key: cord-0938584-jt8qfw1c authors: Iversen, Jenny; Peacock, Amy; Price, Olivia; Byrne, Jude; Dunlop, Adrian; Maher, Lisa title: COVID‐19 vaccination among people who inject drugs: Leaving no one behind date: 2021-03-01 journal: Drug Alcohol Rev DOI: 10.1111/dar.13273 sha: d116aced676e0a1612ee40256b91183918eb665a doc_id: 938584 cord_uid: jt8qfw1c nan Timely rollout and widespread uptake of safe and effective vaccines will be necessary to reduce mortality, improve health outcomes, restore societal well-being and inspire economic recovery from the coronavirus disease (COVID- 19) pandemic. Unprecedented efforts to accelerate vaccine development have resulted in the emergency or expedited approval of several COVID-19 vaccines [1] . The Australian Government has secured access to both the Pfizer and the University of Oxford/AstraZeneca vaccines and plans to commence a national COVID-19 vaccine rollout in early 2021. Phase 1a of the program will immunise priority populations, including frontline health-care workers, quarantine and border staff and aged care and disability care residents and staff [2] . This will be followed by Phase 1b, delivering doses to people aged over 70 years, Aboriginal and Torres Strait Islander people aged over 55 years, younger adults with underlying medical conditions and critical and high-risk workers [3] . These priority populations are similar to those identified in international vaccination efforts [4] . The Australian Technical Advisory Group on Immunisation (ATAGI) has specified those with an increased risk of developing severe disease or dying from COVID-19, including people with pre-existing select medical conditions, as priority populations for immunisation [5] . The ATAGI also noted that communities of low socioeconomic status and those belonging to culturally and linguistically diverse backgrounds are at increased risk of adverse health outcomes from COVID-19 based on international data [5] . While the Commonwealth has provided inprinciple agreement to prioritise people living with human immunodeficiency virus (HIV) for vaccination during Phases 1a and 1b, the Australian Society for HIV Medicine, along with relevant peak bodies, is also advocating to ensure the strategy appropriately prioritises people living with all blood-borne viral infections [6] . Although only one in four people infected with SARS Cov2, the virus that causes COVID-19, have comorbidities, 60-90% of those hospitalised have physical health comorbidities [7] . People reporting problematic use of alcohol and other drugs may represent a high-risk population in this respect, given their high prevalence of comorbid health conditions [8] . In particular, people who inject drugs (PWID) may be at elevated risk of adverse outcomes from COVID-19 given their high prevalence of underlying medical conditions, including respiratory and pulmonary disease, chronic liver disease, cardiovascular disease, cerebrovascular disease, diabetes and compromised immunity [9, 10] . Importantly, such conditions may be underdiagnosed in this population [11, 12] . Early data also indicate that COVID-19 has had a significant impact on patterns of injection drug use and service uptake. Interviews with 884 PWID recruited from Australian capital cities in mid-2020 showed that 1 in 10 (12%) reported difficulties accessing sterile needles and syringes since COVID-19 restrictions were introduced [13] . Among 1324 PWID attending Australian needle and syringe programs (NSP) surveyed in late 2020, the same proportion (12%) reported that they had found it more difficult to access NSP. Of those who last injected an opioid (n = 588), 5% reported starting depot buprenorphine, 15% had started or increased the number of takeaway opioid agonist treatment doses, and 26% had accessed take-home naloxone since the start of the pandemic (Australian NSP Survey 2020, unpublished data). However, compared to the general population, PWID have low rates of vaccine uptake and completion, including for hepatitis B [14] . A recent survey of 872 Australian PWID found that only 24% reported being vaccinated for the 2020 influenza season (i.e. since March 2020) [15] -significantly lower than the 49% of the general population who reported vaccination between January and May 2020 [16] . In relation to hypothetical acceptability of a COVID-19 vaccine, 57% of a sample of 100 PWID interviewed in Melbourne in December 2020 indicated that they would 'definitely' or 'probably' get vaccinated were a vaccine available [17] . However, 15% indicated that they would 'definitely not' get the vaccine and 20% were undecided. While the most frequently nominated concerns were related to vaccine safety, and antivaccination beliefs were rare, COVID vaccine acceptability was lower than the 77% observed in a recent poll of the general