugees. Migrants from the Middle East and North Africa and South Asia were four times more likely to link to at least one hospital record, compared to those from East Asia and the Pacific. Differences in age, sex, visa type, and region of origin between linked and unlinked samples were small to moderate. Conclusion: This linked dataset represents a unique opportunity to explore healthcare use in migrants. However, lower linkage rates disproportionately affected individuals on shorter-term visas so future studies of these groups may be more biased as a result. Increasing the quality and completeness of identifiers recorded in administrative data could improve data linkage quality.

COVID-19 vaccination coverage for half a million non-EU migrants and refugees in England.

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants' COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55-1.79) and third dose (1.55; 1.43-1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23-2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Multi-infection screening for migrant patients in UK primary care: Challenges and opportunities.

Background: Migrants in Europe face a disproportionate burden of undiagnosed infection, including tuberculosis, blood-borne viruses, and parasitic infections and many belong to an under-immunised group. The European Centre for Disease Control (ECDC) has called for innovative strategies to deliver integrated multi-disease screening to migrants within primary care, yet this is poorly implemented in the UK. We did an in-depth qualitative study to understand current practice, barriers and solutions to infectious disease screening in primary care, and to seek feedback on a collaboratively developed digitalised integrated clinical decision-making tool called Health Catch UP!, which supports multi-infection screening for migrant patients. Methods: Two-phase qualitative study of UK primary healthcare professionals, in-depth semi-structured telephone-interviews were conducted. In Phase A, we conducted interviews with clinical staff (general practitioners (GPs), nurses, health-care-assistants (HCAs)); these informed data collection and analysis for phase B (administrative staff). Data were analysed iteratively, using thematic analysis. Results: In phase A, 48 clinicians were recruited (25 GPs, 15 nurses, seven HCAs, one pharmacist) and 16 administrative staff (11 Practice-Managers, five receptionists) in phase B. Respondents were positive about primary care's ability to effectively deliver infectious disease screening. However, we found current infectious disease screening lacks a standardised approach and many practices have no system for screening meaning migrant patients are not always receiving evidence-based care (i.e., NICE/ECDC/UKHSA screening guidelines). Barriers to screening were reported at patient, staff, and system-levels. Respondents reported poor implementation of existing screening initiatives (e.g., regional latent TB screening) citing overly complex pathways that required extensive administrative/clinical time and lacked financial/expert support. Solutions included patient/staff infectious disease champions, targeted training and specialist support, simplified care pathways for screening and management of positive results, and financial incentivisation. Participants responded positively to Health Catch-UP!, stating it would systematically integrate data and support clinical decision-making, increase knowledge, reduce missed screening opportunities, and normalisation of primary care-based infectious disease screening for migrants. Conclusions: Our results suggest that implementation of infectious disease screening in migrant populations is not comprehensively done in UK primary care. Primary health care professionals support the concept of innovative digital tools like Health Catch-UP! and that they could significantly improve disease detection and effective implementation of screening guidance but that they require robust testing and resourcing.

Small numbers, big impact: making a utilitarian case for the contribution of inclusion health to population health in England.

Inclusion health groups make up a small proportion of the general population, so despite the extreme social exclusion and poor health outcomes that these groups experience, they are often overlooked in public health investment and policy development. In this paper, we demonstrate that a utilitarian argument can be made for investment in better support for inclusion health groups despite their small size. That is, by preventing social exclusion, there is the potential for large aggregate health benefits to the whole population. We illustrate this by reframing existing published mortality estimates into population attributable fractions to show that 12% of all-cause premature deaths (95% CI 10.03% to 14.29%) are attributable to the circumstances of people who experience homelessness, use drugs and/or have been in prison. We also show that a large proportion of cause-specific premature deaths in the general population can be attributed to specific inclusion health groups, such as 43% of deaths due to viral hepatitis (95% CI 30.35% to 56.61%) and nearly 4000 deaths due to cancer (3844, 95% CI 3438 to 4285) between 2013 and 2021 attributed to individuals who use illicit opioids. Considering the complexity of the inclusion health policy context and the sparseness of evidence, we discuss how a shift in policy framing from 'inclusion health vs the rest of the population' to 'the impact of social exclusion on broader population health' makes a better case for increased policy attention and investment in inclusion health. We discuss the strengths and limitations of this approach and how it can be applied to public health policy, resource prioritisation and future research.

Integration of migrant and refugee data in health information systems in Europe: advancing evidence, policy and practice.

Coverage of migrant and refugee data is incomplete and of insufficient quality in European health information systems. This is not because we lack the knowledge or technology. Rather, it is due to various political factors at local, national and European levels, which hinder the implementation of existing knowledge and guidelines. This reflects the low political priority given to the topic, and also complex governance challenges associated with migration and displacement. We review recent evidence, guidelines, and policies to propose four approaches that will advance science, policy, and practice. First, we call for strategies that ensure that data is collected, analyzed and disseminated systematically. Second, we propose methods to safeguard privacy while combining data from multiple sources. Third, we set out how to enable survey methods that take account of the groups' diversity. Fourth, we emphasize the need to engage migrants and refugees in decisions about their own health data. Based on these approaches, we propose a change management approach that narrows the gap between knowledge and action to create healthcare policies and practices that are truly inclusive of migrants and refugees. We thereby offer an agenda that will better serve public health needs, including those of migrants and refugees and advance equity in European health systems. Funding: No specific funding received.

National review of reported Yellow fever vaccine incidents in the UK.

