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by Tom Chivers
Thursday, 4
February 2021
Idea
16:30

Should we be vaccinating young people first?

Prioritising 'quality-adjusted life years' over lives saved would change everything
by Tom Chivers
Should we factor in ‘quality-adjusted life years’ to the vaccine debate? Credit: Getty

We have vaccines. Britain has done that remarkably well. But vaccines alone are not enough: we also need a strategy.

Britain also has one of those, and it’s admirably straightforward: vaccinate healthcare workers, plus the oldest and most vulnerable first, and then work down the age groups.


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There’s a really solid rationale for that. Deaths from Covid are hugely concentrated among older people. Roughly speaking, someone diagnosed with Covid in their 80s is about 10 times as likely to die as someone diagnosed in their 60s, and about 100 times as likely to die as someone diagnosed in their 30s. The over-80s and people in care homes account for about 60% of total deaths in the UK.

But someone pointed out a potential wrinkle to me. In healthcare, most of the time, we don’t assess the value of an intervention by the number of lives saved; we talk about “quality-adjusted life years” saved, or QALYs. This makes sense. In the end, everyone dies; so has a drug “saved a life” if it delays death by a year? Who knows. But a drug that delays death by five years on average is probably better, all else being equal, than one which delays death by one year.

We haven’t really talked about QALYs when we talk about vaccinations, though. The life expectancy of a British citizen at age 80 is about nine years (a bit less for a man, a bit more for a woman). The life expectancy at age 60 is about 24 years. If we naively assume that people who die of Covid are representative of those groups (they won’t be, but hopefully they’re both unrepresentative in the same way), then vaccinating an 80-year-old becomes only about three times as effective as vaccinating a 60-year-old.

When you factor in other considerations — that younger people are more likely to spread the disease, and that the bulk of hospitalisations and intensive-care admissions are among people between 50 and 70 — the initially overwhelming case for vaccinating the elderly first becomes more marginal.

In practice, I don’t think this ought to change the strategy. For one thing, although QALYs lost are more evenly distributed than lives lost, they’re still heavily weighted towards the older age groups. And for another, having a simple, unambiguous system for assigning priority is a good idea — if we were to use some complex algorithm to establish “vulnerability”, it would be open to being gamed, usually by pushier, better-off middle-class people like me (as with special educational needs support in schools, where wealthier parents are more likely to demand and pay for assessment).

And another excellent reason is that it would be simply politically unacceptable. “It’s worth letting 2.5 80-year-olds die to save one 60-year-old,” and “800 people may have died today, but our vaccination strategy saved about 4,000 quality-adjusted life years,” is a very hard message to get across from the podium. It’s just too callous-sounding.

But I think it is an (other) excellent reason to remember that the game isn’t over when we’ve vaccinated the very elderly. Letting the disease rip through the 50-to-70-year-olds once the older groups have been vaccinated might bring those headline figures down, but the number of years of life lost (not to mention the spread and the hospitalisations) will still be awful.

ADDENDUM: It’s worth noting (I discover since writing this) that the JCVI in fact did look at QALYs in its assessment. Thanks to Kevin McConway and Kit Yates for pointing that out.

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Fran Martinez
Fran Martinez
2 years ago

If we were prioritsing
‘quality-adjusted life years’ over ‘saved lives’ we were not doing lockdowns at all.

Interesting, you choose to have this view only when it comes to vaccines and not when you see the whole covid response.

Classic Tom Chivers, seeing the vaccine as the ultimate solution to the ultimate problem that we have only created by thinking that ultimately only Covid-19 matters.

The money spent on lockdowns and vaccines could have been used to increase capacity for hospitals and to fund inter-generational families that needed shielding to protect the elderly.

Dennis Boylon
Dennis Boylon
2 years ago
Reply to  Fran Martinez

How does that make big pharma more powerful and more wealthy. We need vaccines and “health” passports. Line up to get your shot or you get no food. All hail our lord and saviour William Henry Gates III.

Brian Dorsley
Brian Dorsley
2 years ago
Reply to  Dennis Boylon

Yes, I’m concerned that a whole Ministry of Health is going to be set up to control the herd – all for our own good of course.

Elizabeth W
Elizabeth W
2 years ago
Reply to  Fran Martinez

Excellent points Fran. The fear has been instrumental of supporting these so-called vaccines that do not prevent coronavirus and only ‘hopefully’ help in the degree of symptoms. For pete’s sake, we have an immune system. Children and young people do not need this jab.

