The Joint Committee on Vaccination and Immunisation (JCVI) has advised that the first priorities for any COVID-19 vaccination programme should be the prevention of COVID-19 mortality and the protection of health and social care staff and systems. Secondary priorities could include vaccination of those at increased risk of hospitalisation and at increased risk of exposure, and to maintain resilience in essential public services.
The committee has reviewed unpublished Phase 1, 2 and 3 safety and efficacy data for the Pfizer/BioNTech mRNA vaccine and will issue a further update following consideration of Phase 3 safety and efficacy data on other COVID-19 vaccines.
Current advice has been developed based on:
- a review of UK epidemiological data on the impact of the COVID-19 pandemic so far1
- data on demographic and clinical risk factors for mortality and hospitalisation from COVID-192,3
- data on occupational exposure4,5,6,7
- a review on vaccine inequalities associated with COVID-198
- Phase 1, 2 and 3 data on the Pfizer/BioNTech mRNA vaccine and headline phase III results on the AstraZeneca vaccine, Phase 1 and 2 data on other developmental COVID-19 vaccines 9-18
- mathematical modelling on the potential impact of different vaccination programmes19
As the risk of mortality from COVID-19 increases with age, prioritisation is primarily based on age. The order of priority for each group in the population corresponds with data on the number of individuals who would need to be vaccinated to prevent one death, estimated from UK data obtained from March to June 20203.
This priority list is as follows:
- residents in a care home for older adults and their carers
- all those 80 years of age and over and frontline health and social care workers
- all those 75 years of age and over
- all those 70 years of age and over and clinically extremely vulnerable individuals
- all those 65 years of age and over
- all individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
- all those 60 years of age and over
- all those 55 years of age and over
- all those 50 years of age and over
It is estimated that taken together, these groups represent around 99% of preventable mortality from COVID-19. JCVI advises that implementation of the COVID-19 vaccine programme should aim to achieve high vaccine uptake. An age-based programme will likely result in faster delivery and better uptake in those at the highest risk. Implementation should also involve flexibility in vaccine deployment at a local level with due attention to:
- mitigating health inequalities, such as might occur in relation to access to healthcare and ethnicity
- vaccine product storage, transport and administration constraints
- exceptional individualised circumstances
- availability of suitable approved vaccines, for example for specific age cohorts.
There are many considerations, including direct protection versus transmission reduction, age, residents in care homes and health and social care workers.
Underlying health conditions
There is good evidence that certain underlying health conditions increase the risk of morbidity and mortality from COVID-19. When compared to persons without underlying health conditions, the absolute increased risk in those with underlying health conditions is considered generally to be lower than the increased risk in persons over the age of 65 years (with the exception of the clinically extremely vulnerable).
The committee’s advice is to offer vaccination to those aged 65 years and over followed by those in clinical risk groups aged 16 years and over.
The risk groups identified by the committee are set out below:
- chronic respiratory disease, including chronic obstructive pulmonary disease (COPD), cystic fibrosis and severe asthma
- chronic heart disease (and vascular disease)
- chronic kidney disease
- chronic liver disease
- chronic neurological disease including epilepsy
- Down’s syndrome
- severe and profound learning disability
- solid organ, bone marrow and stem cell transplant recipients
- people with specific cancers
- immunosuppression due to disease or treatment
- asplenia and splenic dysfunction
- morbid obesity
- severe mental illness.
Individuals within these risk groups who are clinically extremely vulnerable should be discussed separately.
The next phase
As the first phase of the programme is rolled out in the UK, additional data will become available on the safety and effectiveness of COVID-19 vaccines. These data will provide the basis for consideration of vaccination in groups that are at lower risk of mortality from COVID-19.
The committee is currently of the view that the key focus for the second phase of vaccination could be on further preventing hospitalisation.
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
- transport workers
- 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 is asking that Department of Health and Social Care (DHSC) consider occupational vaccination in collaboration with other government departments.
Wider use of COVID-19 vaccines will provide a better understanding of whether they can prevent infection and onward transmission in the population. Data on vaccine impact on transmission, along with data on vaccine safety and effectiveness, will potentially allow for consideration of vaccination across the rest of the population.
As trials in children and pregnant women are completed, a better understanding will be gained of the safety and effectiveness of the vaccines in these persons.
2 Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020 Aug;584(7821):430-436.
3 Clift AK, Coupland CAC, Keogh RH et al. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. BMJ. 2020 Oct 20;371:m3731.
4 Coronavirus (COVID-19) related deaths by occupation, before and during lockdown, England and Wales: deaths registered between 9 March and 30 June 2020, Office for National Statistics
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