Who gets the vaccine next?

I’m losing track of calls for vaccine priority for one group or another. Teachers, police, this morning port workers – one might logically add the whole food supply chain of 4 or 5 million people. Unpaid carers have been raised (currently in group 6 of phase 1 ahead of 60-64 year olds in group 7).

And while everybody surely agrees with the priority given to health and care workers, some health workers are demanding the second dose on the original schedule. Not something I’m qualified to judge.

Occupational priorities are likely to be part of phase 2 of the rollout. The JCVI statement reads

Vaccination of those at increased risk of exposure to SARS-CoV-2 due to their occupation could also be a priority in the next phase. This could include first responders, the military, those involved in the justice system, teachers, transport workers, and public servants essential to the pandemic response. Priority occupations for vaccination are considered an issue of policy, rather than for JCVI to advise on. JCVI asks that the Department of Health and Social Care consider occupational vaccination in collaboration with other government departments.

The problem is not so much finding people who merit priority vaccination but finding people to move down the queue to make way for them. Two groups do come to mind: 1. People like me who don’t need to go out to work. 2. People who have already had covid-19 and therefore have a good degree of natural immunity. Ireland is reportedly considering this. They have even worse case numbers than the UK and are behind in vaccine rollout. There is some doubt how good natural immunity is but this study of healthcare workers in Newcastle is promising.

And prioritising certain occupations is only one aspect of a more precise risk model that could be used to determine vaccine priority and would doubtless save lives.

What other factors could be used in such a model? Well they start to get controversial. Gender. Ethnicity. Body Mass Index. Socio-economic status. There are both technical and political minefields here. Take Ethnicity: people are on a continuum not in discrete boxes, and there are likely to be heated arguments about whether it is fair to take ethnicity into account at all.

So I can understand the reason for the simple 9 group model used for phase 1. But with case numbers as high as they are, a priority list that more accurately reflects risk would save many lives.

Now a multivariate regression that predicted risk as best we can would be incomprehensible to voters and politicians alike. So here’s the compromise that I would suggest:

Start with your age. Add 8 years if you are male. Add 8 years if you are black or Asian. Subtract 15 years if you don’t have to leave your home to work. Subtract 25 years if you have already had covid. Add 12 years for priority occupation. The result is your ‘effective age’ and determines your vaccine priority.

My numbers are illustrative, the actuaries can correct them, and calculate adjustments for other ethnic groups, health conditions etc.

It would be controversial, but it would save lives. If they can delay second doses in a crisis to save lives, then the government can take a bit of controversy on the chin to save lives.

* Joe Otten was the candidate for Sheffield Heeley in June 2017 and Doncaster North in December 2019 and is a councillor in Sheffield.

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20 Comments

  • Little Jackie Paper 14th Jan '21 - 11:10am

    This just sounds too divisive. Well-intentioned but divisive.

    The best thing now is just to get more centres open and get doses to them. There will come a point where energy spent on segmentation of the population is just making the great the enemy of the good. I’m dubious about 24/7 opening which I suspect is niche. Breadth is the priority now, not segmenting the population.

    One thought. Many years ago my Dad worked on production lines and the public health people did mobile tetanus shots at factories. Is there any reason we can’t do mobile covid immunisation at (say) ports?

  • Little Jackie Paper 14th Jan '21 - 11:19am

    Worth adding too. I believe that some countries are giving vaccines to the working population first. I’m not sure why that is, but probably at least worth watching the experiment.

  • John Marriott 14th Jan '21 - 11:26am

    There are, according to Nick Maserati of LBC, currently 22 million doses of vaccine in the U.K. so, that should sort out those of us in the first four categories. So, quit trying to move the goal posts and GET ON WITH IT!

  • I had thought they might allocate everyone a “COVID age” and vaccinate accordingly, and while it might be divisive, I think for this first phase of the roll-out, it’s not practical because it’s too cumbersome and too much extra work and responsibility for GPs. At least while they are vaccinating people aged 70+.

