Europe’s vaccination no-shows: the likeliest explanation

Across Europe, vaccination efforts are running into the same issue: not everyone who is booked in for an appointment turns up, and vaccine doses are left over at the end of the day.

Understanding why someone is a no-show is not straightforward. They may have already received a vaccine elsewhere, and have been calling all morning trying to cancel. They may never have received the invitation because there was a flaw in the system, or their details were wrong.

In one incident in Brussels, only 3,000 of 11,000 primary care workers turned up for their first vaccine shot. The invitations were sent under a federal communications system, while the appointments were run by a regional health service that could not access the appointment data, and therefore did not know why less than a third of the expected patients appeared.

Aside from such extreme examples, experience across Europe is showing that it is difficult to precisely calibrate the preparation of vaccines so that all doses are used at the end of the day.

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In Britain, “vaccinators are turning to police officers, firefighters, taxi drivers, teachers, supermarket staff and family and friends – anyone who can be contacted easily and is free to hotfoot it to the clinic at a few minutes’ notice”, the Guardian recently reported. A code of omertà prevails over the practice because of the risk of controversy over who is given the remaining vaccines.

In Italy the government issued a decree to address the matter. "Any vaccine doses remaining at the end of the day, if they cannot be stored, may exceptionally be administered to whoever is available at the time in order to optimise use while avoiding waste," it read.

Database central

At the heart of the issue is a mundane but crucial piece of healthcare: databases. Having strong digital infrastructure is a secret weapon in the pandemic.

In Estonia, one of Europe's most digitalised countries, 99 per cent of health data is digitalised in a centralised national database that allowed the course of disease outbreaks to be tracked long before the current pandemic. Doctors upload x-rays and test results, make referrals and prescriptions digitally, while the use of a distributed ledger or blockchain technology allows patients to check which doctor has had access to their files.

Ireland is on the other end of the scale, with patient records siloed across different services and an archaic reliance on paper throughout the system, which shocks healthcare workers with experience working abroad. Plans for a single digital patient health record – the most basic of first steps – remain plans. In contrast, Britain's National Health Service began funding GPs to digitalise in the 1980s, and introduced national health infrastructure in 1992.

In this context, it’s not surprising that people who should have already been called up for vaccines have been accidentally left behind. The arrival of a vaccination invitation requires a number of steps underpinned by digital infrastructure. Bluntly, you’re only Group 3 if the computer knows you’re Group 3.

The condition that qualifies you to be in a particular vaccine priority group has to be registered in a recognisable format, in a searchable database, that the administrators of the vaccination programme can access. Your contact details must be correct, and the system for contacting you must work.

Doubling up

If all that functions, it’s is very important for the person next in line for a shot that the clinic where you received a jab can inform the database that you have now received your dose. If the system doesn’t know, if you are on multiple databases, or if you qualify under more than one priority group, you may continue to be invited repeatedly while others wait to be called – an occurrence that is thought to be behind many of Europe’s no-shows.

Then, the system needs to know which vaccine you have been given, and when you need to be called back.

After a variety of system failures thwarted attempts to efficiently get vaccines into arms, Belgium has rigged up a digital patch on the fly.

It’s called QVax, and it’s an online platform where people can sign up to be put on a “reserve list” to be called up in place of no-shows. Clinics with spare vaccines at the end of the day can call people up from the list, in order of age, and invitations must be accepted within 30 minutes.

The system was mobbed with so many applications when it launched this week that there were hours-long waits to register. How successful it will be in getting jabs into arms remains to be seen. From tracing apps to passenger data forms, new digital systems invented during the pandemic have a mixed record. When emergency hits, it’s best to already be prepared.