February 26, 2021

expert reaction to JCVI interim advice on Phase 2 of COVID-19 vaccination programme rollout

The Joint Committee on Vaccination and Immunisation (JCVI) has issued its interim advice on Phase 2 of the COVID-19 vaccination programme rollout.

Professor Dominic Wilkinson, Dr Jonathan Pugh, Professor Julian Savulescu, Oxford Uehiro Centre for Practical Ethics, As part of the UKRI Ethics Accelerator project, said:

“The announcement of the approach for the second phase of vaccine rollout suggests that the government has chosen simplicity and speed over ethics.

“Phase One of the UK’s vaccine prioritisation strategy focused on saving the most lives possible, based on data suggesting that age is the single greatest risk factor for dying following infection by COVID-19. Phase one was targeted 99% of preventable mortality from COVID-19.

“Prioritising in accordance with age in Phase Two will only continue to be the most effective way of minimizing mortality, if the age-associated mortality risk of 40-49 year olds outweighs other identifiable mortality risk factors. These include occupational risk factors; some professions have greater risk of exposure to the virus.

“But continuing to prioritise in accordance with age has the virtue of practicality, and speed since the necessary infrastructure is already in place from the phase one approach.

Other Values

“Since Phase One of vaccine prioritisation targeted 99% of preventable mortality, it might be argued that other moral values ought to have greater recognition in the second phase. There are other moral reasons to prioritise certain groups for vaccination besides their increased risk of death or severe disease.

“Other countries have prioritised those in occupations that are critical to social infrastructure and the state apparatus, such as the police and firemen. These individuals were in the third group of Germany’s vaccine prioritisation.

“Prioritising certain occupations sooner may also make it possible to relieve certain public health restrictions. Prioritising teachers for vaccination might potentially help to ensure that schools remain open.

Fairness

“Prioritising purely by age in the second wave of vaccination will do little to achieve the aim of mitigating inequalities, an aim that the JCVI explicitly acknowledged in their initial prioritisation guidance.

“Furthermore, it does little to recognise reasons of reciprocity to prioritise those who have put themselves at risk in the pandemic in the course of providing essential services.”

From a member of JCVI: Prof Robert Read, Head of Clinical and Experimental Sciences within Medicine at the University of Southampton, and Director of the NIHR Southampton Biomedical Research Centre, said:

“In Phase 2 the fastest way to protect at-risk groups is to vaccinate down through  the age bands, because ascending age is the greatest risk factor of all.  Starting with the 40-49 year-olds is the quickest way to reduce most of the risk of death and hospitalisation in the population under 50 years of age. We currently have in the UK a well-oiled machine that efficiently calls up people by age – keeping that momentum must be a priority, rather than introduction of more complicated factors such as occupation.”

From a member of JCVI: Prof Anthony Harnden, Deputy Chair of Joint Committee on Vaccination and Immunisation, said:

“All priority setting decisions are difficult. But we know that age is the predominant risk factor for severe Covid. And that the success of the current vaccine rollout has been due to the simplicity. So a fast, easily delivered approach, based on risk of severe disease is the cornerstone of our advice for the continued rollout to the adult population.”

Dr Peter English, Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice Magazine, Immediate past Chair of the BMA Public Health Medicine Committee, said:

“Long experience with delivering vaccine programme tells us that one of the most important criteria for success is the programme’s simplicity. As soon as you introduce complexity, you risk a drop in uptake, or delays in implementing the programme.

“In the case of Covid-19, the strongest correlations with the risk of severe disease are age and certain pre-existing conditions. People with pre-existing conditions have already been prioritised, so the next question is whom to prioritise when we have vaccinated the initial 9 groups identified by the Joint Committee on Vaccination and Immunisation.

“It is true that some occupational groups are at increased risk of disease. Health and social care workers have already been prioritised; but there have been suggestions that different occupational groups should also be prioritised. The problem here is that there are so many occupational groups that can reasonably claim to be at increased risk. There has been a lot of support for, for example, prioritising teachers, as they are unable to avoid contact with others (although a lot of the transmission in education settings seems to be in staff rooms rather than classrooms). But police officers, fire services, others “front-line public sector workers” have their advocates. A refuse collector on BBC Radio 4’s “Any Answers” programme on 30 Jan 2021 pointed out that he and his colleagues touch a lot of refuse bins that have been handled by members of the public, which must increase their risk… We had similar problems during the “fuel crisis” in the early 2000s. Asked to identify key workers, who should have priority for fuel, it soon became apparent that – after the first few days – so many people are “key” that it was almost impossible to identify whom to prioritise; and it was complicated.

“The JCVI’s decision – having already prioritised people with pre-existing conditions and health and social care workers – to prioritise solely by age will no doubt be protested against by groups that perceive themselves at greater risk than others; but it has that great virtue of simplicity. Population and patient databases all include the date of birth, so it will be easy to invite people by age group, without any delays in setting this up, and with minimal risk of argument about whether somebody really is in the occupational category they claim.

“And, to reiterate, the strongest risk factor remains age. An older member of an occupational risk group will be considerable more at risk than a younger member of the same group. And the vaccination programme is progressing very quickly. 

“The decision will, no doubt, disappoint many; but – given the realities and practicalities of running a vaccination call and recall scheme – it is the approach most likely to vaccinate the largest number of people in the shortest time, which has to be our greatest priority at the moment.”

Prof Jonathan Ball, Professor of Molecular Virology, University of Nottingham, said:

“There has been mounting pressure to prioritise groups according to risk of infection – perceived or real – and that seems a reasonable viewpoint. However, we know that these vaccines are good at protecting from serious disease, and the likelihood of that increases with age. Therefore, continuing to target vaccine roll-out according to disease risk makes sense, especially if this simplifies the roll-out process. Hopefully we will still see strong vaccine uptake in those groups less likely to suffer from serious disease, as that will help us towards herd immunity and a future free from large numbers of cases of COVID-19.”

Dr Michael Head, Senior Research Fellow in Global Health, University of Southampton, said:

“The UK vaccine roll-out is going brilliantly, and huge credit needs to go to decision-makers at all levels who have enabled this rapid progress. The speed of the vaccination programme has been helped in part by the relative simplicity of the priority groups. This order of priority has in part been based on clinical vulnerability but predominantly based on age groups. In order to maintain this pace of roll-out, it seems a reasonable decision to continue inviting people for immunisation by age.

“There have been discussions around prioritising other front-line workers, such as teachers. There is of course merit in this idea. However, the downside is how best to rapidly identify those most at risk among different groups of employees across sectors and efficiently offer them the vaccination. For example, do you just prioritise teachers, or also include bus and taxi driver and security staff? If not, then why not and which other job roles do you consider? Where is the dividing line in this risk assessment? It’s not an easy exercise and difficult to get right.

“With such additional complexities, this could simply slow down the roll-out and may delay the point that individuals would be offered the vaccine anyway. Therefore, on balance, I think this approach from the JCVI is the best way forward.”

All our previous output on this subject can be seen at this weblink:

www.sciencemediacentre.org/tag/covid-19

Declared interests

Prof Anthony Harnden: “Deputy Chair of Joint Committee on Vaccination and Immunisation (JCVI).”

Prof Robert Read: “Member of JCVI.”

Dr Peter English: “No conflicts of interest to declare – but I have been involved with the practical implementation of vaccination programmes for over 20 years.”

Dr Michael Head: “No COI.”

None others received.