Article Text

Original research
Differences in COVID-19 vaccination coverage by occupation in England: a national linked data study
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  1. Vahe Nafilyan1,2,
  2. Ted Dolby1,
  3. Katie Finning1,
  4. Piotr Pawelek1,
  5. Rhiannon Edge3,
  6. Jasper Morgan1,
  7. Myer Glickman1,
  8. Neil Pearce2,
  9. Martie van Tongeren4
  1. 1 Health Analysis and Life Events Division, Office for National Statistics, Newport, UK
  2. 2 Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
  3. 3 Lancaster Medical School, Lancaster University, Lancaster UK
  4. 4 Division of Population Health, Health Services Research and Primary Care, The University of Manchester, Manchester UK
  1. Correspondence to Dr Vahe Nafilyan, Office for National Statistics, Newport, Newport, UK; vahe.nafilyan{at}ons.gov.uk

Abstract

Background Monitoring differences in COVID-19 vaccination uptake in different groups is crucial to help inform the policy response to the pandemic. A key data gap is the absence of data on uptake by occupation. This study investigates differences in vaccination rates by occupation in England, using nationwide population-level data.

Methods We calculated the proportion of people who had received three COVID-19 vaccinations (assessed on 28 February 2022) by detailed occupational categories in adults aged 18–64 and estimated adjusted ORs to examine whether these differences were driven by occupation or other factors, such as education. We also examined whether vaccination rates differed by ability to work from home.

Results Our study population included 15 456 651 adults aged 18–64 years. Vaccination rates differed markedly by occupation, being higher in health professionals (84.7%) and teaching and other educational professionals (83.6%) and lowest in people working in elementary trades and related occupations (57.6%). We found substantial differences in vaccination rates looking at finer occupational groups. Adjusting for other factors likely to be linked to occupation and vaccination, such as education, did not substantially alter the results. Vaccination rates were associated with ability to work from home, the rate being higher in occupations which can be done from home. Many occupations with low vaccination rates also involved contact with the public or with vulnerable people

Conclusions Increasing vaccination coverage in occupations with low vaccination rates is crucial to help protecting the public and control infection. Efforts should be made to increase vaccination rates in occupations that cannot be done from home and involve contact with the public.

  • COVID-19
  • Occupational Health

Data availability statement

Data may be obtained from a third party and are not publicly available. Whilst data are currently not publicly available, they will be made available via the ONS Secure Research Service once the 2021 Census microdata are cleared for release.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • We searched PubMed for articles on occupational differences in COVID-19 vaccination coverage and hesitancy. While several studies highlight differences in vaccination coverage by ethnicity, religion, sociodemographic factors and certain underlying health conditions, there is very little evidence on how vaccination coverage varies by occupation in the UK and elsewhere. The few studies looking at occupational differences in vaccine hesitancy focus on healthcare workers or only examined broad occupational groups. There is currently no large-scale study on occupational differences in COVID-19 vaccination coverage in the UK.

WHAT THIS STUDY ADDS

  • This study investigated differences in vaccination rates among workers in England, using population-level linked data combining the 2011 Census, Census 2021, primary care records, mortality and vaccination data. We found that the vaccination rates of adults aged 18–64 years differed markedly by occupation. Vaccination rates were higher in health professionals and teaching and other educational professionals and lower in people working in elementary occupations. Adjusting for confounding factors likely to be linked to occupation and vaccination, such as education, did not substantially alter the results. Vaccination uptake was also associated with the ability to work from home, with the vaccination rate being higher in occupations where work can be done from home.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Many occupations with low vaccination rates involved contact with the public or with vulnerable people. Therefore, increasing vaccination coverage in these occupations would be crucial to help protecting the public and control infection. As people working in these occupations tend to be in some of the more deprived groups in society, increasing vaccination rates in these groups would help reduce inequalities in vaccination coverage.

