This guidance was originally published provisionally, ahead of authorisation of any COVID-19 vaccine in the UK, to provide information to those who will be involved in the COVID-19 national vaccination programme.
In the UK, three COVID-19 vaccines are currently in use in the UK national COVID-19 vaccination programme:
- COVID-19 mRNA Vaccine BNT162b2 (manufactured by Pfizer BioNTech) was given authorisation for temporary supply by the MHRA on 2 December 2020
- COVID-19 Vaccine AstraZeneca was given authorisation for temporary supply by the MHRA on 30 December 2020 and then granted conditional marketing authorisation on 24 June 2021
- COVID-19 Vaccine Moderna was given authorisation for temporary supply by the MHRA on 8 January 2021 and then granted conditional marketing authorisation on 1 April 2021.
Information about any other COVID-19 vaccines that are given regulatory approval will be added when this occurs.
The information in this guidance was correct at time of publication. As COVID-19 is an evolving disease, some of the information may change. Updates will be made to this document as new information becomes available. You are therefore advised to consult the online version of the full guidance to ensure you are accessing the latest information.
This summary has been abridged for print. View the full summary at guidelines.co.uk/455707.article
COVID-19 vaccination programme
- The aim of the COVID-19 vaccination programme is to protect those who are at highest risk from serious illness or death from COVID-19 or at risk of transmitting infection to multiple vulnerable persons or other staff in a health or social care environment
- For information about COVID vaccines in development, see the LSHTM COVID-19 vaccine tracker.
Duration of protection and booster doses
- It is not yet known how long protection will last, whether regular booster doses will be needed, and to what extent the vaccine stops people from catching and spreading the virus or just prevents them from becoming ill
- On 30 June 2021, the Joint Committee on Vaccination and Immunisation (JCVI) issuedinterim advice, which stated that any potential COVID-19 booster programme should be offered in two stages from September 2021, starting with those most at risk from serious disease. This includes care home residents, people aged over 70, frontline health and social care workers, clinically extremely vulnerable adults, and those who are immunosuppressed
- The JCVI will continue to review emerging scientific data over the next few months, including data relating to the duration of immunity from the current vaccines. Final advice on booster vaccination may change as a result of this.
Groups affected by COVID-19
- Increasing age and male gender have been shown to be significant risk factors for severe disease, and infection fatality ratios are highest in the oldest age groups
- Comorbidities such as diabetes and severe asthma are associated with an increased risk of death, and obesity and other underlying health conditions can increase the risk for some people
- Deprivation and being from a black, Asian, or minority ethnic group also results in an increased risk of death from COVID-19
- Health and social care workers are at increased risk of acquiring infection in their work setting and they may potentially transmit the virus to their families and to those in their care
- Further information on high risk groups (those who are clinically extremely vulnerable) and moderate risk groups (those who are clinically vulnerable) can be found on the NHS.UK webpage: Who’s at higher risk from coronavirus (COVID-19).
COVID-19 vaccination eligibility
Vaccine priority groups
- See the JCVI: advice on priority groups for COVID-19 vaccination 30 December 2020 statement for information about the first phase of the vaccination programme, and the JCVI final statement on phase two of the COVID-19 vaccination programme (13 April 2021)
- Full details on vaccine eligibility, with detail on the at-risk conditions and the eligibility of health and social care and laboratory staff groups, are included in the Green Book COVID-19 chapter.
- In the UK, three COVID-19 vaccines are currently in use in the UK national COVID-19 vaccination programme. These are:
- COVID-19 mRNA Vaccine BNT162b2 (manufactured by Pfizer BioNTech) given authorisation for temporary supply by the MHRA on 2 December 2020
- COVID-19 Vaccine AstraZeneca given authorisation for temporary supply by the MHRA on 30 December 2020 and then granted conditional marketing authorisation on 24 June 2021
- COVID-19 Vaccine Moderna given authorisation for temporary supply by the MHRA on 8 January 2021 and then granted conditional marketing authorisation on 1 April 2021
- Information about any other COVID-19 vaccines that are given regulatory approval will be added when this occurs
- The Pfizer BioNTech and Moderna COVID-19 vaccines use an mRNA platform and the COVID-19 Vaccine AstraZeneca is an adenovirus vector vaccine
- All the currently authorised vaccines are presented in multi-dose vials and require completion of a two-dose course. Using multi-dose vials can improve the efficiency of vaccine manufacture and distribution, enabling vaccine availability for those eligible at the earliest opportunity.