Malcolm Ripley
Malcolm Ripley
2 years ago

“Letting the disease rip”
That’s the appalling phrase used to attack those who believe in a different approach and not one of them has used the word rip. You should be ashamed of yourself.

Try this phrase :
“Let the diseases pass through a population exactly the same as diseases have always done from the dawn of time” . Let those who are healthy act as the barrier between the disease and the vulnerable. That approach is exactly why we have an immune system that behaves the way it does and why people are social animals. If isolation gave us an evolutionary advantage when combating disease we would all be hermits !

Exposure to the virus itself provides far greater protection and results in immunity against mutations rather than the single spike specific vaccine.

David Uzzaman
David Uzzaman
2 years ago

Most old people who die from COVID die either in their own homes or in care. The hospital beds are occupied by the middle aged. You could therefore make a case for inoculating the 50s to 60s first. This game is practically infinite. Using the same data you can justify selecting any group you like.

Rickard Gardell
Rickard Gardell
2 years ago

About 350 out 12,000 swedish deaths are below 60 years of age. Almost all of these 350 had significant comorbidities. Risk of dying for a healthy 60 and under is pretty much zippo. The sick and vulnerable in this age group would get prioritised with vaccine anyway. The natural immunity in the below 60 is probably quite high now,30-50%??
By mid year when all above 60 are fully vaccinated, the below 60 would be very close to natural immunity anyway so vaccine for that group won’t make much of a difference. A shame that measuring T cell immunity is difficult on an individual level.

Derek M
Derek M
2 years ago

I couldn’t quite figure out the point of this article, given that the author was essentially saying this is my criticism of the strategy but actually it doesn’t change anything, until I got to the last paragraph. The message is, we’re going to vaccinate all these people but actually we still need lockdown. I expect this will be the new message we’re bombarded with, along with the ‘new variants’, we’ll never be allowed to get back to normal.

George Lake
George Lake
2 years ago

Off course we should have vaccinated the young first- they are the future are they not?

By your admission an 80 year old has used up 90% of their life expectancy. Some may linger on for a further 9+ years, but nothing is ever said about the quality of life for those years.

In my experience many of the 80+ Legion are in a near vegetive state, inert, yet luxuriating in the warmth of their excrement filled nappies, and monosyllabic at best. Yes they are technically alive……….but only just.
The classic case of “Lights on but nobody at home”.

We seriously need a national discussion about quality of life, not quantity of life, but I’m not holding my breath.

Joe Blow
Joe Blow
2 years ago
Reply to  George Lake

“In my experience many of the 80+ Legion are in a near vegetive state, inert, yet luxuriating in the warmth of their excrement filled nappies, and monosyllabic at best.”
In your experience? As what? Harold Shipman’s understudy?

George Lake
George Lake
2 years ago
Reply to  Joe Blow

By observation.
Incidentally vulgarity has no place in this forum, so please do not demean yourself.

Joe Blow
Joe Blow
2 years ago
Reply to  George Lake

Neither do unsubstantiated claims: I ask you again… on what ‘experience’ do you base your statement about the 80+ population?

Data?
Prejudice?
wwwDOTbmjDOTcom/content/339/bmj.b4904

George Lake
George Lake
2 years ago
Reply to  Joe Blow

I repeat, by personal observation.

Joe Blow
Joe Blow
2 years ago
Reply to  George Lake

I see. So, you have nothing substantive to go on, and are not aware of the actual data.

George Lake
George Lake
2 years ago
Reply to  Joe Blow

Well what I have observed seems to be backed up ‘official’ research.*

For example, of the 3.2 million over 80’s in the UK, 36% of men & 49% of woman have ‘trouble’ washing, going to the lavatory, eating, dressing etc. Are you perchance one of those unfortunates?

Of the same group about 37% are fully satisfied with their lives! Bravo!

These figures very much mirror my own findings from numerous visits to so called Care Homes, and similar facilities.

So lets hear your data if that is not too much to ask? And do try not be rude, it is so unbecoming, as I’m sure even you agree?

