The UK has met its goal of offering the first dose of COVID-19 for its four main priority groups by mid-February. All people over the age of 70, health professionals and health professionals, care home residents and extremely clinically vulnerable people have been offered a vaccine with more than 15 million people after taking the first dose.
The Joint Vaccination and Immunization Committee (JCVI) strategy has given priority to giving vaccines to those who are likely to die from COVID-19 – predominantly the elderly. It reflects the position of many countries and the World Health Organization (WHO) and has been widely supported so far.
But while age predicts well who will get seriously ill, the relationship is not perfectly linear. In absolute terms, the risk of death under the age of 65 is relatively low. An analysis by the Office for National Statistics released last October found that nearly 90% of deaths from COVID-19 were over 65 years of age.
Nevertheless, JCVI has chosen to prioritize people well below this age threshold. It will continue to move towards age groups until it vaccinates anyone over the age of 50. But whether this is the best strategy – or whether others should start filtering into the order of vaccines – is open to debate.
When deciding how to deploy scarce vaccines – and remember, it will probably take until the fall to vaccinate everyone due to stock constraints – you first need to define the goals of the vaccination program itself. It is estimated that vaccination of the JCVI-favored groups will prevent 99% of deaths from COVID-19 and protect hospitals by reducing admissions.
But while these are obviously important goals, they are not the only ones relevant to the vaccination program. The framework developed by the WHO Strategic Advisory Group of Immunization Experts (Sage) suggests several alternatives. Any of them could be followed for good reason, but each requires compromises as to who is preferred.
Potential strategies diverge
One option would be the strategic distribution of vaccines to maintain basic services. Many U.S. states have already done so by involving key workers in the first phase of vaccination. For example, in Iowa, people over the age of 65 are considered the same priority as emergency services and teachers. This reinforces important services, but could slow down the protection of the elderly.
As is the case in the UK, a 50-year-old official, working from home, will get the vaccine in front of a teacher if the latter is younger, even in just a year. Since most epidemics in schools involve staff members, there is a strong argument that teachers are protected as soon as possible by moving to the queue.
The same principle can be extended beyond the education sector. In the UK, one third of the total workforce is considered key workers (transport staff, food suppliers, emergency services and so on). The risk of exposure to the virus is increased because they cannot work at home, and outbreaks in their workplaces have led to widespread disorders. Vaccination against occupational risk is not only an ethical imperative, but would also be a necessary step to reopen society.
An alternative goal could be to reduce the spread of the virus. This will become increasingly important as mortality falls, as limiting transmission is what will bring an end to the pandemic. Emerging data suggest that vaccines may reduce virus transmission.
Those who live or work in overcrowded areas are at greater risk of infecting and transmitting it, making them major candidates for prioritization if the goal is to slow transmission. Those who are more mobile – such as commuters or more socially active – also pose an increased risk of transmission.
Minimizing the spread of the virus will also reduce the possibility of the emergence of new viral variants, because mutations occur when the virus reproduces. But preventing transmission will be difficult if the intake in these highly related groups is low.
The WHO Sages Framework also specifies that countries’ priority plans should take into account disadvantaged groups. Those with severe learning disabilities are on the current JCVI priority list, but otherwise the British guidelines are ambiguous. Potential health inequalities or exceptional circumstances are presented as an afterthought.
“Group settings”, where many people come into close contact – such as homeless shelters, child and adult protection services and prisons – are not mentioned in the UK’s list of priorities, despite frequent experiences of major epidemics. In contrast, in the U.S. state of Michigan, those who live or work in such places will receive vaccines at the same stage as teachers and first responders in front of other key workers.
People living in poor areas or from ethnic minority backgrounds are also more susceptible to infections. However, the disease often occurs at a younger age in these populations and may remain undiagnosed, meaning that these groups may be overlooked if prioritization is based solely on age or clinical risk.
Locking has also had a disproportionate impact on poor areas: low-income groups make up the majority of the labor force in the hardest hit sectors of the economy, such as retail, catering and private transport. Early vaccination could protect these groups not only from infection but also from socioeconomic devastation.
Ultimately, there is no gold standard method for assigning scarce COVID-19 vaccines. The one we choose to protect first will be the product of selected public health goals and judgments about social value – and cases can be brought for all the groups mentioned. The JCVI age strategy is simple and effective in preventing death and protecting the health system. Nevertheless, a more nuanced strategy offering alternative benefits could be adopted as vaccine introduction progresses.
Vageesh Jain, NIHR Academic Clinical Associate in Public Health Medicine, UCL and Paula Lorgelly, Professor of Health Economics, UCL
This article was published in The Conversation magazine under a Creative Commons license. Read the original article.