Introduction

The UK began an ambitious vaccination programme to combat the COVID-19 pandemic on 8 December 2020; by 28 February 2022, 66.5% of the UK adult population had received three vaccinations and 91.5% at least one vaccination.1

Monitoring differences in uptake in different groups is crucial to inform the policy response. Evidence suggests that rates of COVID-19 vaccination in England differ by ethnicity, religion, sociodemographic factors and certain underlying health conditions.2–4 However, a key data gap is the absence of data on uptake by occupation. Producing vaccination rates by detailed occupational categories is challenging as routinely collected data used for the analysis of vaccination uptake do not contain information on occupation. The use of surveys is limited as a large sample size is needed to precisely estimate vaccination rates in small groups.

As there is evidence that people working in occupations involving contact with patients or the public are at greater risk of COVID-19 infection and death,5–7 it is important to ensure that vaccination coverage is high in these occupations. Measuring vaccination uptake by occupation also has implications for the management of the pandemic, especially as countries such as the UK have lifted all restrictions, ended the furlough scheme and are encouraging workers to go back to the office. If vaccination rates are high in people working in occupations in which working from home is an option, then having workers back to the office would be expected to have less impact on cases and hospitalisation than if the vaccination rates are low. Similarly, imposing working from home where possible would be less effective if vaccination coverage is high in people who can work from home but low in those who cannot.

This study investigates differences in vaccination rates by occupation in England, using nationwide population-level data. We calculated vaccination rates by detailed occupational categories in working age adults aged and estimated adjusted ORs to examine whether these differences were driven by potential confounding factors. We also examined whether vaccination rates differed by the ability to work from home.

Methods

Data

We linked vaccination data from NHS England’s National Immunisation Management System (NIMS) to the Office for National Statistics (ONS) Public Health Data Asset (PHDA) based on NHS number. The ONS PHDA is a linked data set combining the 2011 Census, mortality records, the General Practice Extraction Service data for pandemic planning and research, and the Hospital Episode Statistics. To obtain NHS numbers for the 2011 Census, we linked the 2011 Census to the 2011–2013 NHS Patient Registers using deterministic and probabilistic matching, with an overall linkage rate of 94.6%. All subsequent linkages were performed based on NHS numbers.

We updated the information on occupation in the PHDA by using an extract from Census 2021. We retrieved NHS numbers for 82.1% of Census 2021 participants, using the Personal Demographics Service.

The study population consisted of adults aged 18–64 years, alive on 28 February 2022, who were resident in England, registered with a general practitioner, enumerated at the 2011 Census and 2021 Census and reported an occupation and being employed in the 2021 Census. Of 22 289 910 adults aged 18–64 years who received three COVID-19 vaccinations in NIMS, 17 844 686 (80.0%) were linked to the ONS PHDA. Of the 33 073 531 people enumerated at the 2011 Census in England and Wales, who would be aged 18–64 years on 28 February 2022, we excluded 2 167 841 people (6.6%) who could not be linked deterministically or probabilistically to the NHS Patient register, and 461 951 individuals (1.4%) who had died between the Census and 28 February 2022. An additional 3 906 332 people (11.8%) were not linked to the English primary care records (using location as of 2019), either because they did not live in England in 2019 (the Census included people living in England and Wales) or because they were not registered with the NHS. A further 5 762 544 individuals (17.4%) could not be linked to Census 2021 or were not living in England in 2021, and 5 223 434 people (15.8%) were not employed or did not have occupation information at the time of Census 2021 and were, therefore, excluded from the analysis. After excluding 4778 individuals who had received their vaccine before the beginning of the vaccination campaign (8 December 2020 for first and second vaccinations; 16 September 2021 for third vaccinations), our sample consisted of 15 546 651 individuals (see sample flow diagram in online supplemental table S1). This amounts to 60.1% of people in England aged 18–64 years who are employed, based on estimates from the Annual Population Survey.