Interchangeability of different COVID-19 vaccines
- Evidence from trials suggest that those who receive mixed schedules—including mRNA and adenovirus vectored vaccines—make a good immune response, although rates of side effects following the second dose are higher compared to those who received the same vaccine for both doses. Initial reactogenicity and safety data from the Com-COV clinical trial showed that mixed schedule recipients were more likely to experience feverishness, chills, fatigue, headache, joint pain, malaise, and muscle ache. However, there were no hospitalisations due to these symptoms, and most of the increase in reactogenicity was observed in the 48 hours after immunisation
- Because of this increased risk of side effects, every effort should be made to determine which vaccine the individual received for their first dose and to complete the two-dose course with the same vaccine. Individuals who do receive a different vaccine for their second dose should be informed that they may experience more reactions to the second dose
- For individuals who started the schedule and who attend for vaccination at a site where the same vaccine is not available, for example, if the individual received their first dose abroad, or where the first product received is unknown, it is reasonable, in these circumstances, to offer one dose of the locally available product to complete the schedule. This option is preferred if that individual is likely to be at immediate high risk or is considered unlikely to attend again. In these circumstances, as all three of the COVID-19 vaccines currently authorised in the UK are based on the spike protein of the virus, it is likely that the second dose will help to boost the response to the first dose. Further doses of vaccine would not then be required.
Individuals who received COVID-19 vaccination overseas
- If a person has received a first dose of COVID-19 vaccine overseas that is also available in the UK, they should receive the same vaccine for their second dose
- If the vaccine they received for their first dose is not available in the UK, the most similar alternative should be offered
- If the vaccine received overseas is not listed in the table (see Appendix 1 in the full guidance), a full course of the appropriate vaccine recommended for the individual in the UK (which may depend on their age) should be given
- The various groups of vaccines are:
- adenovirus (ChAdOx) vector: AstraZeneca, Covishield
- mRNA: Pfizer, Moderna
- whole inactivated coronavirus: Sinopharm, Sinovac, Covaxin
- The other adenovirus-based vaccines (Jansen, Sputnik, CanSinoBio) use different vectors and so are not immunologically the same as either the AstraZeneca or Covishield adenovirus vector vaccines. However, as they, and the Novavax vaccine, are all based on spike protein, the vaccine course can be completed with any of the locally available vaccines as appropriate for the individual’s age.
COVID-19 vaccines schedule
- Although the two recommended doses of Pfizer BioNTech vaccine can be given a minimum of 21 days apart and the AstraZeneca and Moderna vaccine doses can be given a minimum of 28 days apart, currently, JCVI is recommending an interval of 8–12 weeks between doses of all the available COVID-19 vaccines. Operationally, this consistent interval should be used for all two-dose vaccines to avoid confusion and simplify booking and will help to ensure a good balance between achieving rapid and long-lasting protection
- The main exception to the 8 week lower interval would be those about to commence immunosuppressive treatment. In these individuals, the minimal intervals (21 days for Pfizer BioNTech vaccine or 28 days for Moderna and AstraZeneca vaccines) may be followed to ensure that the vaccine is given whilst their immune system is better able to respond.
Administering the second dose beyond the recommended interval
- Whilst it is strongly advised that the second dose is given at the recommended interval, if it is inadvertently or unavoidably delayed beyond this interval, for example, because an individual is unable to attend their vaccination appointment, it is unlikely that their response to this second dose and their longer-term protection will be adversely affected
- Evidence shows that delaying the second dose to 12 weeks after the first improves the boosting effect. Data from clinical trials show that the efficacy of the AstraZeneca vaccine was higher when the second dose was given at, or after 12 weeks, and a recent study of people aged over 80 years found that extending the second dose interval to 12 weeks for the Pfizer BioNTech vaccine markedly increased the peak spike-specific antibody response by three and a half times compared to those who had their second vaccine at 3 weeks
- If an interval longer than that recommended is left between doses, there is no need to restart the course and the second dose should be given as soon as it can be arranged (preferably using the same vaccine to complete the course). Although good protection is provided by the first dose, and this is likely to last beyond 12 weeks, individuals should be encouraged to receive their second dose on time as this will significantly boost their protection and prevent further hospitalisations and deaths. Timely administration of the second dose is especially important when COVID-19 community infection rates are high or increasing.
