Begging for Boosters: Still asthmatic, STILL worried!
After almost a year of being told our underlying condition made us clinically vulnerable to Covid19, asthmatics were dismayed and terrified to learn in early 2021 that they would not qualify for a priority vaccine and would have to wait for their age group as lockdown lifted and virus levels increased. When the JCVI’s interim advice was announced this summer, it seemed they had seen sense and would include everyone eligible for an NHS flu vaccine in the Covid booster roll-out: perhaps to allow a smoother roll-out of Covid boosters and flu vaccines at the same time; perhaps because co-infection with flu could double the fatality rate of Covid so anyone at risk of either should be protected from both; or perhaps because newer studies have shown increased Covid risk for a wider group of asthmatics than those who made the initial Group 6 cut.
But then in September, the day before the booster programme was officially announced, JCVI U-turned on their own interim advice, saying boosters would be for Covid priority groups 1–9 only.
They also slightly changed which asthmatics would or would not be in group six, from their own definition of “severe” to a new definition of “poorly controlled”: still based only on oral steroids or hospital admissions, but with different numbers and time limits. Some asthmatics who were told in February to wait for group 12 (and to stop complaining and wait their turn as they were NOT at risk) have now been identified as being at risk after all; others who had been in a priority group before, and are therefore already at or approaching 6 months since their second dose, now face having no access to a booster at all.
So is this new Group 6 definition the last word on which asthmatics are really at risk from Covid? Is it now time for the rest of us to be “reassured” after all? Sadly not, for some of the same old reasons and some new reasons too:
1) JCVI still ignoring exposure
When most asthmatics were excluded from group 6 in the initial roll-out, the evidence cited was the OpenSafely data from the first wave, as analysed by a July 2020 paper and later by the QCovid algorithm. These studies compared the frequency of various underlying conditions among those who died from Covid, compared to how common those conditions are in the population as a whole. Through careful analysis, these studies corrected for the confounding effects of age, and of some people having multiple underlying conditions. What they could not correct for was the level of Covid infection in different groups. The ‘risk’ in these calculations is the total risk of catching and then dying from Covid, and not the risk of death if infected.
In mathematical terms, Risk = Vulnerability x Exposure. So if two groups, e.g. people with and without asthma, have a similar level of risk, this could mean that both vulnerability and exposure are similar for asthmatics and their healthy peers. But it could mean that their higher vulnerability has been mitigated by extra precautions to limit their exposure. A recent scientific paper has raised similar concerns.
We have seen nothing to suggest that the studies used to decide on the new definition of “poorly controlled asthma”, and to conclude that no other asthmatics are at risk, have overcome this limitation.
In fact, questions have also been raised over the Covid risk assessments used by JCVI to reach their (in)decision about vaccinating under-16s: it seems the Covid hospitalisation and mortality risks in their calculations may have been based on data from a time when Covid levels were far lower, without adjusting for the far higher prevalence of Covid in schools this autumn.
2) JCVI still ignoring long Covid
JCVI ignored the risk of long Covid when they cut the only underlying condition so far linked to higher risk of long Covid from the original group six. Then they ignored the risk of long Covid in children, so the need to vaccinate them seemed less pressing, and vaccines for 12- to- 16-year-olds were given the go-ahead too late for the hundreds of thousands of children infected in maskless classrooms since September. And in reneging on their interim advice for boosters, they have yet again ignored the evidence that people with less severe asthma may survive Covid but are still less likely that their healthy peers to make a full and timely recovery. And yet again, eligibility is based only on risk of death, but then policymakers assume that those who are not eligible are not at high risk of any “adverse outcome” at all, and may as well be left to boost their immunity via infection rather than vaccination.
3) JCVI still refusing to take a precautionary approach
The new criterion of two courses of oral steroids in two years recently is, in fairness, more evidence-based than the previous arbitrary rule of three courses in three months ever: but other studies show asthmatics needing just one course, within the last 6 months to one year, could be at risk. Still other studies show that those whose asthma is only controlled enough to avoid oral steroids and hospital admission because they are taking the very highest doses of steroid inhalers, or multiple other medications, are also at risk.
