To jab or not to jab: skewed Covid vaccination priorities and problems

Andrew Watterson asks who judged who to jab and why in Scotland, and with what effect.

Vaccination policies to protect various groups in the population in Scotland – including its workforce from Covid and its variants – have raised many questions over the last twelve months. These involve medical, scientific, public health, political and legal considerations, vaccine budgets and supply, ethics as well as what is practical and effective. Global issues too may impact directly on public health and workers in Scotland. The World Health Organisation (WHO) mantra of ‘no one is safe from Covid until everyone is safe (with vaccinations)’ remains as true in late 2021 as it did before. Scotland does not fully control its own borders and cannot currently prevent travel into it from countries and areas where new Covid variants continue to emerge. The border problems present pressing needs to offer new or reformulated vaccines to continue to protect the population in Scotland.

This article explores what Covid vaccination priority policies should be for workers in Scotland and the communities in which they live. It challenges the view that there are substantial limits on many actions the Scottish Government could take to protect those workers and their communities. It also challenges the view Scotland has always been wise to accept the blanket advice of the UK’s Joint Committee on Vaccination and Immunisation (JCVI) and that such advice reflected an international consensus on vaccine prioritisation because it did not. The Westminster Government is legally obliged to follow JCVI recommendations for England but the Scottish Government is not. The Scottish Government paradoxically produced a very detailed prioritisation matrix for a whole range of key worker groups to be tested for Covid in May 2020 that has been regularly updated yet still simply repeated JCVI advice on vaccine prioritisation with blunt tool of age used to argue all workers will eventually be vaccinated anyway.

Many arguments were put in the Lancet and British Medical Journal in 2020 for a re-ordering of UK and Scottish vaccination priorities to protect society at large, public health and worker health. There has also been a global consensus since late 2020 about the medical, public health and ethical need to prioritise vaccination for older age groups and those in poorest health in the first instance. Vaccine supply sometimes initially meant only these groups could be vaccinated in the UK. However, later priority occupational groups varied a good deal from country to country and diverged from WHO guidelines. Surprisingly, JCVI dithered at an early stage about the need even to vaccinate some key health workers and decided against vaccinations for other groups of workers by using much narrower criteria than the WHO and other European countries.

Across the UK and within Scotland, there has been a perceived lack of transparency about the evidence base used for Covid decision-making and a lack of communication with workers and their organisations. Trust in UK Government Covid policies including vaccination prioritisation has frequently been lacking. It seems occupational health and safety and the related public health consequences for some workers being given low vaccination priority were downplayed and equity was ignored. The position in the WHO, Germany, France and even some US states and federal agencies in 2020 has differed from Scotland’s position at times. This is, perhaps, further evidence of a general UK neglect of occupational health and safety monitoring, inspection, and regulation during and before the pandemic that extended to Scotland where large clusters of early occupational Covid cases occurred in, for example, food production and office workers.

WHO vaccination priorities focussed on workers in its guidelines depending on vaccine supply and aimed at reducing death and disease burdens and social and economic disruption while protecting essential services and maintaining national equity. WHO advised the following when supplies of nationally available Covid-19 vaccines were limited for the general population: If only 1% to 10% of vaccines were available in a country, then health workers at high or very high risk would be vaccinated; if 11% to 20% vaccine availability applied, vaccinators, high priority teachers and school staff would also be vaccinated; if 21%-50% vaccine availability existed, then the following would be vaccinated: low to moderate risk health workers, vaccine producers, high-risk lab staff, other essential workers like police officers, municipal services, child-care providers, agriculture and food workers, miners and food processors, transportation workers, and government workers essential to critical functioning of the state not covered by other categories. The UK had vaccines available for these groups at a relatively early stage but neither England nor Scotland chose to vaccinate school staff, food workers, transport workers, construction workers and police officers despite calls by unions and a number of medical and public health researchers to do so.

In France, by November 2020, the public health, economic and social importance of ensuring early vaccination for a wider group of employees was widely recognised based on workers’ significant public contact. These occupations covered shops, transport, and schools (teachers and other school workers). It further included priority for workers in confined spaces, meat processing workers, construction workers, and migrant workers. The second phase added firefighters and police to the priority list.

Several US states approved school staff vaccination long before most teachers in Scotland would have been covered by the roll out of vaccines on the basis of age. In contrast, the Scottish Government vaccination policy showed a frequent lack of concern about inequalities in health, and protection of what the WHO regarded as ‘key’ workers and vulnerable groups. In Scotland, groups of care workers in community settings and at high risk did not receive early vaccines. At risk construction workers have not been vaccinated. Schools were re-opened during the pandemic but younger school staff were denied vaccines. Some Scottish emergency services at the beginning were denied vaccines. Shop keepers running essential community services were denied vaccines.

