Who the UK vaccinates next is a question of economics, not health

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More than 7.4 million people in the UK have now received the first dose of a Covid-19 vaccine. The country’s plan to vaccinate the most vulnerable is, remarkably, on track to meet its spring deadline. With a limited supply, the government has had to make tough decisions about who should be first in line to receive the jab. As the first phase of the vaccination programme continues at pace, one question keeps cropping up: who’s next on the list?
The UK’s current vaccination priority list was drawn up with a single goal in mind: preventing as many deaths as possible. That meant vaccinating those carrying the highest risk of mortality from Covid-19, as well as protecting the health and social care staff and systems. The government is aiming to offer a first dose to everybody in the top four priority groups by the middle of February. The rest of the list goes down incrementally in age to those aged 50 and over, and younger people with underlying conditions. All together, these groups are estimated to make up 99 per cent of preventable deaths from Covid-19.

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The question of who to vaccinate next is not so simple. The Joint Committee on Vaccination and Immunisation (JCVI), the group of academics responsible for advising the government on immunisation strategies, says that the focus for the second phase of the vaccine rollout “could be on further preventing hospitalisation”. That’s could, not should. According to the JCVI, that might mean vaccinating those in certain occupations who are at greater risk of being infected, such as teachers, police officers, first responders, the military, transport workers, and so on.
Whether targeting potential superspreaders is an effective measure of controlling the pandemic hinges significantly on whether the vaccine actually stops the virus being passed on – something it hasn’t been proven to do yet. However, early data from Israel does look promising, where they saw a drop of up to 60 per cent in spread of infection in people who had the Pfizer/BioNTech vaccine.
Who will be prioritised for the next phase is something that the committee is still discussing, says Jeremy Brown, professor of respiratory infection at UCL and a member of the JCVI; it will depend on whether the first phase succeeds in preventing deaths. If that is the case, then the second phase will be about preventing hospital admissions. The committee is also considering whether a targeted community vaccination policy could prevent transmission. This hinges on whether they can determine which groups are the mainly transmitting the infection to others, and also if the vaccines do indeed prevent transmission.
Another committee member, Adam Finn, has said that the JCVI had been instructed to come up with a plan by the middle of February to determine the priority order of who should be vaccinated next. A Public Health England spokesperson said the JCVI committee would publish its recommendations for phase two of the vaccination programme “in due course” and would not be drawn further on specific timings. The Scientific Advisory Group for Emergencies (Sage) also couldn’t say when the decision would be made, and that this was an issue for JCVI to lead on, advising that it was “the JCVI’s statutory role and therefore not one for Sage”.

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Ultimately, the question of who to vaccinate next is a political and economic one. The JCVI, says Brown, advises on how best to “improve health” – vaccination to aid opening up the economy is not a health question, he adds.
And when politics and economics gets involved in the pandemic, things tend to go awry. A petition to prioritise teachers, school and childcare staff has received almost 500,000 signatures, leading to the issue being rebuffed during a parliamentary debate. That might be with good cause. Data from the ONS shows that there is no evidence of higher rates of positive coronavirus cases between teachers and other professionals in England.
While age has been by far the biggest factor in the prioritisation strategy, it is not the only factor. Other variables, such as ethnicity, sex, and socioeconomic background, also play a big role in influencing mortality risk. The committee relied on an algorithm, called QCovid, to identify who was most at risk from dying from the virus. But this algorithm, developed by researchers at Oxford University, has its faults, as it is likely to miss some vulnerable people; for example, it may underestimate the risk Covid-19 poses to people with rare diseases, committee members have admitted. With all that in mind, are there swaths of the population that the first phase of the vaccine programme is omitting?
There have been calls for ethnic minority groups to be pushed up the queue, as they have been hit significantly harder by the pandemic. Black, Asian and minority ethnic groups have experienced higher rates of infection, severe illness and mortality throughout the entirety of the pandemic; these groups are estimated to be up to twice as likely to die from Covid-19.

