When the government reaches its “phase one” target of vaccinating people over the age of 50, it will have to determine how to prioritise everyone else.
It’s a wide scope, with official directives currently classing that category as simply “the rest of the population” after the priority groups that precede it.
It will not include anyone who is clinically vulnerable, who will have already been prioritised in earlier groups by age and severity of condition. However, there is mounting data that factors such as an individual’s ethnicity, profession and age can still disproportionately affect their risk of contracting the disease.
Earlier this month, health minister Nadhim Zahawi suggested the Joint Committee on Vaccination and Immunisation (JCVI) was considering whether Black and Asian people, and people in higher-risk professions, should be prioritised.
He said: “The JCVI [...] came down very clearly on the side of age as the deciding factor in terms of people’s risk of dying of Covid. This is a race against death hence why we’ve got the nine categories which we are going through and we will continue to do so.”
He added: “I certainly think it would be wrong to change the JCVI recommendation because [groups] 1 to 9 [account for] 99% of mortality. I think when we get into phase two then we would welcome a debate and of course ask the question of the JCVI as to whether professions like teachers, like shop workers, like police officers, who though their work will come into contact with much greater volumes of the virus than others do, and they will then advise us accordingly.”
Phase one is due to be complete by May. The JCVI convened on Tuesday to discuss who should get the vaccine after everyone in the top nine groups has had it. We asked an expert who might be prioritised next.
Dr Laurence Roope, a senior researcher at Oxford University, told HuffPost UK the country will have reached a fork in the road once its elder and more vulnerable population has been vaccinated.
He said: “Now the JCVI will have to decide whether to continue to go further down that age-based approach.”
Up to now, age has been the outstanding factor predicting who is at highest risk of dying of the disease. Though there is evidence that Covid-19 can cause death and severe illness in children, this is extremely rare, the Royal College of Paediatrics and Child Health has stated.
Asked who would be next to be vaccinated after the top nine priority groups, JCVI member Professor Adam Finn told BBC Breakfast: “We’re very focused on the evidence of who’s at the highest risk and at the moment the outstanding factor predicting that is still age.”
But he acknowledged that difficult choices were on their way. “That discussion is ongoing at the moment,” he said, “and of course it goes beyond just medicine and public health as to who society values most and who they think are most important.”
Dr Roope believes once the top nine groups have been vaccinated, the JCVI may begin looking more closely at other factors – including that of ethnicity.
All ethnic minority groups had a higher risk of dying with Covid-19 than white people in the first wave, according to a study of 28.9m people in private households in England.
People from Bangladeshi and Pakistani backgrounds have continued to experience an “alarming” higher risk of dying with coronavirus throughout both waves of the pandemic, and in the second wave, people from Black ethnic groups experienced a similar risk, researchers have found.
A higher proportion of Pakistani and Bangladeshi men work as taxi drivers, shopkeepers and proprietors than any other ethnic background – occupations that all mean frequent exposure to the public and therefore a higher likelihood of catching coronavirus.
Occupation and income
Data released by the Office for National Statistics (ONS) last month showed that men working in process plants, as security guards or as chefs had some of the highest Covid-19 death rates in 2020.
Plant workers recorded a rate of 143.2 deaths per 100,000 males, compared with a rate of 31.4 among men of the same age in the wider population.
For security guards and related occupations the figure stood at 100.7 deaths per 100,000 males. Taxi and bus drivers also saw high death rates.
Among female workers, some of the highest Covid-19 death rates were for jobs involving assembly lines and routine machine operations, such as sewing machinists, as well as care workers and home carers.
Dr Roope said: “It’s always the most disadvantaged families that suffer the most from these things. I think choosing certain occupations has the potential to reduce some of these inequalities.”
The overlap of coronavirus risk in terms of ethnicity and those in lower paid occupations suggests vaccines for this sector of society is a win-win situation.
Dr Roope said: “Although you’re not explicitly targeting someone due to a particular kind of co-morbidity, you are nevertheless targeting groups that are likely to be somewhat at risk and also who are suffering economically – you can help them to do their jobs safely which can help them in both ways.
“We can try to directly tackle inequalities by going out of our way to try and vaccinate people on lower incomes.”
Once schools reopen, this will inevitably lead to an increase of contacts between children from different households, their parents and teachers. Those teachers who are vulnerable in any way will have already received the jab as part of the nine categories of phase one.
