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Priority patients in England were offered COVID-19 vaccination by mid-April 2021. Codes in clinical record systems can denote the vaccine being declined.


We describe records of COVID-19 vaccines being declined, according to clinical and demographic factors.


With the approval of NHS England, we conducted a retrospective cohort study between 8 December 2020 and 25 May 2021 with primary care records for 57.9 million patients using OpenSAFELY, a secure health analytics platform. COVID-19 vaccination priority patients were those aged ≥ 50 years or ≥ 16 years clinically extremely vulnerable (CEV) or ’at risk’. We describe the proportion recorded as declining vaccination for each group and stratified by clinical and demographic subgroups, subsequent vaccination and distribution of clinical code usage across general practices.


Of 24.5 million priority patients, 663,033 (2.7%) had a decline recorded, while 2,155,076 (8.8%) had neither a vaccine nor decline recorded. Those recorded as declining, who were subsequently vaccinated (n = 125,587; 18.9%) were overrepresented in the South Asian population (32.3% vs 22.8% for other ethnicities aged ≥ 65 years). The proportion of declining unvaccinated patients was highest in CEV (3.3%), varied strongly with ethnicity (black 15.3%, South Asian 5.6%, white 1.5% for ≥ 80 years) and correlated positively with increasing deprivation.


Clinical codes indicative of COVID-19 vaccinations being declined are commonly used in England, but substantially more common among black and South Asian people, and in more deprived areas. Qualitative research is needed to determine typical reasons for recorded declines, including to what extent they reflect patients actively declining.