The criterion of “uncontrolled asthma” requiring oral steroids on average once a year seems like a reasonable middle-ground consensus position across the various studies. But that raises the question: why are they going for the middle ground rather than a more precautionary approach of including all those groups identified as being at higher risk in any of the different studies?
It seems they are balancing the risk of excluding people who are vulnerable, against a risk of including some who may not be. But should those risks be weighed up equally? Is it fair to tell someone who might be at risk that they can’t have a booster just in case they’re actually not at such high risk?
One downside to including more people is the use of further vaccine supplies, when in some countries even the most vulnerable haven’t had even a single dose. But the decision of whether to give boosters has to be made as part of the overall national strategy. If the UK had decided only to give boosters to the very elderly and clinically extremely vulnerable, alongside a “vaccines plus” strategy to control the spread of Covid in the wider population, we would accept that. But instead the strategy is “vaccines or bust”, refusing any further restrictions on the basis that “all the vulnerable” will be boosted, leaving anyone who is vulnerable but ineligible in a very difficult and frightening position. The more a country relies on vaccination alone, the more precautionary they should be in deciding who is eligible for those vaccines. If booster eligibility is being limited due to finite vaccine supply, then we must at least enact “Plan B” now.
4) An “unprecented” two year period
The new criteria appear to be based on evidence from published studies, but there is one major flaw: not all 2-year periods are equal, especially when one is pre-pandemic and the other is during. Two courses of oral steroids in two years should include anyone whose asthma becomes uncontrolled, needing oral steroids, whenever they catch a cold: and it makes sense that those are the asthmatics who are at higher risk from Covid. But since March 2020, with lockdown restrictions plus the extra precautions asthmatics were advised to take to avoid Covid, many of us have avoided all the usual coughs and colds as well.
So the studies say any asthmatics who generally need a course of oral steroids during a normal winter are at risk, but the new rules say that only those who still needed those oral steroids despite lockdown will get a booster.
The new hospital admission criteria are based on the same two-year time period. Should someone who was once admitted to hospital as a baby, but hasn’t needed an inhaler for 20 years, be in a vaccine priority group? Probably not. But should someone who was hospitalised by a cold two years and one month ago, but then avoided a repeat admission during lockdown, now be declared “low risk”? Again, probably not.
And for someone who had a hospital admission as a child, and now has severe asthma requiring high-dose inhaled steroids and more, the old group 6 criteria gave what was probably the right answer (include them), albeit for the wrong reason (hospital years ago rather than medication requirements now).
5) Waning sooner
Finally, the very act of initially identifying more asthmatics as being at risk, has meant that some of us really will be at higher risk now. Some were originally included in group 6, only to be excluded because their last hospital admission or 3-month-long exacerbation fell outside of the chosen 24-month period. Others, excluded from group 6 but unconvinced of the safety of this decision, went to extra efforts to secure an early vaccination through alternative- but still legitimate- means: whether by appealing to their doctor’s clinical judgement, by volunteering for vaccine clinical trials, or by going to vaccine centres at the end of the day in search of a spare dose which could then go into a willing arm instead of going in the bin.
This meant they were protected as lockdown lifted, but now it means they will reach the 6-month mark, where protection has started to fade, with no booster on offer, just as we head into the winter when cold, damp weather and seasonal viruses cause asthmatic lungs to struggle even without the added threat of Covid.
JCVI have said that a decision on boosters for “healthy” under-50s is not needed until the main group 10–12 cohorts approach the 6 month mark. But this means anyone who was vaccinated early yet now finds themselves excluded from groups 1–9 has been designated- without their consent- as the canary in the coal mine for waning immunity in younger adults. We will be the hospital admission statistics which (JCVI will eventually concede) show that under-50s do need boosters after all.
If JCVI were to decide already that boosters will be due after 6 months for under-50s as well, then people who don’t reach the 6-month mark until the new year wouldn’t be lining up for boosters until the new year anyway, but those who hit that worrying milestone earlier wouldn’t be left unprotected in the meantime.