Following the second wave, it has looked like younger workers in pubs, clubs and catering establishments who may not yet have been vaccinated would be at greater risk. This was at a time when there was more evidence about the likelihood of precarious and vulnerable workers in deprived communities suffering significant long Covid effects. Serious fault lines in UK and Scottish-specific health and workplace policy making and evidence gathering were exposed. Vaccination, of course, in itself will not end the pandemic but it has an important role to play along with other upstream zero Covid strategies to supress the pandemic.

Dilemmas exist for unions too. Unions argued for collective action to press government, employers, and regulators to raise and apply the best possible Covid health and safety standards available. Many unions like UNITE pressed for vaccines to be made available as a matter of priority to essential and key workers exposed to Covid in the workplace and more widely to all workers. Unions argued for greater efforts to reach those workers and communities that had either been effectively neglected by vaccine programmes, marginalised in siting of vaccine centres or were fearful for good historical reasons of past vaccine policies. Assuming vaccine delivery and vaccine hesitancy problems have been addressed sensitively, unions are now faced with new problems. In the form of workers choosing to refuse vaccination. Employers may well decide that if such workers refuse vaccination and cannot be redeployed to other work, then dismissal will result. This is a matter for employment tribunals and the courts to resolve. If employers do not move or dismiss ‘refusers’, will unions then argue on health and safety grounds that refusers put other employees and the public at risk and so will not work with them? Additionally, if ‘equitable’ vaccine passports are introduced, will unions argue that those who choose not to get vaccinations and hence lack passports, as distinct from those unable to get vaccinations who lack such passports, should not be admitted to clubs, pubs, shops etc where they may put employees at risk of contracting Covid?

Finally, questions will need to be asked by unions about who owns, controls, invests in, markets, and profits from Covid and other related vaccines. Unions would be expected to challenge excessive profiteering and government handouts to pharmaceutical companies. Hence, vaccine development, supply, and availability locks into other important debates now well underway in Scotland. These include ones about just transition, ‘socially useful work’, fair work, employer and governmental accountability and good health and safety at work that should benefits employees and their communities.

At last, there is growing recognition of the threat zoonotic diseases such as Covid now present to global public health, and may do so at any time. The principles and practices of vaccine policy raised by Covid, therefore, need to be, if not resolved, at least more fully addressed in the future to protect public health including all employees but especially precarious and economically-disadvantaged workers. The UK JCVI and the UK Group of Chief Medical Officers should not be the supreme arbiters in the future for pandemic vaccination policies. The Scottish Government has almost formulaically followed the lead of UK decision-makers on some issues in ways that have had serious consequences especially during the early stages of the Covid pandemic.

Future transparency, communication and engagement by the Scottish Government need to reflect best international practice in the future on vaccine prioritisation for workers, drawing – if necessary – upon WHO guidelines. This would reflect the important principles already embedded with the Fair Work Convention established by Scottish Government. It would further recognise the fact that although occupational health and safety is reserved to Westminster, the pandemic has opened up the topic and provided the Scottish Government with the means to act on worker health and safety for public health reasons. Establishing better practice on worker vaccination during this and future pandemics is, therefore, not only possible but vital and necessary.

Andrew Watterson is Professor of Health in the Occupational and Environmental Health and Public Health and Population Health research groups at the University of Stirling.

Useful references
Connexion ‘France sets out future Covid-19 vaccine priority plan’, 27 November 2020
Hassan-Smith, Z., Hanif, W. and Khunti, K. ‘Who should be prioritised for COVID-19 vaccines?’ Lancet 396 Issue 10264: 1732-1733. 28 November 2020.
Committee on Vaccination and Immunisation ‘Independent report: interim advice on priority groups for COVID-19 vaccination’ 18 June 2020.…
National Academies of Sciences, Engineering and Medicine, USA ‘A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus’ October 2020,…
Roope, L., Clarke, P., and Duch, R. ‘Who should get the coronavirus vaccine first? France and the UK have different answers’, 16 November 2020…
Scottish Government ‘COVID Vaccine delivery: Health Secretary’s statement’, 19 November 2020
Watterson, A. ‘Covid-19 vaccine prioritisation in the UK and workers beyond health and social care who may go missing’, 2020
Weaver, M. and Siddique, H. ‘Unions call for frontline UK workers to be prioritised for Covid vaccine’, Guardian 20 November 2020.
WHO ‘SAGE values framework for the allocation and prioritization of COVID-19 vaccination’, 14 September 2020…