Supplemental material

Outcome

The primary outcome was being fully vaccinated against COVID-19, that is having received three COVID-19 vaccinations as recorded in the NIMS data by 28 February 2022. Third vaccinations had been offered to all eligible adults in England aged 18 years and over by 31 December 2021. Therefore, by the end of February 2022, we would expect most people who wanted to be vaccinated to have received their third vaccination. Third vaccination may refer to a booster vaccination or a third dose vaccination received as part of the primary course. Third vaccinations that were received prior to 16 September 2021, and, therefore, prior to the official booster campaign, were excluded from this analysis.

We also examined having received no COVID-19 vaccine as a secondary outcome.

Exposure

The main exposure was occupation at the time of Census 2021. Occupations were coded using a hierarchical classification, the Standard Occupation Classification (SOC) 2020.8 The most detailed classification (Unit group, with four-digit codes) included 412 categories, while a more aggregated (submajor group, with two-digit codes) has 26 groups. We used both SOC submajor groups and unit groups in this paper.

Covariates

In addition to crude vaccination rates, we estimated ORs adjusted for a range of factors known to be associated with vaccination uptake and occupation,9 and, therefore, likely to confound the relationship between occupation and vaccination. We adjusted for sex (male and female), age (10-year age bands), region, ethnicity (White British, Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Mixed, Other, Pakistani, White other), disability status (non-disabled, disabled and limited a little, disabled and limited a lot), highest level of qualification (level 4+, level 3, apprenticeship, level 2, level 1, other, no qualification) and pre-existing health conditions (1+) based on the QCovid risk model (see online supplemental table S2 for more detail).

Occupation characteristics

We also used occupation-level (unit group) data on ability to work from home. These data were derived by ONS based on data from the Occupational Information Network (O*NET), which contains information about the features and the nature of the work of the USA.10 Occupations were assigned a score of between 1 and 5 to reflect the frequency and importance of different tasks and characteristics to various jobs. Factors considered included whether the job has to be carried out in a specific location; the amount of face-to-face interaction with others; exposure to infections and other hazards; whether the job requires physical activity; and use of tools or protective equipment. An overall score was derived by summing the category scores, which were first rescaled to between 0 and 1. The final score was also rescaled to between 0 and 1, with one indicating a high ability to work from home.

Statistical analyses

First, we estimated the rate of people aged 18–64 who had received three COVID-19 vaccinations by occupation. Second, we estimated age-standardised vaccination rates for the different unit groups, whereby the age distribution within each group was standardised to the 2013 European Standardised Population. We also estimated vaccination coverage by sub-major group and sex, and sub-major group and age groups (18-39, 40-64)

Third, we examined whether differences were driven by other sociodemographic and clinical factors likely to be associated with vaccination uptake and occupation. We selected factors known to be associated with vaccination uptake in England9 and to be linked to occupation. We used logistic regression to estimate the odds of being fully vaccinated (having received three vaccinations) by occupation, adjusting for sex, age, geographical and sociodemographic characteristics, disability status and pre-existing conditions. The occupations used as the reference category were elementary administration and service occupations (SOC submajor group) and sales and retail assistants (SOC unit group)—these are large groups with relatively low vaccination coverage. We estimated unadjusted ORs, ORs adjusted for age and sex and fully adjusted ORs.

Finally, we investigated the association between vaccination rate and the ability to work from home. We visualised the relationship using a scatter plot and estimated the strength of the association using univariate linear regression models. We also used logistic regression models to estimate the association between working from home and the odds of being fully vaccinated, after adjusting for other characteristics. We used the same approach as for occupation and estimated SE clustered at occupation level. Because the working from home score was standardised with a mean of 0 and an SD of 1, the OR for the score can be interpreted as the effect of an increase by one SD. Analyses were conducted using R V.3.5.

Results

Characteristics of study population

Our study population included 15 546 651 adults aged 18–64 years who lived in England at the beginning of the pandemic and reported being employed in Census 2021. 74.5% of people had received three vaccinations against COVID-19 by 28 February 2022, while 7.2% had not received any COVID-19 vaccination. The average age was 44.1 years and 51.5% were women; 83.0% identified themselves as White British. 17.3% of people had at least one of the health conditions included in the QCovid risk model. Table 1 provides detailed characteristics of the sample.