For recommendations on exceptional circumstances in which a different second vaccine to the first can be given, such as for housebound patients or care home residents, and individuals who experience severe adverse reactions after the first dose, refer to the full guideline.
For recommendations on administration of the COVID-19 vaccine, view the full summary at guidelines.co.uk/455707.article
Administration of COVID-19 vaccine
Infection prevention and control
- All those attending for vaccination and those delivering vaccination should wear appropriate personal protective equipment as described in the infection prevention and control advice current at the time of administering the vaccine
- Hand hygiene is critical to prevent the spread of infection and hands should be cleaned with alcohol-based gel or soap and water before vaccine preparation, between patients, and so on. Those preparing and administering the vaccine should maintain good hand hygiene throughout and should take care not to touch the vial bung with their fingers.
- COVID-19 vaccines should be administered by intramuscular injection, preferably into the deltoid muscle of the upper arm
- Individuals who have minimal muscle mass in the deltoid area of the upper arm, or a particular reason to avoid immunisation in the deltoid muscle, can be given their vaccine in the vastus lateralis muscle in the thigh if necessary
- The area for injection should be clearly visible and accessible. Garments with long or tight sleeves may need to be removed. The injection site does not need to be cleaned unless visibly dirty. If cleaning is required, water should be used, and the area dried with a gauze swab. It is not necessary to disinfect the skin
- Insert the needle into the injection site far enough to ensure it will deliver the vaccine into the muscle and depress the plunger. There is no need to pull back on the plunger (aspirate) before the plunger is depressed to release the vaccine into the muscle because there are no large blood vessels at the recommended injection sites
- Ensure the full dose is administered, as a partial dose will not evoke a full immune response. Remove the needle and if there is any visible blood at the injection site, the patient can apply pressure to the site with a piece of gauze or cotton wool.
For information on administering COVID-19 vaccine to individuals with bleeding disorder and/or taking anticoagulants, refer the full guideline.
Timing of administration of COVID-19 vaccine to individuals who are immunosuppressed
- Individuals who have immunosuppression and HIV infection (regardless of CD4 count) should be given COVID vaccine in accordance with the recommendations and contraindications stated in the COVID-19 vaccine PGDs and Protocols and Green Book COVID-19 chapter
- Individuals with immunosuppression may not make a full immune response to vaccination
- As there is limited evidence on response in immunosuppressed individuals there is also no evidence upon which to base advice on the optimal timing of delivery. However, a recent study suggested immune responses were better in patients with cancer who received their chemotherapy at least 2 weeks earlier
- Specialists may advise their patients based on their knowledge and understanding of their immune status and likely immune response to vaccination but should also consider the risk from COVID-19 and the patient’s likelihood of exposure
- The small number of patients who are about to receive planned immunosuppressive therapy should be considered for vaccination prior to commencing therapy
(ideally at least 2 weeks before), when their immune system is better able to make a response. Where possible, it would also be preferable for the two-dose schedule to be completed prior to commencing immunosuppression. This would entail offering the second dose at the recommended minimum for that vaccine (3 or 4 weeks from the first dose) to provide maximum benefit that may not be received if the second dose was given during the period of immunosuppression. Any decision to defer immunosuppressive therapy or to delay possible benefit from vaccination until after therapy should not be taken without due consideration of the risks from COVID-19 and from their underlying condition
- Although the immune correlates of protection are currently unknown, post-vaccination testing for spike antibody may be considered. Until further information becomes available, vaccinated patients with immunosuppression should continue to follow advice to reduce the chance of exposure, and their adult household contacts should also be offered vaccine.