    I did wonder if there might be a bit of discretion for GPs or hospitals to let some younger, vulnerable patients go a bit earlier, but it would have to be for very restricted reasons, or they’d become overwhelmed with requests from demanding relatives. But I’m thinking of people with life limiting illnesses who deserve a bit of respite for whatever time they have left. You’d also think that vaccinating people who are due to go into hospital for planned procedures would benefit the hospital as much as the individual.

    I recall a discussion on tv a while ago trying to devise a person’s COVID age, which was more about risk assessments for the workplace than a vaccine queue, but that didn’t seem to come to anything.

    Personally, I’d have no qualms about allocating appropriate vaccine points to men and those from black and Asian communities, and am relaxed about doing the same for people in certain professions. But as you say Joe, there are a lot of blurring of categories and quickly becomes a source of contention.

    Perhaps you could delay the vaccinations for those who recently recovered from COVID, but what about those who are still struggling with long COVID?

    What about people who are overweight? Never mind the resentment of the pious healthy, could someone be tempted to gain weight to get an early vaccine?

    As much as I like the idea of a more risk-based approach to vaccine order, I think it would be a distraction if we tried to be too clever about it. Efforts must be focused on increasing the volume of vaccines provided.

    However, I think it would be reasonable for that to include making it as easy as possible for teachers to become vaccinated, so when the time comes, just vaccinate all of the teachers and teaching assistants at a school in one go. The same for vaccinating supermarket staff or postal workers. Additional efforts to ramp up vaccinations in deprived areas should be encouraged, especially when it can reasonably be demonstrated that cramped living standards are contributing towards the spread in those areas.

  • As the current phase of the exercise hopefully reduces the demand on ICU beds the next categories of the needy should become obvious. These will be the ones still filling up our hospitals because of Covid. The data is presumably collected on hospital admission and would provide answers to Joe’s question.

  • Adding layers of complexity to a process that is already under pressure (viz the government’s unwillingness to provide timing/numbers of available yesterday, anecdotal stories of computer go slows over the weekend) is a recipe for chaos. Just because people can design algorithms to prioritise access to a vaccine, whatever the merits of doing so, it doesn’t mean that trying to implement anything like this is practical, not least because of the scale of the task.

  • Graham Jeffs 14th Jan '21 - 2:25pm

    This tedious chuntering about Covid isn’t going to get us anywhere.

    How about taking on board John Pugh’s article. That is something that we ought to be able to do something about. But of course that would require personal effort.

  • I don’t regard discussion of a vaccine strategy as “tedious chuntering” and Joe is right to raise awkward questions about it. But we need some perspective in what is in danger of becoming an overheated discussion in media outlets rather less responsible than this platform. We can applaud the speed of vaccine research and see roll-out as one of the game changers, but it is not the whole story. Another game changer would be putting track and trace in the hands of local public health professionals rather than the unqualified and expensive Deloitte and Serco.

  • Graham Jeffs 14th Jan '21 - 3:56pm

    Wouldn’t do to engage with something we might actually be able to influence, would it?

  • Helen Dudden 14th Jan '21 - 4:12pm

    Lack of foresight and planning is a problem. The use of very expensive private companies, for the children’s boxes, was a very good example.
    I think most of us like value for what we spend.
    So much wasted on Track and Trace. Government must be more accountable.

  • @ John Marriott – ”There are, according to Nick Maserati of LBC, currently 22 million doses of vaccine in the U.K.”

    Yes, I also heard that somewhere (though not on LBC). Unfortunately, it seems the government is being economical with the truth.

    As far as I have been able to gather given the appalling state of our mainstream media that seems to think reporting is the same as recycling government press releases (it’s not!), the ‘22 million doses’ refers to vaccine that has completed the ‘brewing’ process but it still in bulk form.

    After ‘brewing’ each batch must be quality checked by the Medicines and Healthcare products Regulatory Agency (MHRA). Around New Year, I heard one source say this was taking 20 days. Presumably the MHRA got dumped on from a dizzy height – at any rate it’s now said to be just five days.

    Then it has to be put into glass vials for distribution. There is a world shortage of vials (not something anyone could possibly have forecast!!! /sarc). I haven’t heard if the UK has any vial-making capacity nor whether any were purchased in advance.

    There is an (Indian-owned) plant in Wrexham with a reported capacity for filling ~ 6 million vials/week but I haven’t heard whether any capacity has been booked.

