Ines Campos-Matos

Background: The migration status of the 9.8 million migrants living in England is not consistently recorded in primary care electronic health records (EHRs). Codelist approaches enable creation of cohorts of individuals who have had a predefined, optional migration-related code (for example, ‘refugee’) added to their EHR. Aim: To explore the use of migration-related Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) codes to inform future research using primary care data. Design & setting: We used our OpenCodeCounts tool to explore data published by NHS England on SNOMED CT code usage in English primary care. Method: We created migration-related codelists and described their use from 1 August 2011 to 31 July 2025. To understand code usage in the context of known information on migrants in England, we compared code usage with trends in migration-related statistics from the Home Office and the 2021 census. Results: There were 34.2 million uses of 1119 migration-related codes from 2011–2025. Migration-related coding increased over time, generally exceeding the increase observed for coding overall, with a sharp increase from 2020, particularly for country of birth and language. Language-related coding represented 65% of code usage, and where country of birth was recorded there was mixed agreement with the 2021 census. Coding of immigration legal statuses was low and overwhelmingly about asylum or refugee status. Conclusion: Utilising OpenCodeCounts, we demonstrate the feasibility of using migration-related SNOMED CT codelists within primary care EHRs and highlight some of the potential biases that cohorts created based on these codelists may have to inform future research.

Background: The migration status of the 9.8 million migrants living in England is not systematically recorded in primary care electronic health records (EHRs). Codelist approaches enable us to create cohorts of individuals who have had a predefined, optional migration-related code (e.g. “refugee”) added to their EHR. Aims: We aimed to explore the use of migration-related SNOMED CT codes to inform future research using primary care data. Design and Setting: We used our Open Code Counts tool and R package to explore data published by NHS England on SNOMED CT code usage in English primary care. Method: We created migration-related codelists and described their use from 1st August 2011 to 31st July 2024. We compared code usage to trends in migration-related statistics from the Home Office and the 2021 Census. Results: There were 29.1 million uses of 1,114 migration-related codes from 2011 to 2024. Migration-related coding increased over time, exceeding the increase observed for coding overall, with a sharp increase from 2020, particularly for country-of-birth and language. Language coding represented 71% of code usage and where country of birth was recorded, there was mixed agreement with the census estimates. Coding of immigration legal statuses was low and overwhelmingly about asylum or refugee status. Conclusion: Rapid assessment of migration-related coding using Open Code Counts highlights that a non-English first language is the most strongly represented characteristic in migrant cohorts in English primary care EHRs, which should be considered when interpreting future research findings. How this fits in: This study offers population-wide insights into migration-related SNOMED CT coding in primary care in England from 2011 to 2024 using our new open-source tool, Open Code Counts. Here, we show that a first language that is not English is the most commonly recorded aspect of migration, which must be considered when interpreting results from studies that use this methodology for researching migrants’ health in primary care EHRs. We also show that migration-related coding has increased, particularly after the start of the pandemic and for country-of-birth and language codes. The increased use of these code types offers the opportunity for GP practices to better identify patients requiring language support and potential screening and service needs based on their country of birth. Summary sentence: Language is the most commonly coded aspect of migration in primary care, which must be considered when interpreting primary care data studies.

Introduction: Electronic health records can be used to understand the diverse presentation of post-acute and long-term health outcomes following COVID-19 infection. In England, the UK Health Security Agency in collaboration with the University of Oxford have created the ECHOES dataset to monitor how an initial SARS-CoV-2 infection episode is associated with changes in the risk of health outcomes that are recorded in routinely collected health data. Methods: The ECHOES dataset is as a national level dataset combining national level surveillance, administrative, and healthcare data. Entity resolution and data linkages methods are used to create a cohort of individuals who have tested positive and negative for SARS-CoV-2 in England throughout the COVID-19 pandemic, alongside information on a range of health outcomes including diagnosed clinical conditions and mortality, and risk factor information. Results: The dataset contains comprehensive COVID-19 testing data and demographic, socio economic and health related information for 44 million individuals, who tested for SARS-CoV-2 between March 2020 and April 2022, representing 15,720,286 individuals who tested positive and 42,351,016 individuals who tested negative. Discussion: With the application of epidemiological and statistical methods, this dataset allows a range of clinical outcomes to be investigated, including pre-specified health conditions and mortality. Furthermore, understanding of potential determinants of health outcomes can be gained, including pre-existing health conditions, acute disease characteristics, SARS-CoV-2 vaccination status and genomic variant.

