Who should be prioritised for COVID-19 vaccines?

As effective vaccines and preventive medications become available for COVID-19, demand is likely to outstrip supply, so we need to develop a strategy to prioritise their use to ensure maximum public health and societal benefits. Interim advice from the Joint Committee on Vaccination and Immunisation¹ suggests that people older than 65 years of age, those in shielding groups, and health-care workers should be prioritised for vaccination. The advice lacks detail, and it is essential that a plan is developed that takes the growing body of evidence on the effect of comorbidities, occupational, and socioeconomic factors on COVID-19 severity into account.

People living in areas with the highest levels of poverty and lowest levels of educational attainment have the highest rates of hospitalisation and are 1.9 times more likely to die from COVID-19.² Physical crowding, homelessness, poor air quality, and smoke exposure are also associated with poorer outcomes.² The disproportionate impact on minority ethnic groups is clear, and these communities are also more likely to be socioeconomically deprived, live in overcrowded conditions, and hold key worker or high exposure occupations.³

Planning for a culturally competent, transparent, and effective public health campaign is needed to ensure that vaccinations and preventive treatments are taken up in those most at risk of severe disease. Responsible messaging is needed to ensure adequate uptake and avoid stigmatisation and discrimination of disproportionately affected groups. This is critical when vaccines are being developed at an unprecedented rate and trust in safety and efficacy will be key. Previous work has suggested that enthusiasm for a vaccine during a pandemic is highest around the time that it is made available, so a well planned programme with outreach and education is needed to capitalise on this, and it is critical that a strategy is developed now.⁴

We propose a draft schema for prioritisation of vaccines and preventive medications based on our analysis of at-risk groups (appendix). This includes groups at risk of severe infection, including those with non-communicable diseases (eg, diabetes, hypertension, obesity, and cardiovascular disease) that should also be prioritised. High-risk occupational groups including those working in public facing roles, such as those in security and transport should also be included. Socioeconomic factors associated with adverse outcomes in COVID-19 should also be considered, and an effective strategy would include vaccination of those living in overcrowded conditions or in institutions such as care homes. Clinical prediction tools under development could be used to inform further risk stratification.⁵