DESPITE REPEATED ISSUES with supplies, the vaccination programme has moved through the priority list, and is now focused on those aged over 70 and people with very high risk conditions.

After a rocky start in the first three months, the health service is hoping to significantly ramp up the roll-out in the second quarter of the year.

The government still expects just under one million doses to be delivered in April, 1.25 million in May and 1.68 million in June.

As part of our Reader Q&A series, we have been breaking down the latest developments with vaccines and the roll-out in Ireland, trying to answer as many of your questions as we can.

This week, most of the questions were about how the health service will manage the roll-out of vaccines to those considered to be at very high risk of severe disease. 

IDENTIFYING HIGH RISK GROUPS

The majority of the questions we received from readers related to the recent change in the sequencing list which saw patients with certain very high risk conditions moved up. 

• I understand the government are vaccinating people based on certain medical conditions which makes perfect sense but no one has explained who decides the severity and classification of the disease. There is no database for this information in Ireland so are we leaving this decision up to individual consultants, GPs or HSE administrators? How is this data being assimilated? Should patients contact their GP or consultant to ensure they are not overlooked or is this pointless?
• Who decides between group seven and four of the vaccine roll out. Who will decide who is ‘very high risk’ and who is ‘high risk’?
• Why only now is HSE trying to find who is vulnerable in the community after three months it was known that a vaccine will be available?
• My mother is 90 years old and she is bed-bound. Her medical condition is life threatening and to transport her to a medical centre could exacerbate her condition. How will she get her vaccine?

Last month the Minister for Health announced an update to the vaccine allocation strategy, based on a recommendation from the National Immunisation Advisory Committee (NIAC).

He said based on national and international evidence on underlying conditions that may increase the risk of severe disease or death, NIAC had been able to more comprehensively identify those conditions, to “distinguish between those which place a person at very high or high risk of severe disease if they contract the virus”.

A new ‘Cohort 4′ was created on the priority list; people aged 16-69 who are at very high risk of severe disease.

Here’s the full list of Cohort 4 conditions, with the specific patient criteria for each:

Cancer

• All cancer patients actively receiving (and/or within 6 weeks of receiving) systemic therapy with cytotoxic chemotherapy, targeted therapy, monoclonal antibodies or immunotherapies and radical surgery or radiotherapy for lung or head and neck cancer.
• All patients with advanced/metastatic cancers.

Chronic kidney disease

• Chronic kidney disease, on dialysis, or eGFR 40 Kg/m2.

Chronic neurological disease or condition

• Chronic neurological disease or condition with evolving ventilatory failure (requiring non-invasive ventilation), for example: motor neurone disease, spinal muscular atrophy.

Chronic respiratory disease

• For example: severe cystic fibrosis, severe COPD, severe pulmonary fibrosis.

Diabetes

• Uncontrolled diabetes, for example: HbA1C ≥58mmol/mol.

Immunocompromised

Severe immunocompromise due to disease or treatment, for example:

• Transplantation: Listed for solid organ or haematopoietic stem cell transplant (HSCT), post solid organ transplant at any time, post HSCT within 12 months;
• Genetic diseases: Autoimmune polyendocrinopathy candidiasis ecto- dermal dystrophy, inborn errors in the interferon pathway;
• Treatment:  Included but not limited to Cyclophosphamide, Rituximab, Alemtuzumab, Cladribine or Ocrelizumab in the last 6 months.

Inherited metabolic diseases

• Disorders of intermediary metabolism/at risk of acute decompensation, for example: Maple Syrup Urine Disease.

Intellectual disability

• Down Syndrome.

Obesity

• BMI >40 Kg/m2.

Sickle cell disease

There is still another group, lower down on the list, of at risk groups. Those aged 18-64 who are considered at high risk – rather than at very high risk – are in Cohort 7. A full list of conditions covered in this cohort can be found here.

How they’re identified

HSE CEO Paul Reid has said due to the very high risk conditions captured in the recommendation from NIAC, it is assumed that the majority of the most at risk will be under the care or treatment of hospitals.

