Stuart Carroll
Director of Market Access and Policy Affairs, Moderna, UK and IrelandIn this article, Stuart Carroll, Director of Market Access and Policy Affairs at Moderna, sets out why the Government needs to match Moderna’s commitment to equitable access in healthcare research.
The COVID-19 pandemic shone a light on stark health inequalities and highlighted the urgent need to address these. It quickly became apparent that, whilst the disease did not discriminate, there were large discrepancies between the way that different ethnic and social groups were impacted by the deadly virus.
Barriers to equal vaccine coverage
During the pandemic, people in the Black African ethnic group were at higher risk of death involving COVID-19. During the first wave, Black African males were 2.2 times more likely, and Black African females 1.5 times more likely, to die from COVID-19 than their white British counterparts.1 In the third wave, even after adjusting for various factors including age, measures of disadvantage, occupation, and pre-existing conditions, Black Caribbean and Black African ethnic groups were still at higher risk of COVID-19 mortality than White British.
However, after adjusting for vaccination status, there was no evidence of greater risk of death amongst these groups, suggesting that the vast differences in vaccination coverage rates accounted for a significant portion of the excess risk.2 As of July 2021 – the onset of the third wave – 92.6% of White British people aged over 40 were vaccinated compared to 63.6% of Black Caribbean, 67.8% of Black African, 70.3% of Pakistani, and 72.8% of White other people in the same age group.3
We know that vaccines are one of the most effective public health interventions, with some estimates showing that vaccines led to a 79% global reduction of deaths from COVID-194. It is critically important to understand and address the reasons behind barriers to equal vaccine coverage if we are to reduce unnecessary illness and death in the future.
Beyond vaccination: broader health inequalities
In the UK, some ethnic minority groups are more likely to report being in poorer health, and those from White Gypsy or Irish Traveller, Bangladeshi, and Pakistani communities are reported as having the poorest health outcomes across a range of indicators.5 Additionally, rates of infant mortality, cardiovascular disease, and diabetes are higher among Black and South Asian groups than white groups.6 Unravelling the precise cause of these disparities can be challenging. The evidence points to a complex interplay of many factors, including deprivation, environmental conditions, and health-related behaviours.
It is also important to consider the role that evidence generated by clinical research has to play in fostering trust towards healthcare professionals. Ethnic minority groups are consistently underrepresented in clinical trials for a variety of reasons including geography, language, and digital exclusion. This results in data bias, where the impact and outcome of new medicines is predominantly assessed on white patients. This imbalance in representation can build a culture of mistrust toward healthcare professionals, influencing the way users interact with health services both now and in the future.
One of the most effective ways to tackle health inequality is direct and targeted community engagement. By working with different groups in society – for example in places of worship, community groups, and sporting clubs – healthcare professionals can develop a deeper understanding of concerns with vaccination and help alleviate these fears, and close community relationships can help to overcome the mistrust of healthcare professionals.
Taking action: a call for equal access
Healthcare inequality is a significant issue, and one that should concern us all. The issues surrounding diversity, access, and disparate treatment of different patient groups has prompted Moderna to enshrine equality as one of its core pillars. We are committed to designing our products for everyone.
To provide an example of how we are achieving this goal globally, Moderna took the decision to slow enrolment in a US arm of our Coronavirus Efficacy (COVE) study to ensure sufficient representation from all patient groups. We achieved this through several measures, including providing staff with training on conscious inclusion to enhance understanding of barriers to minority enrolment, and preparing staff for culturally sensitive conversations to address potential participant concerns. All efforts were made to ensure that trials were representative, with a data-directed strategy which utilised strategic satellite sites and added sites with means to recruit those from minority groups.
In the end, 37% of trial participants were from ethnic minority backgrounds.7 We continue to apply lessons learned from the COVE trial to our clinical research, with an average of 40% of participants belonging to an ethnic minority background across our studies.
The UK has made positive steps to address healthcare inequalities, but there is still work to be done, as evidenced by the recent Health and Social Care Committee report into prevention and vaccination.8 To deliver real change, the Government should take the following steps:
First, the Government must take immediate action to ensure clinical trials in the UK are more representative of the population. To give an example of the glaring disparity in action, as of October 2020 only 7% of those signed up for clinical trials for COVID-19 vaccines were from an ethnic minority group.9 That is simply not good enough. In order to build trust with diverse patient groups and reassure them that a vaccine is suitable for them, we must improve access to clinical trials and the representation of patient groups involved. This could be achieved through enhanced digital communication about the availability of clinical trials, more targeted community engagement, and the collection of more comprehensive demographic dataset so we can swiftly and effectively identify gaps.
Second, the Government should place greater emphasis on community outreach to groups with historically worse health outcomes. Moderna recognises that improving vaccination rates amongst underserved communities requires discussion with those communities to truly understand their wants and needs. We are delivering on our commitment to representation in clinical trials by working with community groups across the UK to co-develop solutions to identified barriers to access. These solutions could involve mobile vaccination units to target underserved groups, as well as information outreach to community leaders – for example, in places of worship – to listen to concerns and educate on risks and benefits of healthcare choices. Integrated Care Systems could take a leading role in this, creating teams to target groups that have historically lower vaccine uptake. These groups can help to address the concerns of local communities where vaccine confidence issues are more prevalent.
Third, there needs to be an increased role for healthcare professionals other than doctors in vaccine rollouts. Pharmacists, often better known and trusted in hard-to-reach communities, could facilitate more open conversations about other healthcare options while administering vaccinations. As the Policy Exchange suggested in their recent report, ‘A Fresh Shot’, nurses, GPs, and pharmacists could perform a leadership and supervisory role in the rollout of high-volume vaccinations, with medical, pharmacy, and nursing students volunteering to administer the vaccines.10
The UK needs to adopt a strategy that ensures no community is left behind. The Government should build on the successful model and culture of the Vaccine Taskforce to establish a clear mission to tackle these unacceptable health inequalities. One of the Prime Minister’s key pledges is to cut NHS waiting lists, and the steps outlined in this article will contribute to this goal, albeit in the longer term. The Government must recognise that voters will appreciate a party that actively works to improve health outcomes for all citizens, regardless of ethnicity, fostering a healthier and more equitable society for all.
References
- ONS, Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England: 8 December 2020 to 1 December 2021
- ONS, Population denominators by ethnic group, regions and countries: England and Wales, 2011 to 2018