Vaccine Q&A: With targets in the balance, what is going on with the rollout?

Decision to recommend an age-based rollout may mask a bolder play to avoid wastage

Confronted by the prospect of hundreds of thousands of vaccines going to waste, the decision was taken to recommend sticking with an age-based rollout. File photograph: Sao Paulo State Government/AFP via Getty Images

Confronted by the prospect of hundreds of thousands of vaccines going to waste, the decision was taken to recommend sticking with an age-based rollout. File photograph: Sao Paulo State Government/AFP via Getty Images

 

Over the May Bank Holiday weekend, those involved in Ireland’s vaccine rollout were scrambling to redraw the programme yet again.

Confronted by the prospect of hundreds of thousands of vaccines going to waste, the decision was taken to recommend sticking with an age-based rollout. Close observers believe this seemingly orthodox approach masks a bolder play to avoid wastage.

With targets in the balance, just what is going on with the vaccine rollout?

The problem

Last week Niac opened up eligibility for the AstraZeneca and Johnson&Johnson (J&J) vaccines to the over 50s. At first this looked like a bonus for the programme. However, with deliveries weighted towards the end of the quarter it was feared many of those eligible for these vaccines could have received a different jab by the time substantial numbers arrived, rendering them useless.

For a time it seemed like the 50- to 59-year-olds might be asked to wait for these vaccines to come in, while Pfizer and Moderna would simultaneously be given to people in their 40s.

However, this was doubly uncomfortable. In addition to varying the simple age-based approach, it also meant they could be caught out by any delays to delivery schedules from AstraZeneca (where delays are rife) and J&J.

The solution

On the face of it the decision doesn’t get rid of the original problem – hundreds of thousands of doses arriving into the State with no readily apparent arms to receive them. This is more of an issue for J&J than AstraZeneca; 71 per cent of J&J deliveries are due in June, while for AstraZeneca large quantities will be allotted as second doses to the hundreds of thousands of people who have received a first shot.

The way out of this, officials believe, is to offer J&J and AstraZeneca to people aged under 50. The view is that this wouldn’t contravene Niac recommendations.

Flexibility

The headline recommendation for both vaccines is clear: they should be offered to the over-50s only. But officials believe there is sufficient cover in Niac letters sent to the chief medical officer (CMO) last month to allow other vaccines to be offered.

On April 29th, Niac wrote that when a two-dose course of an mRNA vaccine is “not a feasible alternative” for people aged from 18-49, the J&J vaccine “can be considered”.

Earlier in April Niac told the CMO that AstraZeneca could be used in adults aged under 60 “where the benefits clearly outweigh the risk… and the person has made an informed decision based on an understanding of the risks and benefits”. The more recent letter, which also included advice on AstraZeneca, doesn’t reiterate this advice, and it’s not clear which takes primacy.

The verdict

Opposition figures say the strategy is clear to see. “It seems to me the HSE are pushing to get as much J&J used as possible, and it seems to me a sensible solution,” says Labour leader Alan Kelly.

It’s a view shared by Sinn Féin’s health spokesman David Cullinane. “Niac have made the recommendation and the Government have accepted that, but there is flexibility in it, and it’s important for the HSE to avail of those flexibilities.”

What could go wrong?

Much depends on interpretation, and not just by those directing the vaccine rollout. Contrary to initial indications, there was no decision made by the Cabinet on Tuesday over the new plan. Given the explicit advice on the use of the two vaccines, and the less precise definitions of when this can be varied, different interpretations may be one to watch out for.

For example, what exactly constitutes “where the benefits clearly outweigh the risk?” And what is a “feasible alternative?” If a person makes an “informed decision” to accept AZ or J&J, is that sufficient in and of itself?

Minister for Health Stephen Donnelly is set to consult with Niac, and the CMO, on the plan. It is not known yet if it would need full Cabinet approval.