From initial feedback from the hospitals and community services, the HSE estimates there are around 150,000 people in this group.

Hospital groups have been asked to identify the relative populations based on definitions provided and they will then contact them. There will also be some input at a later stage from GPs, where patients are not in regular contact with a hospital, such as those with certain categories of diabetes.

The vaccination process for this cohort has already started and next week up to 20,000 people in this very high risk group are due to receive their first dose.

When asked by TheJournal.ie this week why work to identify high risk groups was not started earlier, HSE Chief Clinical Officer Dr Colm Henry said NIAC’s original document in December had a broad description and it was not until it issued its recent recommendation that it “mined much deeper into this group of people”.

“They decided to look at each of those 13 conditions and decide, in those conditions, what are the clinical criteria that would put people at very high risk,” he said.

“So the most recent document – instead of describing generally people who are high risk, because they have diabetes, or because [of] their lung disease or because they have Cystic Fibrosis – is much more specific.

For example, the timing of cancer treatment, whether it’s active, or whether it’s within six weeks; it talks about immunosuppression, in terms of specific medication; it talks about kidney disease very specifically in terms of whether you’re on dialysis, or whether you have what’s called a GFR – that’s a measure of severity of renal failure of less than 15. So the criteria that came out in the most recent documents were much more specific.

Officials expect the vaccination of this group to continue through March and April and the vaccinations will be administered in whichever setting is believed to be best for the patient. In many cases, this will be in the hospital where they receive treatment, though some may be able to go to vaccination centres. 

Home-bound patients

The HSE has estimated there are up to 1,500 people aged over 70 who are home-bound. 

Trained National Ambulance Service vaccinators will deliver the vaccines in people’s homes. 

HSE CCO Dr Colm Henry said rather than differentiate between age groups, moving down from those aged over 85, to those aged over 80, then those aged 75+ and so on, the entire group will be done in parallel.

“We’re going to approach them as an entire entity, because of the numbers and because of the way the vaccine has been constituted, the ambulance service will have to plan for five, six or seven based on one vial and try to deal with it geographically,” he explained.

He said this will start in north Leinster this week, rolling out across the country in the following weeks. 

PRIORITY LIST

The recent changes to the vaccination sequencing list have caused some confusion, with some readers saying they are now unclear about when they might get their vaccine:

• When are the over 70s going to get their first vaccination. I am a 74-year-old widow, living alone. On receiving chemotherapy my lungs were damaged and I am now and have been for three years now on oxygen 24/7. I would imagine I am a priority case?
• In relation to teachers, I would like to know approximately when can we expect to get the Covid-19 vaccine.

Although the vaccination of the ‘very high risk’ category has started now, this does not mean the roll-out to the over 70s has paused – this is continuing. Almost all over 85s have now been vaccinated and the programme will move down through the age groups with those aged 80-84 next, then people aged 75-79 and so on. 

The HSE has said there is some flexibility within this. For example, if the 80-year-old spouse of an 85-year-old person accompanies them to get their vaccine, they can also be given the vaccine if the GP surgery has enough supplies.

Additionally, some GP surgeries only have small numbers of patients in this cohort on their books. If this is the case, in order to avoid wasting doses, they may vaccinate all of their over 70s in a short period of time, ahead of the wider national schedule. 

A significant portion of next week’s vaccine doses will be given to people in the over 70 cohort, which is Cohort 3. 

In relation to teachers, those working in education are part of Cohort 11. There is no date set out for the start of the roll-out to this particular cohort, but there are a number of large groups in society ahead of it. 

Here’s what the sequencing list looks like, following the recent change in relation to high risk groups:

Cohort 1: Residents of long-term care facilities who are aged over 65.

Cohort 2: Frontline healthcare workers in direct patient contact.

Cohort 3: Those aged over 70.

Cohort 4: People aged 16-69 and at very high risk of severe Covid-19 disease.