While there is no real compelling evidence that teachers are at any particularly higher risk of contracting the virus than the working age population, moving them up the list could allow schools to open safely and smoothly, with less staff sickness and potentially less transmission.
Dr Roope said: “If we can do something that enables us all to feel happier about our children going back to school, that’s going to be a huge advantage for children – particularly those who are missing out from less advantaged backgrounds. But also to parents who are finding it extremely difficult to balance their own work with also schooling their children.”
Labour and dozens of school leaders have urged the government to vaccinate all teachers as classrooms prepare to reopen from March.
This month 135 headteachers, mostly from independent schools, signed a letter calling for staff from all educational settings to be vaccinated. The letter said: “The emotional and social wellbeing of young people is a significant concern to us, and every day we see the need for pupils to be in school; with each hour that passes, the need to be back with their peers and teachers grows stronger.”
But International Development Secretary Liz Truss has argued that vaccinating teachers could leave other vulnerable groups at risk.
Police and firefighters
Dr Roope, who is a contributing author into a study of public preferences for the coronavirus vaccine in 13 countries (including the UK) found that there was broad support across the sample for police forces and firefighters to receive the jab.
He said: “The argument for police and firefighters is perhaps a little bit more about protecting critical infrastructure of the country in a sense and also these are obviously not jobs that can be done from home. The security of the country is at stake in many ways if we don’t have a well-functioning police and firefighting force.”
These professions were rated almost as highly by the public as health and social care roles, as were those working in water and electricity services, showing a drive to protect central infrastructure.
Dr Roope said: “The thing striking about it was that the preferences were similar across all countries. Within each country there was a remarkable consistency in age – older and younger people broadly had the same preferences – they both supported older people getting it, low income and key workers. Most surprisingly of all, the preferences were stable across the left and the right, which of course is something we haven’t seen in attitudes to lockdown. It is interesting that the public seems to agree on something when it comes to vaccine priorities.”
The impact of vaccines on transmission is still largely a grey area, with two key PHE studies on the matter not due until next month. The Times has reported a separate study which has found lower rates of asymptomatic infection in healthcare workers who have been vaccinated, which was interpreted as a key sign that jabs are reducing transmission.
Dr Roope said: “Certainly after offering the vaccination to the most vulnerable people, you are trying to vaccinate people who are at most risk of catching on and passing on the virus [...] – it seems like quite a logical thing to do.
“We still need a lot of evidence to what extent the different vaccines do reduce transmission, but it’s likely that they do to some extent. It might be that if we’re targeting young and healthy people – those people who are doing jobs that bring them into close contact with the public – that might be a good way to go too, rather than necessarily someone who can easily do their work from home and is unlikely to be out socialising.”
Studies have found that people from South Asian groups are more likely to live in deprived areas and in large, multigenerational households and there have been calls for all members of such households to be vaccinated at the same time.
In France, the final phase of vaccinations, due to begin in spring, will encompass those living in confined quarters.
What else have other countries done?
French health minister Olivier Veran said priority will be given to professionals “on the front line” in essential sectors such as security, education or food, “vulnerable and insecure people and the professionals who take care of them”, and those in confined living quarters before proceeding with the rest of the adult population.
Spain had planned to prioritise the jab by age, starting from the oldest and finishing with the youngest, but priority will now be given to those deemed to be at a higher risk of contracting the virus – including day-care workers, physiotherapists, police, firefighters and teachers.
In Canada, essential workers who can’t do their jobs from home have been moved up into the second stage of the national vaccination programme, bumping health workers with lower-risk jobs down. This stage is due to begin in the spring and, as is being considered in the UK, will take in those who are from ethnic groups disproportionately affected by the virus, first responders, caregivers, and staff working in homeless shelters, prisons and migrant worker quarters.
Israel is unanimously seen as being the country with the most advanced vaccination programme worldwide, delivering the first shots of the Pfizer-BioNTech vaccine to more than 1.5m people in just over two weeks – almost 20% of the population and more than 70% of citizens aged 60 or older. Also on the priority list were pregnant women, anyone with clinical vulnerabilities and some emergency workers.
During this stage of the drive, many younger people were also vaccinated, with centres offering the vaccine to walk-ins outside the high-risk cohort at the end of the day to avoid thawed doses going to waste.
According to Israeli media, the next phase will see teachers, individuals hospitalised for mental health reasons, then soldiers, then the rest of the population.