    Back in April 2020, as soon as the Oxford-Astra/Zeneca vaccine passed lab tests, the government purchased a reported 100 million doses of vaccine – a sensible risk IMO. But it seems actual manufacture only started when formal MHRA approval came through at the end of December – and then entirely predictable problems came out of the woodwork. ASTONISHING!

    So, questions:
    1. Why were the first, say, 30 million (depends on shelf life) doses already purchased NOT put into production in, say, October? By then the Oxford-Astra/Zeneca vaccine looked a good bet even though formal regulatory approval was not yet given. At ~£2/dose that’s a no-brainer financially.
    2. Which is the rate-limiting step currently? And which becomes rate-limiting if/when that is fixed?
    3. Is it possible to integrate regulatory oversight with production as in the aircraft industry? And if so, why not?
    4. Do we make vials in this country? Were any stockpiled in advance? If not, why not?
    5. Was adequate capacity for vial filling booked in advance?

    Some Parliamentary questions are indicated.

  • Peter Martin 15th Jan '21 - 4:08am

    Probably it would be better to vaccinate the most socially irresponsible persons first. The ones who won’t stick to the rules. Not so much because we need or want to protect them as individuals but because we are protecting the many other people they would otherwise pass their incubated viruses on to.

    But this is a very counter intuitive argument which is going to be impossible to win enough support for.

    So the next best thing is to not worry too much about who gets it first or who should have priority. We just need to get as many people vaccinated as possible and as quickly as possible..

  • “The problem is not so much finding people who merit priority vaccination but finding people to move down the queue to make way for them”

    Absolutely, this is key. Anyone arguing to promote any group higher up the priority list should also clearly state who they are demoting at the same time.

    As a middle-aged (ahem), middle-class, white man who has had Covid, I’ll happily give up my place in the vaccination queue for any of the other groups mentioned, but I’m not sure there are enough like me to make a big difference?

  • Another timely and thoughtful article. You might have mentioned that the UK has vaccinated more people than the entire EU put together 😉

    As others have said, prioritising by risk would likely add an undesirable layer of complexity. Asking people to voluntarily delay until later in the year if they KNOW they have already had the virus would be simple and should speed up vaccination differentially in urban areas with previous high infection rates. The advised criteria could be a positive PCR test AND concurrent symptoms. This would be supported by evidence from the SARS-CoV-2 Immunity and Reinfection EvaluatioN (SIREN) study. Dr. John Campbell provides an analysis of this study and the immunity conferred by previous infection in this video…

    Reinfection rate, very low:
    https://www.youtube.com/watch?v=8UTC9hW_VsA

    Provide 83% protection against reinfection

  • What is the purpose of priority vaccination? Is it to protect the vulnerable, minimise transmission or reduce infection. The situation is dire because of our almost total dependence on it. If we had decent test and trace facilities we could focus on protecting the vulnerable.

  • Peter Hirst 16th Jan ’21 – 12:49pm:
    What is the purpose of priority vaccination?
    In the UK, it appears to be to reduce the number of deaths so restrictions can once again be prematurely relaxed or removed, leaving those yet unvaccinated at even greater risk of infection and being left with life-changing damage to their health.

    If we had decent test and trace facilities we could focus on protecting the vulnerable.
    There are several countries that have successfully used an effective Test, Trace and Isolate (TTI) system to suppress the virus and some which have used TTI to eliminate the virus from community spread, but can you cite an example of one which has successfully used TTI to protect the vulnerable (other than those which have protected their entire population with an elimination strategy)?

  • Peter Martin 17th Jan '21 - 12:05pm

    @ Jeff,

    “Asking people to voluntarily delay until later in the year if they KNOW they have already had the virus would be simple….”

    Good Point.

    I tested positive in early Nov with ultra mild symptoms. I thought it might just be a cold and I nearly didn’t bother getting the test. I suppose I could say I wasn’t totally sure of its accuracy and ask for an antibody test, but I’d be happy to go to the back of the queue once I was.

    Everyone who even thinks they might have had it could be tested too and that would free up supplies of vaccine for those with a greater need to be immunised.

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