Despite evidence suggesting that some migrants are at risk of under-immunization and have experienced severe health inequities during the pandemic, data are limited on migrants’ COVID-19 vaccine coverage globally. Here we linked data from non-European Union migrants and resettled refugees to the national COVID-19 vaccination dataset in England. We estimated patterns in second and third dose delays and overdue doses between 12 December 2020 and 20 April 2022 by age, visa type and ethnicity. Of the 465,470 linked records, 91.8% (427,073/465,470) of migrants received a second dose and 51.3% (238,721/465,470) received a third. Refugees had the highest risk of delayed second (adjusted odds ratio 1.66; 95% confidence interval 1.55–1.79) and third dose (1.55; 1.43–1.69). Black migrants were twice as likely to have a second dose delayed (2.37; 2.23–2.54) than white migrants, but this trend reversed for the third dose. Older migrants (>65 years) were four times less likely to have received their second or third dose compared with the general population in England aged >65 or older. Policymakers, researchers and practitioners should work to understand and address personal and structural barriers to vaccination for diverse migrant populations.

Persons experiencing homelessness (PEH) or rough sleeping are a vulnerable population, likely to be disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. The impact of COVID-19 infection on this population is yet to be fully described in England. We present a novel method to identify COVID-19 cases in this population and describe its findings. A phenotype was developed and validated to identify PEH or rough sleeping in a national surveillance system. Confirmed COVID-19 cases in England from March 2020 to March 2022 were address-matched to known homelessness accommodations and shelters. Further cases were identified using address-based indicators, such as NHS pseudo postcodes. In total, 1835 cases were identified by the phenotype. Most were <39 years of age (66.8%) and male (62.8%). The proportion of cases was highest in London (29.8%). The proportion of cases of a minority ethnic background and deaths were disproportionality greater in this population, compared to all COVID-19 cases in England. This methodology provides an approach to track the impact of COVID-19 on a subset of this population and will be relevant to policy making. Future surveillance systems and studies may benefit from this approach to further investigate the impact of COVID-19 and other diseases on select populations.