Period of observation following immunisation with COVID-19 vaccine
- Following COVID-19 vaccine administration, individuals should be observed for any immediate reactions whilst they are receiving any verbal post-vaccination information (such as possible reactions and what, if anything, to do about these). They, or their carers, should also be informed where they can obtain further advice if they require it following vaccination
- It is recommended that individuals are observed for a minimum of 15 minutes following administration of the Pfizer BioNTech and Moderna vaccines. There is no requirement for 15 minutes observation following the AstraZeneca vaccine. However, as fainting can occur following vaccination, all those vaccinated with any of the COVID-19 vaccines should either be driven by someone else or should not drive for 15 minutes after vaccination.
Advice to vaccine recipients following immunisation with COVID-19 vaccine
- Following COVID-19 vaccine administration, vaccine recipients should be given information about possible reactions to the vaccine (see the section on adverse reactions in the full guideline), how to treat these, and when and from whom to seek further advice if required
- Vaccinators should ensure they are familiar with the content of the latest version of the What to expect after your COVID-19 vaccination leaflet given to vaccine recipients.
Thrombosis with thrombocytopenia syndrome
- A rare condition involving serious thromboembolic events accompanied by thrombocytopaenia, has been reported after AstraZeneca vaccination
- Vaccinated individuals should be advised to seek immediate medical attention if they develop new symptoms from around 4 days to 4 weeks after vaccination such as:
- new onset of severe headache, which is getting worse and does not respond to simple painkillers
- an unusual headache that seems worse when lying down or bending over, or may be accompanied by blurred vision, nausea and vomiting, difficulty with speech, weakness, drowsiness, confusion, or seizures
- new onset of unexplained pinprick bruising or bleeding
- shortness of breath, chest pain, leg swelling, or persistent abdominal pain.
Myocarditis and pericarditis
- Worldwide, there have also been recent, rare cases of myocarditis or pericarditis (inflammation of the heart) reported after the Pfizer BioNTech and Moderna COVID-19 vaccines. The reported rate appears to be highest in those under 25 years of age and in males, and after the second dose. Onset is within a few days of vaccination and most cases are mild, recovering within a short time following standard treatment and rest without any sequalae
- Vaccinated individuals should be advised to seek immediate medical attention should they experience new onset of chest pain, shortness of breath, palpitations, or arrhythmias.
Additional advice for recipients
- Vaccine recipients should also be advised that it may take a few weeks for protection from the vaccine to develop and that they should continue to follow advice current at the time regarding practicing social distancing, wearing a facemask, and washing their hands thoroughly and frequently
- Vaccinees should also be advised to follow the current advice on testing and self-isolation if they develop any coronavirus symptoms or undergo regular testing as a health or social care worker. Vaccination will not affect testing. The lateral flow device test detects a different protein of the virus than the one encoded in the vaccine, and the polymerase chain reaction (PCR) test detects different genes of the virus than the one included in the vaccine
- It is not yet known whether vaccination will stop people from catching and passing on the virus and as no vaccine is completely effective, some people may still become infected with COVID-19 despite having been vaccinated (although this should be less severe)
- The vaccine cannot cause COVID-19 infection.
For information on COVID-19 vaccine and clinical trial participants, surveillance of COVID-19 cases in vaccinated individuals, and adverse reactions following vaccination (including reporting adverse reactions), refer to the full guideline.
COVID-19 vaccine contraindications and precautions
COVID-19 vaccine contraindications
- COVID-19 vaccine should not be given to those who have had a previous systemic allergic reaction (including immediate-onset anaphylaxis) to:
- a previous dose of the same COVID-19 vaccine
- any components (excipient) of the vaccine, for example polyethylene glycol (PEG)
- The COVID-19 chapter of the Green Book provides full details about the contraindications and precautions to COVID-19 vaccine. Everyone involved in the COVID-19 vaccination programme should ensure they have read the latest online version of this Green Book chapter so that they are familiar with all the contraindications and precautions to the COVID-19 vaccines. Where there is any doubt as to whether the vaccine can be given, appropriate advice should be sought from the relevant specialist, or from the local immunisation team or health protection team.