Table 1

Characteristics of the study population

Vaccination rates by occupation

As of 28 February 2022, vaccination coverage in workers aged 18–64 was high but differed by SOC submajor group. The proportion of people having received three vaccinations was highest in health professionals (84.7%) and teaching and other educational professionals (83.6%). Those working in elementary trades and related occupations had the lowest vaccination rate with 57.6% of people having received three vaccinations (figure 1).

Figure 1

Vaccination coverage by SOC submajor group. SOC, Standard Occupation Classification.

Vaccination coverage also differed markedly by occupation unit groups (table 2 for selected occupations, online supplemental table S5 for all occupations). Third vaccination rates were highest in specialist medical practitioners (93.3% (93.1 to 93.6)), senior police officers (92.8% (92.1 to 93.6)), public relations and communication directors (92.0% (91.5 to 92.5)) and speech and language therapists (92.0% (91.5 to 92.6)). The third vaccination rate was over 85% in 64 out of 412 occupation unit groups, accounting 1 809 550 (11.6%) workers.

Table 2

Third vaccination coverage and ORs for having received three vaccinations for SOC unit groups, top and bottom 20

The proportion of people having received three vaccinations was lower than 50% in three occupations, accounting for 97 205 (0.6%) people in the data set. These included scaffolders, stagers and riggers (46.3% (45.5 to 47.0)), elementary construction occupations not elsewhere classified (48.2% (47.8 to 48.6)) and roofers, roof tilers and slaters (49.8% (49.1 to 50.4)).

The third vaccination rate was lower than 65% in 63 out of 412 occupations; 3 122 825 (20.1%) people worked in these occupations. The larger occupations, those with more than 100 000 workers, with low vaccination rates included electricians and electrical fitters (58.7% (58.4 to 59.0)), warehouse operatives (59.9% (59.7 to 60.1)), kitchen and catering assistants (61.2% (60.9 to 61.4)) and carpenters and joiners (62.0% (61.8 to 62.3)). Low rates of vaccination were also found in sales and retail assistants (62.7% (62.6 to 62.9)) and care workers and home carers (68.2% (68.0 to 68.3)), two large occupational groups—over 1 million workers in our sample—which involve working with the public.

Among health professionals and health and social care associate professionals, there was some variation in vaccination rates. Most unit groups among healthcare workers had vaccination rates above average, with 93.3% (93.1 to 93.6) of specialist medical practitioners having received three vaccinations and 92.0% (91.5 to 92.6) of speech and language therapists. Vaccine coverage was low in early education and childcare practitioners (63.0% (62.6 to 63.4)); complementary health associate professionals (64.4% (63.5 to 65.3)), which includes homoeopaths, hypnotherapists and others; and therapy professionals not elsewhere classified (71.9% (71.2 to 72.6)), which includes acupuncturists, nutritionists, chiropractors, art therapists and others. Vaccination rates were also low in care workers and home carers (68.2% (68.0 to 68.3)).

Standardising for age or adjusting further for other factors likely to be linked to occupation and vaccination did not substantially alter the results (see online supplemental table S5). Adjusted OR for being fully vaccinated (three vaccinations) was lowest in scaffolders, stagers and riggers (0.41 (0.39 to 0.42)), complementary health associate professionals (0.41 (0.40 to 0.43)), roofers, roof tilers and slaters (0.42 (0.41 to 0.44)) and plasterers (0.45 (0.44 to 0.46)). The highest ORs for being fully vaccinated were found in healthcare occupations: generalist medical practitioners (5.97 (5.82 to 6.13)), speech and language therapists (4.99 (4.62 to 5.39)), specialist medical practitioners (4.75 (4.56 to 4.95)) and clinical psychologists (4.64 (4.28 to 5.02)).

Results were similar when looking at people who had not received any vaccine (see online supplemental table S6), suggesting that the results are not driven by people working in some occupation being less likely to have been eligible to receive their second or third vaccination.