population [18] . These data indicate the need for increased efforts to inform PWID about vaccine efficacy and safety to reduce hesitancy and uncertainty and increase acceptability. The logistics of reaching and vaccinating PWID are not insignificant. While the Australian government is responsible for selecting, purchasing and transporting vaccines and specifying priority populations, state and territory governments are responsible for providing the vaccine delivery workforce and identifying specific vaccination sites. Vaccination locations that have been identified include general practice (GP), GP respiratory clinics, dedicated vaccination clinics, workplace clinics, locations identified by the Aboriginal and Torres Strait Islander Community Controlled Health sector, pharmacies and in-reach vaccination for aged care facilities and 'other vulnerable people or targeted populations who cannot access another location' [5] . It will be important to have a range of effective methods of vaccine rollout targeting PWID and other vulnerable groups, including incarcerated populations. Despite being at higher risk of a wide range of physical and mental health disorders [19] , PWID are underserved in relation to primary health care and are more likely to present late, increasing the risk of significant mortality and morbidity [20, 21] . PWID are also overrepresented among emergency department presentations [22, 23] . A study of 2395 Australian PWID found that emergency departments were the health provider most recently accessed by 14% of respondents [24] . A pilot project that placed a nurse-led mobile immunisation service at locations accessed by vulnerable populations in Australia, including homeless shelters and an NSP, successfully increased the uptake of influenza vaccine [25] . Along with emergency departments, NSP, homeless shelters/temporary accommodation and prisons provide important access points to PWID; with an appropriately trained and qualified immunisation workforce and resources, including access to anaphylaxis management, these services could potentially be tasked to access and provide opportunistic vaccination to this population. With an estimated 1280 publicly funded alcohol and other drug (AOD) treatment services [26] and 2950 opioid agonist treatment (methadone and buprenorphine) dosing points [27] in Australia, AOD treatment services and dosing points also provide an important touchpoint for COVID-19 immunisation rollout to vulnerable populations, ideally as sites for vaccination and, at minimum, as settings for education and referral. A recent study found that PWID who reported being vaccinated for influenza in the past year were more likely to be enrolled in opioid agonist treatment [15] . Contact with the health system through AOD treatment is also an important way to communicate health messages designed to increase vaccine confidence. AOD treatment providers, especially those with specialist peer workers, have the infrastructure and experience with low literacy health communications to work with clients to encourage cooperation with public health messages and recommendations, reduce misunderstanding and improve knowledge. Consideration of other evidence-based strategies, such as conditional cash transfers or contingency management, may also be necessary to ensure that COVID-19 vaccines reach PWID in a timely manner, especially because effective immunisation will require two doses within a specified time frame. Our randomised trial of per-dose incentives for hepatitis B vaccine completion found that PWID randomised to the incentive condition were more than three times more likely to complete the series than those randomised to the control condition [28] . The use of incentives to encourage vaccine uptake and completion by PWID has also been adopted by the World Health Organization [29] . People with lived experience of injecting drug use have an essential role to play in informing and driving strategies to maximise vaccination uptake; community-led networks must be key partners in developing and delivering vaccination systems and strategies [30] . While the strong engagement with scientific research and a commitment to best practice helps to ensure that Australia's services are well placed to interact with the drug-using community, bolstering community infrastructure and resources to disseminate information and build trust and confidence will be crucial to this engagement. For many vulnerable communities, including PWID, COVID-19 represents a pandemic on top of one or more epidemics [31] , and the constant need for vigilance and risk reduction on multiple fronts is challenging and exhausting. In times of crisis, these communities face challenges such as being unable to access health services or receiving the same quality of health care