A commentary piece published in the Journal of the Royal Society of Medicine addresses the UK’s colour-blind strategy to COVID-19 vaccine allocation.
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I responded previously to the advice from the Joint Committee on Vaccination and Immunisation (JCVI)’s interim advice on Phase 2 of COVID-19 vaccination programme rollout.2 3
I understand and sympathise with the views of the authors of this commentary about prioritising people in BAME groups for vaccination; but, from my experience of running vaccination programmes, I suspect that the marginal benefits that might be available from vaccinating some groups slightly earlier are likely to be outweighed by the problems this would cause.
I fully agree with the authors about addressing the barriers to vaccination that might apply to people from BAME groups.
The Royal Society of Medicine paper makes two main points: that people in Black, Asian and Minority Ethnic (BAME) groups are at higher risk of Covid-19 disease; and that there are issues with access to and confidence in vaccination in such groups. Further, they argue that the more transmissible B.1.1.7 variant which is prevalent in the UK, exacerbates this.
There is now overwhelming evidence, as the authors claim, that people from BAME groups have been disproportionately (more severely) affected by Covid-19 disease. Most, if not all, of the reasons for this are socioeconomic and occupational: the authors describe this well. There is also some evidence that some occupations are more at risk than others.4
Their argument that the B.1.1.7 variant exacerbates this is also likely to be correct (although their claim that it is 30% more deadly is – so far, at least – less well founded in evidence than their claim that it is 70% more transmissible).
Nevertheless, the strongest risk factor – for people in BAME groups, as well as for everybody else – remains age. The older you are, the greater the risk that you will be seriously ill or die if you contract Covid-19; and this age-related variation applies to all ethnic and occupational groups. It is more important to vaccinate 60+ year-old people in BAME groups as a high priority, than to vaccinate younger people in those groups.
It is not clear that the variation in risk associated with BAME or occupational group membership is as high as the variation in risk due to age; nor that there is enough granularity in the data to say that, for example, BAME individuals aged 35-40 should be in the same risk group as 40-45 year olds who are not from BAME groups. That seems to be the implication of implementing the sort of “fair prioritisation strategies and targeted decisions” that the authors are calling for. (I do not think they would prefer low risk BAME individuals to be vaccinated ahead of higher-risk non-BAME individuals – unless, perhaps, the indirect benefits of vaccinate would justify this.)
Given the importance of age as a risk factor, adding membership of BAME and/or occupational groups to the algorithms for vaccine allocation is unlikely – it seems to me – to bring forward vaccination for people in such groups by more than a few weeks; and the authors do not appear to have considered the scale of effect of such “fair prioritisation”.
As I explained in my previous response, the priority is to get those people who are most at risk vaccinated (at least with their first dose of vaccine) as soon as ever possible.2 3
You could generate complicated risk scores taking into account ethnicity and occupation, as well as age. But long experience with delivering vaccination programmes shows that complexity slows things down – quite apart from the arguments that this would likely generate about the evidence base for not putting one group ahead of others. The relatively simple approach of offering vaccination by order of descending age (all databases include date of birth) ensures the fastest rollout of vaccination: that appears to be the explanation for not prioritising BAME and occupational groups (other than health and social care workers).3
Aspiring to fairness is unarguable; but if the effect is small, and the complexity likely cause delays, the harm done by a more complicated approach might well outweigh the benefits.
The authors are correct in their discussion on accessibility, hesitancy, and uptake in BAME groups. There are issues with vaccine acceptance and take-up varying between ethnic groups; and the issues of vaccine hesitancy in minority groups have been much discussed.5 6 It is vital that vaccination is made accessible to everybody; that people’s concerns are heard, and they are, where appropriate, reassured; and that disinformation is corrected appropriately (without reinforcing it, as can happen7). There is a huge literature on addressing vaccine-hesitancy, which one would expect the people organising the vaccination programme to be aware of.5
Vaccination is the safest and most effective way to protect ourselves and those around us from COVID-19, but it is only through high levels of coverage that we can stop the spread of this disease within our communities. Black, Asian and Minority Ethnic groups have been disproportionally affected by the pandemic – we must work together to ensure high vaccine uptake within those communities to prevent exacerbating existing health inequalities.
There are many positive actions we can take to remove the existing barriers to vaccine access and uptake for ethnic minorities. Regular community outreach based on open and transparent communication will pave the way to engage with different communities and set up supportive platforms for listening to questions and addressing concerns about COVID-19 vaccines. Community leaders have a key role in building vaccine confidence within their communities so we must raise those trusted voices and empower them to share reliable information. Accessibility and convenience to vaccination services will also facilitate vaccine uptake so it’s vital to tackle these physical barriers through practical support and adequate funding of immunisation services.
The JCVI have explained at length1 the justification for the initial prioritisation which did consider the increased relative risk of some ethnic minorities (as well as those of certain occupations, from more deprived backgrounds and men.)
They decided that priority should be given to those at highest absolute risk of death (and those working with them in health and social care) as this would save the most lives. Age is by far the biggest risk factor for death, followed by certain co-morbidities.
For example, a 40 year old black African male has a 1 in 20000* risk of death which may be 4 times higher than a 40 year old white male but is much lower than a 60 year old white male who has a 1 in 5000* risk of death.
However, it was also recognised that having a combination of risk factors including ethnicity (not due to genetics or biology as the authors rightly point put, but as a proxy for underlying socioeconomic risk factors); comorbidities and deprivation could increase the absolute risk for younger ethnic minorities. The absolute risk for a black male with, for example, diabetes, obesity and living in a deprived area is 1 in 3000* and so higher than a 60 year old white male without comorbidities.
Therefore the government and NHS2,3 introduced the use of the QCOVID individual risk calculator4 in February which includes ethnicity, deprivation and co-morbidities and this added 800,000 high risk individuals to the priority list for vaccination in cohort 6 which will therefore disproportionately benefit ethnic minorities.
This is the right approach as it takes into account risk factors at the individual level and so all those at high risk from all ethnicities are now being prioritized and should now have been offered vaccination.
I assume the editorial was written before this decision was made which is why it is not referenced but this should now address the authors concerns about prioritisation.
Finally, given the increased risk of infection and death from COVID in most ethnic minorities, it is even more important that we increase vaccine confidence in these communities so they can protect themselves, their families – particularly elderly relatives – and society as a whole. We need to continue working together to build trust and reassure them the vaccines, having been taken by tens of millions of people, are safe and effective and explain that any mild, short-term side-effects are minimal compared to the risk of being admitted to hospital, to intensive care or even dying from COVID.”
*All figures from QCOVID risk calculator (https://qcovid.org/ )