Objectives: To explore attitudes and intentions towards COVID-19 vaccination, and influences and sources of information about COVID-19 across diverse ethnic groups (EGs) in the UK. Design: Remote qualitative interviews and focus groups (FGs) conducted June-October 2020 before UK COVID-19 vaccine approval. Data were transcribed and analysed through inductive thematic analysis. Setting: General public in the community across England and Wales. Participants: 100 participants from 19 self-identified EGs with spoken English or Punjabi. Results: Mistrust and doubt were common themes across all EGs including white British and minority EGs, but more pronounced amongst Bangladeshi, Pakistani, Black ethnicities and Travellers. Many participants shared concerns about perceived lack of information about COVID-19 vaccine safety, efficacy and potential unknown adverse effects. Across EGs participants stated occupations with public contact, older adults and vulnerable groups should be prioritised for vaccination. Perceived risk, social influences, occupation, age, co-morbidities and engagement with healthcare influenced participants’ intentions to accept vaccination once available; all Jewish FG participants intended to accept, while all Traveller FG participants indicated they probably would not. Facilitators to COVID-19 vaccine uptake across all EGs included: desire to return to normality and protect health and wellbeing; perceived higher risk of infection; evidence of vaccine safety and efficacy; vaccine availability and accessibility. COVID-19 information sources were influenced by social factors, culture and religion and included: friends, family; media and news outlets; and research literature. Participants across most different EGs were concerned about misinformation or had negative attitudes towards the media. Conclusions: During vaccination programme roll-out, including boosters, commissioners and vaccine providers should provide accurate information, authentic community outreach, and use appropriate channels to disseminate information and counter misinformation. Adopting a context-specific approach to vaccine resources, interventions and policies and empowering communities has potential to increase trust in the programme. Article summary: strengths and limitations: This is amongst the largest qualitative studies on attitudes to the COVID-19 pandemic in the UK general public across ethnic groups (EGs), ages and religions, adding insights from a broader range of participants. Qualitative methodology enabled discussion of participants’ responses around COVID-19 vaccination, probing to collect rich data to inform recommendations across EGs. Most data collection was undertaken in English, possibly excluding sectors of the population who may access COVID-19 information through different sources due to language. Data collection was June-October 2020 before COVID-19 vaccines were licensed. Attitudes are highly responsive to current information around a COVID-19 vaccine, as well as the state of the pandemic and perceived risk. Data were collected prior to much of the intervention work, putting the attitudes and intentions expressed in this study in a context of minimal community engagement and support. This provides a baseline snapshot of attitudes, providing the option to explore and assess the impact of such interventions. Socioeconomic data and index of multiple deprivation were not collected, limiting the ability to determine a possible accumulative effect of factors such as socioeconomic status, ethnicity and age.

Objectives To explore public reactions to the COVID-19 pandemic across diverse ethnic groups. Design Remote qualitative interviews and focus groups in English or Punjabi. Data were transcribed and analysed through inductive thematic analysis. Setting England and Wales June-October 2020. Participants 100 participants from 19 diverse ‘self-identified’ ethnic groups. Results Dismay, frustration and altruism were reported across all ethnic groups during the first six to nine months of the COVID-19 pandemic. Dismay was caused by participants’ reported individual, family and community risks, and loss of support networks. Frustration was caused by reported lack of recognition of the efforts of minority ethnic groups (MEGs), inaction by government to address COVID-19 and inequalities, rule breaking by government advisors, changing government rules around: border controls, personal protective equipment, social distancing, eating out, and perceived poor communication around COVID-19 and the Public Health England (PHE) COVID-19 disparities report (leading to reported increased racism and social isolation). Altruism was felt by all, in the resilience of NHS staff and their communities and families pulling together. Data, participants suggested actions, and the Behaviour Change Wheel informed suggested interventions and policies to help control COVID-19. Conclusion To maintain public trust, it is imperative that governmental bodies consider vulnerable groups, producing clear COVID-19 control guidance with contingency, fiscal, service provision and communication policies for the next rise in COVID-19 cases. This needs to be combined with public interventions including information, education, modelling and enablement of infection prevention through local community involvement and persuasion techniques or incentivisation. Government policy needs to review and include town and social planning leading to environmental restructuring that facilitates infection prevention control. This includes easy access to hand-washing facilities in homes, work, all food providers and shopping centres; toilet facilities as our Travellers mentioned, and adequate living accommodation and work environment facilitating IPC for all. Strengths and limitations This is amongst the largest qualitative studies on attitudes to the COVID-19 pandemic in the UK general public across ethnic groups, ages and religions, adding insights to previous smaller qualitative studies, from a broader range of participants. The qualitative methodology allowed us to discuss participants’ responses around the COVID-19 pandemic, probing their answers to obtain detailed data to inform needs across ethnic groups. Most data collection was undertaken in English and therefore excludes non-English speaking sectors of the population who may have experienced the COVID-19 pandemic differently. We did not obtain the views of older members of the population over 70 years, who were most at risk. The data reflect public perceptions six to nine months into the pandemic when some of the social distancing rules had been relaxed in England; as the pandemic progresses attitudes and needs may well change.