In online supplemental tables S7 and S8, we estimated vaccination coverage by SOC submajor group broken down by age groups (18–39, 40–64) and sex, respectively. While the proportion of people who had received three vaccinations was higher in those aged 40–64 than in those aged 18–39, the differences between occupation were similar. These differences were also similar when breaking down the coverage by sex.

Vaccination rates and job characteristics

Vaccination rates were associated with the ability to work from home, as assessed based on O*NET data. Figure 2 shows that vaccination rates tend to be higher in occupations in which working from home is more easily possible. The association was strong, with an R2 of 0.313 and a F-statistic of 185.4. Results from a logistic regression model suggest that 1 SD increase in the working from home score was associated with 3.68 (3.66 to 3.70) times higher odds of being fully vaccinated. Adjusting for geographical factors, sociodemographic characteristics and health reduced the ORs but did not substantially affect the results (adjusted ORs 3.01 (2.99 to 3.03)), indicating that working from home is independently associated with an increase in the odds of being fully vaccinated.

Figure 2

Association between third vaccination rates and ability to work from home at unit group level. The size of each point represents the number of people in the study population employed in the given SOC unit group. SOC, Standard Occupation Classification.

Discussion

Main findings of this study

Using whole population level-linked data in England, our analysis shows that the vaccination rates of adults aged 18–64 years differed markedly by occupation. Vaccination rates were high in health professionals and teaching and other educational professionals and low in people working in elementary occupations. Vaccination rates were also associated with the ability to work from home, with vaccine coverage being higher in occupations, which can be performed from home—this relationship remained when sociodemographic characteristics were adjusted for.

Comparison with other studies

Few studies have investigated how COVID-19 vaccination coverage varies by occupation. Several studies investigated vaccine hesitancy and vaccine coverage in healthcare workers, highlighting some differences between different job roles, with doctors having slightly higher vaccination coverage and lower hesitancy than midwives and nurses.11 12 Similarly, we found, once controlling for sociodemographic, geographic and health factors, Generalist Medical Practitioners—including doctors, general practitioners, house officers and others—were most likely to have received three vaccinations among health professionals (see online supplemental table S5). Nurse practitioners, community nurses, other nursing professionals, midwifery nurses and mental health nurses comprised five of the eight least likely occupations to have received three vaccinations among health professionals—there are 25 occupations in this SOC submajor group.

Our findings that vaccination rates are higher among managers, directors and senior officials and in people working in professional occupations, compared with those working in elementary occupations, are in line with studies showing that vaccination rates in the UK and the US are higher in more wealthy areas and among people from higher socioeconomic status.2–4 13 Our results are also consistent with a study from the US showing that vaccine hesitancy varied widely by occupation category, with hesitancy being low in people working in professional occupations, especially in the life, physical and social sciences and particularly high in people working in construction and extraction.14

Strengths and limitations

A major strength of this study is the use of nationwide linked population-level data from clinical records and the Census. This study is the first to examine how vaccination rates vary by occupation using population-level data. Because information on occupation is not collected in electronic health records, we used data from the Census to assess people’s occupation. Some surveys collect data on both occupations and vaccination but face the issue that non-response is likely correlated with the propensity to be vaccinated. Having population-level data based on electronic health records and the Census, which is mandatory and has a high response rate, we were able to precisely estimate vaccination rates for detailed occupational groups. A further strength is the use of occupation information from Census 2021, providing recent occupation information at a population level.

The main limitation of our study is that, because the PHDA was based on the 2011 Census, it excluded people who were living in England in 2011 but who did not take part in the Census as well as respondents who could not be linked to the 2011–2013 NHS patient register and recent migrants. Those that did not take park in Census 2021, as well as those who could not be linked to an NHS number, were also excluded. Our data set contains 15 546 651 people, which amounts to 60.1% of people aged 18–64 years who are employed, based on estimates from the Annual Population Survey. Another limitation is that we could not provide data on the type of vaccine used. However, all booster doses were administered using messenger RNA vaccines.

