Health workers at risk, older adults and residents of long-term care facilities to be prioritized for COVID-19 vaccination
Select categories of health workers, older adults and residents of long-term care facilities should be prioritized for access to COVID-19 vaccines in the context of limited supply. This was recommended by WHO’s European Technical Advisory Group of Experts on Immunization (ETAGE) at its online meeting on 11–12 November 2020.
Preparing for vaccination in the context of limited supply
Accelerated progress in the development and clinical trials of various candidate COVID-19 vaccines has brought the potential global rollout of the first licensed vaccines closer to fruition. With supply expected to be very limited in the initial stage of delivery, all countries must decide who should be vaccinated first to maximize the impact of limited doses in reducing the burden of disease in each country context. ETAGE met to provide countries in the WHO European Region with detailed guidance for making this important decision.
Based on the current understanding of the epidemiology of COVID-19 in the WHO European Region and the findings from modelling studies, ETAGE concurred with the recommendations laid out in the global WHO Strategic Advisory Group of Experts on Immunization (SAGE) Roadmap for prioritizing uses of COVID-19 vaccines in the context of limited supply, and provided more detailed guidance on how to adapt the global recommendations to the context of countries in the WHO European Region.
ETAGE also stressed the important role of independent national immunization technical advisory groups (NITAGs), which will use the global and regional guidance to make specific recommendations for their own countries to facilitate national planning and preparedness for the deployment of COVID-19 vaccines and vaccination.
Recognizing the heterogeneity present within the Region, ETAGE noted that – depending on vaccine availability, disease epidemiology and the size and proportion of each priority group – countries may decide, during the initial stage of immunization, to prioritize more than one group at a time.
All recommendations are also subject to review and revision as additional information and evidence on virus transmission, disease epidemiology and vaccine characteristics and supply become available.
Recommendations
ETAGE provided the following recommendations for countries in the Region:
1) The WHO SAGE Roadmap provides recommendations on prioritizing population groups for different stages of vaccine availability and for different epidemiological settings, namely either no cases, sporadic or clusters of cases, or community transmission. Since it is envisioned that most countries in the Region will experience COVID-19 community transmission for the foreseeable future, ETAGE recommends that NITAGs develop national recommendations applicable to the community transmission setting.
2) ETAGE recommends that NITAGs take into consideration the vaccine supply situation, local epidemiology and the size and proportion of each eligible population group in their country for developing recommendations on prioritizing populations for vaccination. Based on these data they may consider both stages 1a and 1b priorities (below) alongside each other as they make their policy decisions.
3) ETAGE concurs with SAGE recommendations that in the initial stage of very limited vaccine availability (1-10% of national population):
- to maintain the most critical essential services, maximize the impact of available vaccines in reducing severe disease and deaths and in line with the principle of reciprocity, health workers (including care workers in hospitals and long-term care facilities, such as nursing homes and residential facilities) at high and very high risk of acquiring infection, transmitting infection to vulnerable persons with high risk for severe disease outcome or developing severe disease themselves should be prioritized for COVID-19 vaccination (stage 1a);
- to maximize the impact of available vaccines in reducing severe disease and deaths, older adults should be prioritized for COVID-19 vaccination (stage 1b).
Additionally, ETAGE encourages countries to consider including all residents and staff of long-term care facilities for the elderly as a priority group for COVID-19 vaccination in stage 1.
4) ETAGE recommends categorizing health workers as very high risk according to the following criteria:
- Health workers at very high risk of acquiring infection:
- because they undertake aerosol-generating procedures and/or are in direct contact with COVID-19 patients; and
- Health workers considered at very high risk because they can transmit infection to vulnerable persons:
- because they have direct contact with patients that are at high risk for severe disease outcomes from COVID-19 (e.g. patients in intensive care units, patients in oncology wards, patients in older age groups, residents of long-term care facilities).
ETAGE recommends that health workers considered at high risk of developing severe disease, because they are aged ≥60 years or are aged <60 years with an underlying clinical risk factor, should be prioritized for COVID-19 vaccination (stage 1a). The specific age cut-off should be adapted according to local epidemiology.
5) ETAGE recommends that, to maximize the impact of available COVID-19 vaccines in reducing severe disease and deaths, countries should prioritize individuals ≥60 years of age for COVID-19 vaccination. The specific age-related strategy should be designed according to local epidemiology and the size and proportion of each age category. Countries should begin by vaccinating the oldest individuals first who are at the highest risk of severe disease, progressing to younger age categories in this group as sufficient vaccine doses become available.
6) ETAGE concurs with SAGE recommendations that groups with comorbidities determined to be at significantly higher risk of severe disease or death should be further prioritized for COVID-19 vaccination in stage 2 of limited vaccine availability (11-20% of national population).
To further reduce severe disease and deaths, ETAGE recommends that countries should prioritize individuals <60 years of age with the following underlying conditions (as feasible and in no particular order):
- cancer
- chronic cardiac disease
- chronic kidney disease
- chronic liver disease
- chronic respiratory disease
- diabetes
- immunocompromised, including solid organ transplant
- neurological disease, including cerebrovascular disease
- obesity.
The specific age cut-off should be adapted according to local epidemiology. Based on data availability and programmatic feasibility, countries may further define the above comorbidity groups.