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  1. National Health Service (NHS) England. Enhanced Service Specification: COVID-19 vaccination programme 2020/21: NHS; 13 April 2021. Available from: https://www.england.nhs.uk/coronavirus/documents/enhanced-service-specification-covid-19-vaccination-programme-2020-21 /
  2. National Health Service (NHS) England. Next phase of NHS COVID-19 vaccination campaign. London: NHS; 13 April 2021. Available from: https://www.england.nhs.uk/coronavirus/documents/next-phase-of-nhs-covid-19-vaccination-campaign/
  3. Curtis HJ, Inglesby P, Morton CE, MacKenna B, Green A, Hulme W,, et al. Trends and clinical characteristics of COVID-19 vaccine recipients: a federated analysis of 57.9 million patients’ primary care records in situ using OpenSAFELY. Br J Gen Pract. 2021;72(714):e51-62.
  4. National Health Service (NHS) England. COVID-19 vaccine programme: Maximising vaccine uptake in underserved communities: a framework for systems, sites and local authorities leading vaccination delivery. London: NHS; 26 March 2021. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2021/03/C1226-maximising-vaccine-uptake-in-underserved-communities-a-framework-.pdf
  5. OpenSAFELY. About OpenSAFELY. Oxford. Accessed: 21 Jun 2021]. Available from: https://https://www.opensafely.org/about/ /
  6. National Health Service (NHS) Digital. Delen: Home: terminology & classifications news: COVID-19 vaccination codes. Leeds: NHS Digital. [Accessed: 9 Jul 2021]. Available from: https://hscic.kahootz.com/t_c_home/viewBlogArticle?articleID=655513
  7. PRIMIS. National covid-19 Vaccination Uptake Reporting Specification. Nottingham: University of Nottingham. [Accessed: 18 Mar 2021]. Available from: https://www.nottingham.ac.uk/primis/covid-19/covid-19.aspx
  8. UK Health Security Agency. The Green Book, chapter 14a - COVID-19. Coronavirus (COVID-19) vaccination information for public health professionals. London: GOV.UK; 2020 [Accessed: 19 Jan 2021]. Available from: https://www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a
  9. Ministry of Housing, Communities and Local Government. English indices of deprivation. London: gov.uk. [Accessed: 21 Jun 2021]. Available from: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019
  10. Ministry of Housing, Communities and Local Government. English indices of deprivation. London: gov.uk. [Accessed: 21 Jun 2021]. Available from: https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019
  11. MacKenna B. What is the dm+d? The NHS Dictionary of Medicines and Devices. EBM DataLab. 27 Aug 2019. Available from: https://ebmdatalab.net/what-is-the-dmd-the-nhs-dictionary-of-medicines-and-devices
  12. Batty GD, Deary IJ, Altschul D. Pre-pandemic mental and physical health as predictors of COVID-19 vaccine hesitancy: evidence from a UK-wide cohort study. Ann Med. 2022;54(1):274-82.
  13. Parveen N, Mohdin A, McIntyre N. Call to prioritise minority ethnic groups for Covid vaccines. The Guardian. 2021 Jan 18. Available from: http://www.theguardian.com/world/2021/jan/18/call-to-prioritise-minority-ethnic-groups-for-covid-vaccines
  14. Robinson E, Jones A, Lesser I, Daly M. International estimates of intended uptake and refusal of COVID-19 vaccines: A rapid systematic review and meta-analysis of large nationally representative samples. Vaccine. 2021;39(15):2024-34.
  15. Allington D, Duffy B, Moxham-Hall V, McAndrew S, Murkin G. Covid-19: vaccine take-up and trust. Economic and Social Research Council; 2021. Available from: https://www.kcl.ac.uk/policy-institute/assets/covid-19-vaccine-take-up-and-trust.pdf
  16. Royal Society of Public Health (RSPH). New poll finds ethnic minority groups less likely to want COVID vaccine. London: RSPH; 16 Dec 2020. Available from: https://www.rsph.org.uk/about-us/news/new-poll-finds-bame-groups-less-likely-to-want-covid-vaccine.html
  17. Robertson E, Reeve KS, Niedzwiedz CL, Moore J, Blake M, Green M, et al. Predictors of COVID-19 vaccine hesitancy in the UK household longitudinal study. Brain Behav Immun. 2021;94:41-50.  https://doi.org/10.1016/j.bbi.2021.03.008  PMID: 33713824 
  18. Ward C, Byrne L, White JM, Amirthalingam G, Tiley K, Edelstein M. Sociodemographic predictors of variation in coverage of the national shingles vaccination programme in England, 2014/15. Vaccine. 2017;35(18):2372-8.  https://doi.org/10.1016/j.vaccine.2017.03.042  PMID: 28363324 
  19. Loiacono MM, Mahmud SM, Chit A, van Aalst R, Kwong JC, Mitsakakis N, et al. Patient and practice level factors associated with seasonal influenza vaccine uptake among at-risk adults in England, 2011 to 2016: An age-stratified retrospective cohort study. Vaccine X. 2020;4:100054.  https://doi.org/10.1016/j.jvacx.2020.100054  PMID: 32072152 
  20. Jain A, Walker JL, Mathur R, Forbes HJ, Langan SM, Smeeth L, et al. Zoster vaccination inequalities: A population based cohort study using linked data from the UK Clinical Practice Research Datalink. PLoS One. 2018;13(11):e0207183.  https://doi.org/10.1371/journal.pone.0207183  PMID: 30439975 
  21. Bajos N, Spire A, Silberzan L, EPICOV study group. The social specificities of hostility toward vaccination against Covid-19 in France. PLoS One. 2022;17(1):e0262192.  https://doi.org/10.1371/journal.pone.0262192  PMID: 34990482 
  22. Aw J, Seng JJB, Seah SSY, Low LL. COVID-19 vaccine hesitancy-a scoping review of literature in high-income countries. Vaccines (Basel). 2021;9(8):900.  https://doi.org/10.3390/vaccines9080900  PMID: 34452026 
  23. Freeman D, Loe BS, Yu L-M, Freeman J, Chadwick A, Vaccari C, et al. Effects of different types of written vaccination information on COVID-19 vaccine hesitancy in the UK (OCEANS-III): a single-blind, parallel-group, randomised controlled trial. Lancet Public Health. 2021;6(6):e416-27.  https://doi.org/10.1016/S2468-2667(21)00096-7  PMID: 33991482 
  24. Willis DE, Selig JP, Andersen JA, Hall S, Hallgren E, Williams M, et al. Hesitant but vaccinated: assessing COVID-19 vaccine hesitancy among the recently vaccinated. J Behav Med. 2022;1-10. Online ahead of print.  https://doi.org/10.1007/s10865-021-00270-6  PMID: 35032254 
  25. National Health Service (NHS). Who can get the coronavirus (COVID-19) vaccine. London: NHS. [Accessed: 18 Jun 2021]. Available from: https://web.archive.org/web/20210319000117/https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/who-can-get-the-vaccine
  26. Kidney Care UK. Covid-19 vaccination for adult patients with kidney disease. Alton: Kidney Care UK. [Accessed: 21 Jun 2021]. Available from: https://www.kidneycareuk.org/news-and-campaigns/news/covid-19-vaccination-adult-patients-kidney-disease/
  27. National Health Service (NHS) Digital. BETA – Data Security Standards. Leeds: NHS Digital. [Accessed: 30 Apr 2020]. Available from: https://webarchive.nationalarchives.gov.uk/ukgwa/20220404205413//digital.nhs.uk/about-nhs-digital/our-work/nhs-digital-data-and-technology-standards/framework/beta---data-security-standards
  28. National Health Service (NHS) Digital. Data Security and Protection Toolkit. Leeds: NHS Digital. [Accessed: 30 Apr 2020]. Available from: https://digital.nhs.uk/data-and-information/looking-after-information/data-security-and-information-governance/data-security-and-protection-toolkit
  29. National Health Service (NHS) Digital. ISB1523: Anonymisation Standard for Publishing Health and Social Care Data. Leeds: NHS Digital. [Accessed: 30 Apr 2020]. Available from: https://digital.nhs.uk/data-and-information/information-standards/information-standards-and-data-collections-including-extractions/publications-and-notifications/standards-and-collections/isb1523-anonymisation-standard-for-publishing-health-and-social-care-data
  30. Department of Health and Social Care and The Rt Hon Matt Hancock MP. Coronavirus (COVID-19): notification to organisations to share information. London: gov.uk. [Accessed: 1 Apr 2020]. Available from: https://web.archive.org/web/20200421171727/https://www.gov.uk/government/publications/coronavirus-covid-19-notification-of-data-controllers-to-share-information

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