BACKGROUND: Yellow fever (YF) vaccination is the single most important preventative measure against YF infection, however the live attenuated vaccine has associated serious adverse events. All YF vaccinations in England, Wales and Northern Ireland (EWNI) are administered in YF Vaccination Centres and comply with National Travel Health Network and Centre (NaTHNaC) Conditions of Designation and Code of Practice, including reporting of vaccine incidents to NaTHNaC. In this study we evaluated the number and type of YF vaccine incidents in EWNI to identify areas for improvement. METHODS: NaTHNaC's telephone advice line database was retrospectively searched from 1st January 2016 to 31st December 2018 for YF vaccine incidents. Calls were categorised and analysed according to incident type. RESULTS: Seventy-eight YF vaccine incidents were reported from a total of 17250 calls. The commonest incident was incorrect timing of measles, mumps and rubella vaccine in relation to YF vaccine, where the recommended 28-day interval was not observed (n = 21). Other incidents included accidental partial vaccination (n = 11), inappropriate vaccination (n = 5) and invalid vaccination due to expiry or cold chain breach (n = 4). Inadvertent vaccination in contraindicated individuals occurred in two travellers with thymectomies (resulting in one death), and five immunocompromised travellers. CONCLUSIONS: YF vaccine incidents represent a small proportion of total calls. Similar incidents likely occur with other vaccines, but YF vaccine incidents are of particular concern; whilst most incidents were not harmful, vaccination in contraindicated individuals resulted in one death. These findings helped to inform new guidance and update training for staff in YF vaccination centres.

Migrants' primary care utilisation before and during the COVID-19 pandemic in England: An interrupted time series analysis.

Background: How international migrants access and use primary care in England is poorly understood. We aimed to compare primary care consultation rates between international migrants and non-migrants in England before and during the COVID-19 pandemic (2015-2020). Methods: Using data from the Clinical Practice Research Datalink (CPRD) GOLD, we identified migrants using country-of-birth, visa-status or other codes indicating international migration. We linked CPRD to Office for National Statistics deprivation data and ran a controlled interrupted time series (ITS) using negative binomial regression to compare rates before and during the pandemic. Findings: In 262,644 individuals, pre-pandemic consultation rates per person-year were 4.35 (4.34-4.36) for migrants and 4.60 (4.59-4.60) for non-migrants (RR:0.94 [0.92-0.96]). Between 29 March and 26 December 2020, rates reduced to 3.54 (3.52-3.57) for migrants and 4.2 (4.17-4.23) for non-migrants (RR:0.84 [0.8-0.88]). The first year of the pandemic was associated with a widening of the gap in consultation rates between migrants and non-migrants to 0.89 (95% CI 0.84-0.94) times the ratio before the pandemic. This widening in ratios was greater for children, individuals whose first language was not English, and individuals of White British, White non-British and Black/African/Caribbean/Black British ethnicities. It was also greater in the case of telephone consultations, particularly in London. Interpretation: Migrants were less likely to use primary care than non-migrants before the pandemic and the first year of the pandemic exacerbated this difference. As GP practices retain remote and hybrid models of service delivery, they must improve services and ensure primary care is accessible and responsive to migrants' healthcare needs. Funding: This study was funded by the Medical Research Council (MC_PC 19070 and MR/V028375/1) and a Wellcome Clinical Research Career Development Fellowship (206602).

Immunisation status of UK-bound refugees between January, 2018, and October, 2019: a retrospective, population-based cross-sectional study.

BACKGROUND: WHO's new Immunization Agenda 2030 places a focus on ensuring migrants and other marginalised groups are offered catch-up vaccinations across the life-course. Yet, it is not known to what extent specific groups, such as refugees, are immunised according to host country schedules, and the implications for policy and practice. We aimed to assess the immunisation coverage of UK-bound refugees undergoing International Organization for Migration (IOM) health assessments through UK resettlement schemes, and calculate risk factors for under-immunisation. METHODS: We undertook a retrospective cross-sectional study of all refugees (children <10 years, adolescents aged 10-19 years, and adults >19 years) in the UK resettlement programme who had at least one migration health assessment conducted by IOM between Jan 1, 2018 and Oct 31, 2019, across 18 countries. Individuals' recorded vaccine coverage was calculated and compared with the UK immunisation schedule and the UK Refugee Technical Instructions. We carried out multivariate logistic regression analyses to assess factors associated with varying immunisation coverage. FINDINGS: Our study included 12 526 refugees of 36 nationalities (median age 17 years [IQR 7-33]; 6147 [49·1%] female; 7955 [63·5%] Syrian nationals). 26 118 vaccine doses were administered by the IOM (most commonly measles, mumps, and rubella [8741 doses]). During the study, 6870 refugees departed for the UK, of whom 5556 (80·9%) had at least one recorded dose of measles-containing vaccine and 5798 (84·4%) had at least one dose of polio vaccine, as per the UK Refugee Technical Instructions, and 1315 (19·1%) had at least one recorded dose of diphtheria-containing vaccine or tetanus-containing vaccine. 764 (11·1%) of refugees were fully aligned with the UK schedule for polio, compared with 2338 (34·0%) for measles and 380 (5·5%) for diphtheria and tetanus. Adults were significantly less likely than children to be in line with the UK immunisation schedule for polio (odds ratio 0·0013, 95% CI 0·0001-0·0052) and measles (0·29, 0·25-0·32). INTERPRETATION: On arrival to the UK, refugees' recorded vaccination coverage is suboptimal and varies by age, nationality, country of health assessment, and by disease, with particularly low coverage reported for diphtheria and tetanus, and among adult refugees. These findings have important implications for the delivery of refugee pre-entry health assessments and catch-up vaccination policy and delivery targeting child, adolescent, and adults migrants in the UK, and other refugee-receiving countries. This research highlights the need for improved data sharing and clearer definition of where responsibilities lie between host countries and health assessment providers. FUNDING: UK National Institute for Health Research (NIHR300072) and Medical Research Council (MR/N013638/1).