Thrombosis and thrombocytopenia
- Thrombocytopenia presents with unusual venous thrombosis, including cerebral venous sinus thrombosis, portal vein thrombosis, and sometimes arterial thrombosis, with low platelet count and high D-dimer measurements. The condition has similarities to heparin-induced thrombocytopenia and thrombosis (HITT or HIT type 2) and patients usually have positive antibody to platelet factor 4. The majority of the events have occurred between 5 and 16 days following vaccination
- Individuals who experience a clotting episode with concomitant thrombocytopaenia following the first dose of AstraZeneca vaccine should be properly assessed. If they are considered to have the reported condition, further vaccination should be deferred until their clotting has completely stabilised, and they should then be considered for a second dose of an alternative product
- Individuals who have received the first dose of AstraZeneca vaccine without developing this rare condition are advised to receive the second dose of the same vaccine at the currently recommended interval. To date, there is no signal of an increased risk of this condition after the second dose and the rate of other reactions is lower at the second dose than after the first dose of this vaccine. Using an alternative product for the second dose is more likely to lead to common side effects.
- PHE’s Information for healthcare professionals on COVID-19 Vaccine AstraZeneca advises that, as a precautionary measure, administration of the AstraZeneca vaccine in patients with a history of heparin-induced thrombocytopenia and thrombosis (HITT or HIT type 2) or cerebral venous sinus thrombosis should only be considered when the benefit outweighs any potential risks
- Extremely rare reports of capillary leak syndrome have been reported after AstraZeneca vaccine in individuals with a prior history of this condition. These individuals may be offered vaccination with an alternative COVID-19 vaccine
The revised contraindications and precautions to the AstraZeneca vaccine, including changes to age group recommendations for this vaccine, are detailed in the COVID-19 chapter of the Green Book
Further detailed information is also available in PHE’sInformation for healthcare professionals on blood clotting following COVID-19 vaccination document and a COVID-19 vaccination and blood clotting leaflet is available for patients.
Minor illnesses at time vaccination due
- Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation
- If an individual is acutely unwell, immunisation may be postponed until they have fully recovered. This is to avoid confusing the differential diagnosis of any acute illness (including COVID-19) by wrongly attributing any signs or symptoms of the illness as being possible reactions to the vaccine.
Vaccination of individuals with a current or previous history of COVID-19 disease
- People currently unwell and experiencing COVID-19 symptoms should not receive COVID-19 vaccine until they have recovered. This is to avoid wrongly attributing any new symptom or the progression of symptoms to the vaccine (and to prevent infecting anyone else in the vaccination centre)
- Vaccination of individuals who may be infected or asymptomatic or incubating COVID-19 infection is unlikely to have a detrimental effect on the illness. Vaccination should be deferred in those with confirmed infection to avoid confusing the differential diagnosis
- As deterioration in some people with COVID-19 can occur up to 2 weeks after infection, ideally vaccination should be deferred until they have recovered and around 4 weeks after onset of symptoms or 4 weeks from the first confirmed positive test in those who are asymptomatic
- There is no evidence of any safety concerns from vaccinating individuals with a past history of COVID-19 infection, or with detectable COVID-19 antibody, so people who have had COVID-19 disease (whether confirmed or suspected) can still receive COVID-19 vaccine
- Children or adults who have tested positive for COVID-19 infection in the previous 28 days and who require other vaccines (such as DTaP/IPV/Hib/HepB-containing vaccines) can receive these vaccines once they have recovered and have completed the required isolation period for COVID-19. If they fulfil these two conditions, they do not have to wait 28 days but the parent/carer who brings them for vaccination would need to ensure they are following current COVID-19 guidance and not attend if they are symptomatic or self-isolating
- Recent vaccination with other vaccines such as MMR and Td/IPV-containing vaccines will not affect testing for COVID-19 infection. The lateral flow device test looks to detect a protein of the SARS-CoV-2 virus and the PCR test looks for genes from the SARS-CoV-2 virus.
Vaccination of people experiencing prolonged COVID-19 symptoms (‘long COVID’)
- Having prolonged COVID-19 symptoms is not a contraindication to receiving COVID-19 vaccine but if the patient is seriously debilitated, still under active investigation, or has evidence of recent deterioration, deferral of vaccination may be considered to avoid incorrect attribution of any change in the person’s underlying condition to the vaccine.