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“It stands to reason that these people should be prioritised for vaccination,” says Mohammad Razai, a scientist at St George’s, University of London. Razai is calling for ethnic minority groups to be pushed to near the top of the vaccine priority list, to as high as people who are over 70 or frontline health care workers. They should be considered clinically extremely vulnerable, he says, as pre-existing health conditions, such as diabetes, high blood pressure and obesity, have been shown to be a major risk factor for mortality from Covid-19, and these are all conditions found in the highest proportion in ethnic minority groups.
Indian, Pakistani, Bangladeshi and black Caribbean individuals are much more likely than white British people to report one or more long-term health problems, including diabetes, blood pressure or heart issues. If they are not to be included in the first phase, he thinks they should at least be prioritised in the second one.
Brown maintains that although there is an increased risk for these groups, “the strength of this effect is much weaker than the effect of age in the older age groups; hence age is the main factor dictating risk prioritisation”. By targeting everyone over the age of 50, or those who have an underlying illness that increases risk, he says that the effects of ethnicity will be covered too, by default. Members of the JCVI have also said that the decision not to prioritise these groups for the first phase was on the basis that “being given early access to a new vaccine may feel like exploitation or experimentation rather than inclusivity” for them. It may risk damaging their trust in the vaccine, for fear they feel they are being used as guinea pigs.
There has also been demand for people with learning disabilities to be prioritised for the next phase, as they are estimated to be four to six times more likely to die from Covid-19. Simon Stevens, the chief of the NHS, recently called for a “legitimate discussion” with the committee on giving new vaccine priority after February 15 to these groups, as only those with “a severe or profound learning disability” have been included in the first wave. Brown maintains that people with learning disabilities “are already covered to a large extent” by the existing vaccin priority system.
Other countries have taken a slightly different tack. In Israel, the current world leader in vaccine rollout speed, the country has started vaccinating teenagers between the ages 16 and 18, with the aim of speeding up their return to school. Some have chosen to prioritise rebooting their economy over reducing mortality rates. Indonesia is skipping the elderly altogether and adopting a ‘youth-first’ strategy: after frontline workers, the country is targeting the younger workforce, those aged between 18 and 59, as they believe it’s their best chance of achieving herd immunity. China is taking the same approach, solely focusing on vaccinating the working population, with the elderly and those with underlying conditions coming after, as the country has decided it most important to keep the economy going.
How the vaccine is allocated is essentially a question of justice, says Julian Savulescu, the director of the Oxford Uehiro Centre for Practical Ethics, a research institute. And there are different approaches to justice: the approach that the government has opted for is bringing about the greatest benefits by maximising the number of lives saved. But that’s only one measure of benefit, he says; you could also aim for saving the greatest numbers of years of life, or the greatest number of quality-adjusted life years.
If the government does decide to let workers such as teachers and police officers go first, one way of making it fairer, Savulescu says, would be to adopt a hybrid strategy: prioritising the individuals from within these groups who are at higher risk: older teachers, for example, or those with pre-existing conditions.
But this complicates things: if we prioritise everyone who has a higher risk of dying than the average population, where do we draw the line? That means prioritising not just the elderly and those with underlying conditions, but also ethnic minority groups and those from lower socioeconomic groups. You could give higher priority to males, as they’re more likely to die than females. Smokers too could, in theory, be bumped up the vaccine queue, like they have in a couple of states in the US, because they’re also more at risk of dying.
“There is no right vaccination strategy; there are a number of different justifiable strategies,” Savulescu says. If he was calling the shots, Savulescu would opt for the Dutch approach, which he says is the most fair. In the Netherlands, everyone over the age of 60 has an equal chance of receiving the vaccine – in essence, it’s a lottery. That means fewer lives would be saved, but it “also gives some weight to fairness,” he says.
Grace Browne is a science writer at WIRED. She tweets from @gracefbrowne
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