Mechanisms

Our analysis highlights substantial differences in vaccination coverage between occupations, with vaccination rates being higher in health professionals and teaching and other educational professionals and lower in people working in elementary occupations. These differences were only partially explained by other factors, including education, suggesting that some occupations are independently associated with vaccination status. While vaccination was not mandatory, health workers were prioritised during the vaccination campaign, which might partly explain their high vaccination coverage. However, by the end of our study, all adults would have been eligible for a booster dose. People working in elementary occupations may have little job control and, therefore, may find it more difficult to attend vaccination or may be put off by the potential side effects, which could prevent them from working. Existing evidence suggests that occupational characteristics, such as job strain, can affect health behaviours, such as compliance with treatment.15 Vaccine hesitancy may also be driving differences in uptake. The drivers of vaccine hesitancy are complex, and occupation may play a part. Indeed, we find that vaccine coverage is low in complementary health associate professionals, such as homoeopaths and hypnotherapists, and therapy professionals not elsewhere classified, such as acupuncturists, nutritionists and chiropractors. They may be more likely to reject mainstream medicine than other groups. The rates were also low in sports players, who may be more likely to believe they are very healthy and, therefore may not need the vaccine.

Conclusion

In our study population of working-age adults in England, 74.5% had received three vaccinations against COVID-19 by 28 February 2022, which is high by the standards of most Western countries. However, many occupations with lower vaccination rates involved contact with the public (bar staff, sales and retail assistants, waiters and waitresses) or with vulnerable people (care workers and home carers). Therefore, increasing vaccination coverage in these occupations would be important, not only to protect workers in these occupations but also to help protect the public and to control infection. Our results also show that vaccination rates are associated with the ability to work from home, with vaccination rates typically being higher in occupations, which can be done from home. Therefore, policies such as ‘work from home if you can’ may only have limited impact on hospitalisations and deaths, as the vaccination rates are already higher in the occupations that can be done from home and lower in those which cannot. Efforts should, therefore, be made to increase vaccination rates in occupations that cannot be done from home. This includes many elementary occupations where it may be difficult to get time off work to be vaccinated, or where workers may not have the spare time or resources to access vaccination or are worried about missing work because of the side effects of the vaccines. As these are some of the more deprived groups in society, increasing vaccination rates in these groups would help reduce inequalities in vaccination coverage. Our results could also help inform future vaccination strategy and future models of COVID-19 transmission.

Vaccination is just one of the strategies that can be used to prevent or control infections from SARS-CoV-2, although one of the most important ones as it also reduces the risk of developing symptoms and severe disease. Other important strategies involve particularly the use of face masks and ventilation, and for that reason, a ‘vaccine plus’ strategy has been advocated by some commentators.16 However, recent studies show that vaccines continue to have extremely good effectiveness even against new variants, such as Omicron.17 18

Data availability statement

Data may be obtained from a third party and are not publicly available. Whilst data are currently not publicly available, they will be made available via the ONS Secure Research Service once the 2021 Census microdata are cleared for release.

Ethics statements

Patient consent for publication

References

Supplementary materials

  • Supplementary Data

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Footnotes

  • VN and TD are joint first authors.

  • NP and MvT are joint senior authors.

  • Twitter @martievt

  • Contributors Study conceptualisation was led by VN and TD. VN and TD contributed to the development of the research question, study design, with development of statistical aspects led by TD and VN. TD and VN were involved in data specification, curation and collection. TD, PP and VN conducted and checked the statistical analyses. VN, TD, KF, RE, MG, NP, MvT, contributed to the interpretation of the results. VN wrote the first draft of the paper. TD, MG, KF, RE, NP, MvT contributed to the critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. VN had full access to all data in the study and takes responsibility of the integrity of the data and the accuracy of the data analysis. VN affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained. VN is the garantor of the study, and accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding This work was funded by ONS and supported by funding through the National Core Study 'PROTECT' programme, managed by the Health and Safety Executive on behalf of HM Government.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.