Time interval between treatments for COVID-19 disease (for example dexamethasone, convalescent plasma, monoclonal antibody or antiviral medicines) and vaccine administration
- As the currently authorised COVID-19 vaccines are non-live vaccines, it is not anticipated that dexamethasone, convalescent plasma, or monoclonal antibody treatments would contraindicate the vaccine
- As none of the currently authorised COVID-19 vaccines contain live replicating virus, response to the vaccine will not be affected by prior or recent receipt of anti-viral medication.
Co-administration of COVID-19 vaccine with other inactivated or live vaccines
- First principles would suggest that interference between inactivated vaccines with different antigenic content is likely to be limited
- Based on experience with other vaccines, any potential interference is most likely to result in a slightly attenuated (weaker) immune response to one of the vaccines. There is no evidence of any safety concerns, although it may make the attribution of any adverse events more difficult
- As the Pfizer BioNTech, AstraZanenca, and Moderna COVID-19 vaccines are considered inactivated, where individuals in an eligible cohort present having received another inactivated or live vaccine, COVID-19 vaccination should still be given. The same applies for most other live and inactivated vaccines where COVID-19 vaccination has been received first or where a patient presents requiring two vaccines. It is generally better for vaccination to proceed to avoid any further delay in protection and to avoid the risk of the patient not returning for a later appointment. An exception to this is shingles vaccination, where a 7-day interval should ideally be observed given the potential for an inflammatory response to COVID-19 vaccine to reduce the response to the live virus
- Where co-administration does occur, patients should be informed about the likely timing of potential adverse events relating to each vaccine.
- Although clinical trials on the use of COVID-19 vaccines during pregnancy are not advanced, the available data do not indicate any harm to pregnancy. The JCVI has therefore advised that women who are pregnant should be offered vaccination at the same time as non-pregnant women, based on their age and clinical risk group
- There have been no specific safety concerns from any brand of COVID-19 vaccine in relation to pregnancy but more research is needed and there is more safety data available for the Pfizer BioNTech and Moderna vaccines, which is why these two vaccines are currently the preferred vaccines to offer to pregnant women
- Clinicians should discuss the risks and benefits of vaccination with the woman, who should be told about the limited evidence of safety for the vaccine in pregnancy
- Routine questioning about last menstrual period and/or pregnancy testing is not required before offering COVID-19 vaccine
- Women who are planning pregnancy or in the immediate postpartum can be vaccinated with a suitable product for their age and clinical risk group
- If a woman finds out she is pregnant after she has started a course of COVID-19 vaccine, she may complete vaccination during pregnancy using the same vaccine product (unless contraindicated). Alternatively, vaccination should be offered as soon as possible after pregnancy
- Termination of pregnancy following inadvertent immunisation should not be recommended
- Surveillance of inadvertent administration of COVID-19 vaccines in pregnancy (where the woman did not know she was pregnant at the time of vaccination) is being conducted for the UK by the PHE Immunisation Department. If a pregnant woman is inadvertently given COVID-19 vaccine, from the first day of her last menstrual period to any time in pregnancy, this should be reported to PHE. Women who are inadvertently vaccinated in early pregnancy should be offered the second dose of the same product
- Further information about the safety of COVID-19 vaccines when given in pregnancy is available on the PHE website.
- There is no known risk associated with giving non-live vaccines whilst breastfeeding
- Breastfeeding women may be offered vaccination with any suitable COVID-19 vaccine
- The developmental and health benefits of breastfeeding should be considered along with the woman’s clinical need for immunisation against COVID-19, and at the same time, the woman should be informed about the absence of safety data for the vaccine in breastfeeding women.
For information on adverse reactions, legal aspects of vaccine administration, inadvertent vaccine administration errors, and storage and preparation of the COVID-19 vaccines, refer to the full guideline.
Want to learn more about this guideline?
Read the related Guidelines in Practice article, ‘COVID-19 vaccination programme: practice pointers for primary care’.
Public Health England. COVID-19 vaccination programme: information for healthcare practitioners. Version 3.9. June 2021. Available at: gov.uk/government/publications/covid-19-vaccination-programme-guidance-for-healthcare-practitioners
Contains public sector information licensed under the Open Government Licence v3.0.
Published date: 27 November 2020.
Last updated: 06 July 2021.