as others due to high rates of social and economic disadvantage, homelessness and criminalisation, as well as low health literacy and stigma and discrimination from health-care providers [10] . Consistent with the right to science, there is a need for public access to the knowledge and products of science in this pandemic [32] . Equity of access to interventions to prevent, diagnose and treat COVID-19 means ensuring that vaccines are accessible and available free of charge to everyone everywhere, especially those who are under-served and at increased risk of adverse health outcomes [33] . Given strong peer networks, high coverage of treatment and harm reduction interventions [34, 35] , and the availability of other access points, which could serve as settings for COVID-19 immunisation and/or points of contact for vaccine education and referral, Australia is well positioned to ensure PWID are not left behind. AP has received untied educational grants from Seqirus and Mundipharma for post-marketing surveillance of opioid medications in Australia. Funding from these organisations has now ceased, funding was for work unrelated to this project, and the funding bodies had no role in study design, analysis and reporting. AD has received grants from Braeburn/Camurus AB to conduct clinical studies with buprenorphine products and travel support to Hunter New England Local Health District, which employs AD. AD is an honorary investigator on an Indivior-funded study of buprenorphine products and has served as an honorary on an advisory board for Mundipharma. Other authors (JI, LM, OP, JB) have no conflicts. The granting of emergency use designation to COVID-19 candidate vaccines: implications for COVID-19 vaccine trials Australian COVID-19 vaccination policy. Canberra: Australian Government Australia's COVID-19 vaccine national roll-out strategy. Australian Government, Canberra WHO SAGE roadmap for prioritizing uses of COVID-19 vaccines in the context of limited supply Preliminary advice on general principles to guide the prioritisation of target populations in a COVID-19 vaccination program in Australia. Canberra: ATAGI COVID-19 taskforce on HIV, viral hepatitis, and sexual health: Australia's COVID-19 vaccine roll-out strategy Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic Prevalence and correlates of obstructive lung disease among people who inject drugs Contemporary epidemiology of chronic liver disease and cirrhosis Impact of COVID-19 and associated restrictions on people who inject drugs in Australia: findings from the illicit drug reporting system 2020. Drug trends bulletin series. Sydney: National Drug and Alcohol Research Centre Ongoing susceptibility to hepatitis B virus infection among people who inject drugs in Sydney Taming of the flu: engagement, barriers and correlates of influenza vaccination uptake among people who inject drugs in Australia. Sydney: National Drug and Alcohol Research Centre Household Impacts of COVID-19 Survey COVID-19 vaccine acceptability among people who inject drugs in Melbourne. COVID-19 Now 77% of Australians would get a vaccine for COVID-19 -down 10% points since Mortality among people who inject drugs: a systematic review and meta-analysis Time to initiating highly active antiretroviral therapy among HIV-infected injection drug users Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: room for improvement Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis Are people who inject drugs frequent users of emergency department services? A cohort study Healthcare utilisation and disclosure of injecting drug use among clients of Australia's needle and syringe programs Results from a mobile outreach influenza vaccination program for vulnerable and high-risk populations in a high-income setting: lessons learned Australian Institute of Health and Welfare. Alcohol and other drug treatment services in Australia 2018-19. Drug treatment series no. 34. Cat. no. HSE 243. Canberra Australian Institute of Health and Welfare. National Opioid Pharmacotherapy Statistics Annual Data collection 2019. Cat. no. PHE 266. Canberra: Australian Institute of Health and Welfare A randomised controlled trial of financial incentives to increase hepatitis B vaccination completion among people who inject drugs in Australia Guidance on prevention of viral hepatitis B and C among people who inject drugs COVID-19 -enacting a 'new normal' for people who use drugs COVID-19, HIV and key populations: cross-cutting issues and the need for population-specific responses General comment No. 25 on Science and economic, social and cultural rights Art world leaders unite in call for a people's vaccine against COVID-19 Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review Estimating the number of people who inject drugs and syringe coverage in Australia