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Vaccinating against Covid-19

This hasn’t been a smooth process. We knew the vaccine would be delivered to Primary Care Networks (co-operating groups of General Practices) in December 2020. I volunteered my services to the inner city practice where I work as a locum doctor and expected to start work as a vaccinator on 18th December. This was rearranged three times over the next four weeks before I jabbed my first patient with the vaccine.

Breaking the rules… again.

Organising a mass vaccination campaign is complicated:

Vaccine – you need sufficient supplies and cold storage facilities (especially for the Pfizer Biontech BNT162b2 vaccine).

Premises – you need a building big enough to cope with social distanced queuing, registering, vaccinating and post-vaccination observation for fifteen minutes (the guidance changed in December when two patients with serious allergies collapsed soon after being vaccinated). There should be plenty of car parking available. The Peepul Centre (@PeepulEnt) fit the bill.

Identification of the most vulnerable patients, contacting them by post/SMS/telephone/letter to explain the vaccination, check for allergies, get basic consent and give out appointments.

Staff – you need crowd controllers, volunteers to provide wheelchairs for disabled patients, multilingual clerks (many older patients in Leicester are not fluent in English and speak Gujarati, Hindi, Urdu or Punjabi) to fill in the vaccination forms, guides to take the patients to the vaccination hall, nurses and doctors to vaccinate, pharmacists to ensure the cold chain is intact and the vaccine is diluted properly and a receptionist to survey the patients waiting for fifteen minutes following their jabs.

Supplies – you need paper, computers, pens, masks, wipes, together with all the medical paraphernalia to give injections.

Training – the vaccinators need to be familiar with two new vaccines. Although each patient received a leaflet and several pages of detailed information about the vaccine, vaccinators needed to be able to answer their questions and give appropriate advice. As an active GP, I only had to complete three electronic learning elements; retired health workers had about twenty to complete before being eligible to give the vaccine.

I was disappointed, but not surprised, when the vaccination starting date was changed several times. This is a high profile operation and we had to make sure the mass campaign went smoothly.

Brief insert:

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I have been involved with mass vaccinations several times during my career overseas. In Burkina Faso (1979), we vaccinated thousands of children in villages across the Sahel against measles, tuberculosis, yellow fever, diphtheria, tetanus, pertussis and polio.

Mass vaccination in a village in the Sahel Region of Upper Volta (now Burkina Faso)

In The Gambia (1983), I was regional medical officer for the eastern part of the country when there was an outbreak of Group A meningococcal meningitis. After a thousand cases, with over a hundred deaths, the Ministry of Health organised a mass vaccination campaign. We vaccinated over 90% of the population in just five weeks. Imagine the logistics of the campaign: only one stretch of tarmac road, limited river crossings, no accurate maps or census data, refrigerators powered by kerosene to store vaccine, supplies of diesel fuel for the Land Cruisers and Rovers.

Using a dermal jet gun to vaccinate at a school in Eastern Region of The Gambia

The Rohingya refugee camp in Cox’s Bazar, Bangladesh was the largest in the world in late 2017. Medecins Sans Frontieres organised the vaccination of 170,000 children against measles in just ten days, stopping an epidemic in its tracks. We were lucky to have over 300 Rohingya health volunteers and the benefit of maps produced from drone flights, but this was a tremendous achievement. I left in November, just as a diphtheria epidemic was breaking out.

Child with severe measles in Kutupalong Health Facility, Cox’s Bazar, Bangladesh

More recently, while I was working in rural Zambia in 2019, I vaccinated 2,250 school children over a few weeks. Injecting vaccine into arms was the easy bit; I had a great team of helpers – teachers, crowd controllers, scribes to record the details of each patient in a ledger, to give each patient a vaccination card, someone to help me draw up the vaccine and a health educator. We had to work fast and cut corners in the process. This quick-and-dirty approach isn’t appropriate for modern Britain.

Vaccinating in Mfuwe Day School, Eastern Province, Zambia

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I arrived at the Peepul Centre (Gautama Buddha gained enlightenment while meditating under a sacred Peepul (fig) Tree; Hindus and Jains also hold the tree to be holy) half an hour before the first patients arrived. This was fortunate, because I had parked in the wrong place and had to move my car to avoid a parking fine.

Two Primary Care Networks were using the auditorium at the same time. We had six vaccination stations, well-stocked with needles, syringes, plastic aprons, antiseptic wipes, cotton wool, masks, gloves and a laptop. The doctor in charge gave the vaccinators a pep talk and explained how to fill in the paperwork. Each vaccinator received a single vial of vaccine and we were locked and loaded, ready to get to work.

Almost all the patients were over 80 years old (one was 100), most of whom were of South Asian descent (this is typical of East Leicester). Most elderly patients were accompanied by a relative or carer who could help with clothing and communication. Few patients spoke English fluently, many of them were profoundly deaf and they were all wrapped up in multiple layers of clothing (it was bitterly cold outside). One lady was wearing six cardigans which I managed to peel away to reveal a patch of upper arm for the vaccination.

Some ladies were wearing short blouses, covered by a sari. The sleeves were so tight that I needed to undo the front buttons. Of course, I asked for permission to do this, so I could slip the blouse off their shoulder to access the deltoid muscle. One lady said, “You can touch me, you are my son!” which amused her daughter. It did require some tactical covering by her dupatta (scarf/shawl) to preserve their modesty.

I like a bit of banter with my patients, even when their English is as limited as my Gujarati. I find it is a perfect way to distract the patient from the injection. Intramuscular injections are less painful when the arm is hanging down and the muscles relaxed, so I learned the Gujarati term for “relax your arm”. This makes the patients think I know their language and they start a conversation.

Occasionally, I will detect a patient’s accent and share a little common history. “Where do you come from?” I ask as I roll up a sleeve. “Sunderland,” replied the patient. “My uncles took me to the Fulwell End at Roker Park to see Sunderland play when I was six. I still support them,” I said, after disposing of the needle and syringe. “It’s a cross we have to bear,” said the patient (Sunderland are languishing in the middle of the third tier of the football league).

One Indian lady invited me to have tea with her. Another gave me a non-socially-distanced hug (we were both masked and gloved). Several patients asked God to bless me and many others were very thankful. This was the first time that many of them had been outside their homes since March.

After half a dozen jabs, one gets the hang of things and the process becomes slick and efficient. The practice booked in patients every six minutes, but I could easily vaccinate two or three in that time, acquiring a reputation for being “quick on the draw”.

I usually flick the skin just before the injection, on the assumption that this non-painful stimulus shuts the nerve “gate” to subsequent painful stimulus, carried by slower c type nerve fibres. (Gate Theory of Pain, Melzak and Wall, 1965). One of the health workers I vaccinated said it was the best injection she had ever had, completely painless – cue “Yesss!” and fist pump from me.

Each constituted vial contains 2ml of fluid, which provides six doses of vaccine (6 x 0.3ml), with 0.2ml left over, which is discarded. I offered to use the remnants of each vial to make another dose, but this was rejected. “I don’t mind having the dregs for my dose of the vaccine,” I told the supervisor. “You can’t have the jab today in case you have side effects and are unable to vaccinate tomorrow,” he replied. I got my first dose at close of play the following day. I had absolutely no side effects.

I will be back in the Peepul Centre next week to do more vaccinating.

By Dr Alfred Prunesquallor

Maverick doctor with 40 years experience, I reduced my NHS commitment in 2013. I am now enjoying being free lance, working where I am needed overseas. Now I am working in the UK helping with the current coronavirus pandemic.

2 replies on “Vaccinating against Covid-19”

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