Cohort 5: Those aged 65-69 and at high risk of severe Covid-19 disease.

Cohort 6: All others aged 65-69, other healthcare workers not in direct patient contact and workers key to the vaccination programme (these will all be done in parallel).

Cohort 7: Those aged 16-64 and at high risk of severe Covid-19 disease.

Cohort 8: Residents of long-term care facilities aged 18-64.

Cohort 9: People aged 18-64 living or working in crowded accommodation, where self-isolation/social distancing is difficult to maintain.

Cohort 10: Key workers who cannot avoid high risk of exposure such as those in food supply and public transport.

Cohort 11: Those who are essential to education, such as teachers, SNAs and childcare workers.

Cohort 12: People aged 55-64.

Cohort 13: Those in occupations important to the functioning of society, such as lecturers and people in entertainment and goods producing industries. 

Cohort 14: People aged 18-54 who did not have access to the vaccine in prior phases.

Cohort 15: If evidence demonstrates safety and efficacy, children and pregnant women (note there is specific guidance for pregnant women).

VACCINES AND LIFTING RESTRICTIONS

Several readers are looking for the light at the end of the tunnel, wondering whether this roll-out of vaccines will mean an easing of restrictions, allowing people to move around more and mix.

• Is our opening of society solely dependant on vaccinations?
• If there’s an acceleration on vaccines (both supply and administrations) will there be an acceleration to open society?
• We had a three-week camping trip booked for France at the end of June, I accept that this will not happen now. My question is, when will the campsites in Ireland be allowed to open? I would hope that once the high risk groups are vaccinated the country can move out of restrictions or is that a very simplistic view?

There are a number of criteria that are considered when public health officials and the government consider potential easing of restrictions. These include familiar factors such as hospitalisation and ICU numbers and the rate of transmission in the community. But the success of the vaccination programme will also be key to any relaxation of restrictions.

In the US, the Center for Disease Control and Prevention (CDC) has said people who are fully vaccinated can gather indoors with other vaccinated people, without wearing a mask or social distancing.

The recommendations also say vaccinated people can come together in the same way — in a single household — with people considered at low risk for severe disease, such as in the case of vaccinated grandparents visiting healthy children and grandchildren.

CDC director Dr Rochelle Walensky called the guidance a “first step” towards restoring normality in how people come together.

She said more activities would be cleared for vaccinated individuals once caseloads and deaths decline, more Americans are vaccinated, and as more science emerges on the ability of those who have been vaccinated to get and spread the virus.

In Ireland, we saw the first movement on restrictions linked to vaccinations this week, with the announcement that nursing home residents will be able to receive more regular visits from 22 March. Health officials have said there is a clear link between the low levels of disease in these settings currently and the vaccination of residents that has been taking place since the start of the year.

Residents will be able to have two visits per week if 80% of residents and staff at the nursing home have been vaccinated. There is no requirement to limit these visits to under an hour.

Ultimately, having the majority of the population vaccinated will be a significant factor in a return to ‘normal’. In the shorter-term, as we approach the 5 April deadline set by the government to assess the situation and the restrictions in place, the vaccination programme will not impact on those decisions.

Any easing will still depend on a significant reduction in transmission levels and hospital numbers.

Speaking earlier this week, Tánaiste Leo Varadkar said some measures that might be on the table in April are further outdoor activities like non-contact sports, a change to the 5km rule and the wider return of construction work. But any wider re-opening of society is a long way off.

“We want to get to the point where this is a virus that we can live with, that it’s like the flu – it’s there but it doesn’t force us to close down our country,” he told Galway Bay FM. “And that prospect is definitely there for this year. We could be there this summer, we could be there this autumn.

“But there are things we just don’t know. Among things we just don’t know is how long does your immunity last for after you get the vaccine? And also to what extent could the virus evolve to outwit the vaccines and become resistant to the vaccine.

“So there is a concern in the scientific community and the government would share this, that we can’t relate problems next winter, because not only could Covid come back next winter, there’s also all the other respiratory viruses.”