* ageing-better.org

George Lake
George Lake
2 years ago
Reply to  Joe Blow

Well what I have observed seems to be backed up by ‘official’ research.*
For example, of the 3.2 million over 80’s in the UK, 36% of men & 49% of woman have ‘trouble’ washing, defecating, eating, dressing etc. Are you perchance one of those unfortunates?
Of the same group about 37% are fully satisfied with their lives! Bravo!
These figures very much mirror my own findings from numerous visits to so called Care Homes, and similar facilities.
So lets hear your data if that is not too much to ask? And do try not be rude, it is so unbecoming, as I’m sure even you agree?
* ageing-better.org.uk/sit

George Lake
George Lake
2 years ago
Reply to  Joe Blow

This is my third attempt to reply to you, but the Censor seems to horrified by the use of the word used to describe the discharge of faeces from the body! This in 2021. The two earlier attempts were sent 3-4 hours ago!

Well what I have observed seems to be backed up by ‘official’ research.*
For example, of the 3.2 million over 80’s in the UK, 36% of men & 49% of woman have ‘trouble’ washing, dressing, eating, bathing etc. You are not perchance one of those unfortunates?
Of the same group about 37% are fully satisfied with their lives! Bravo!
These figures very much mirror my own findings from numerous visits to so called Care Homes, and other similar facilities.
So lets hear your data if that is not too much to ask? And do try not be rude, it is so unbecoming, as I’m sure even you agree?

*ageing- better uk

LUKE LOZE
LUKE LOZE
2 years ago
Reply to  Joe Blow

Have a vote for the that

Johnny Sutherland
Johnny Sutherland
2 years ago
Reply to  Joe Blow

Well done. Someone proposes a rational discussion and you see if you can block it by using emotion.

Joe Blow
Joe Blow
2 years ago

Asking him upon what experience he bases his claim is hardly emotional diversion.

George Lake
George Lake
2 years ago
Reply to  Joe Blow

No, I agree, but the language was unusually rude, which makes me suspect you are an aged, ill-bred toad. Am I correct?

Joe Blow
Joe Blow
2 years ago
Reply to  George Lake

Neither my parents, nor the species I might be, have any relevance to your ignorance of the data.

LUKE LOZE
LUKE LOZE
2 years ago

If it was meant to be rational it’s basically writing off 80 years olds as not worth saving – so I hope it was at least meant to be funny.

LUKE LOZE
LUKE LOZE
2 years ago
Reply to  George Lake

We do need a more serious discussion about quality of life. If for example we spend 100k per person on their treatment whilst dying – I’d rather live months less with good care and attention, than be treated badly by stretched carers but receive lots of intrusive medical treatments.

The problem is there’s plenty of very healthy 85 year olds with 20+ years of reasonable life left. There’s no easy one size fits all solution.

George Lake
George Lake
2 years ago
Reply to  LUKE LOZE

Agreed, but I would like to know how many ” very healthy 85 year olds” there are.
In my experience not many could be described as ‘fighting fit’, and of those, appearances can be very deceptive. Heart block, strokes etc tend to come like the snipers bullet, ‘out of the blue’, as we used to say.

Joe Blow
Joe Blow
2 years ago
Reply to  George Lake

I posted a decent study from the BMJ above. You might consider reading it.

George Lake
George Lake
2 years ago
Reply to  Joe Blow

Yes, where can I find it?

No need, found it, thanks!

Is it the Newcastle study?

George Lake
George Lake
2 years ago
Reply to  Joe Blow

Is this the paper you were referring to?
Conclusions: This large cohort of 85 year olds showed good levels of both self rated health and functional ability despite significant levels of disease and impairment. Hypertension, ischaemic heart disease, atrial fibrillation, depression, and dementia may be underdiagnosed. Notable differences were found between the sexes: women outnumbered men and had more disease and disability.
It doesn’t sound very different from the piece I post from ‘ageing-better uk.
I like the expression ” good levels of self rated health”. That sounds like me, delusional, as it turned out, but c’est la vie!

Johnny Sutherland
Johnny Sutherland
2 years ago
Reply to  George Lake

As a diabetic I fully approve of the concept of a quantity vs quality debate. If I followed the guidance and only ate / drank what I’m supposed to, exercised properly I’d probably add 5 years to my life, but I’m not sure I’d want to. Pass the chocolate!

George Lake
George Lake
2 years ago

I couldn’t agree more.
However as Mr Blow has amply demonstrated any conversation about quality of life versus quantity of life is anathema.

In fact our attitude to death seems to have regressed to a state of primitive fear. What ever happened to logic, and stoic understanding?

Elizabeth W
Elizabeth W
2 years ago
Reply to  George Lake

But the young and healthy do not need this vaccine.

George Lake
George Lake
2 years ago
Reply to  Elizabeth W

Yes, HMG is ‘hoist with its own petard’ to bowdlerise the Bard.

The almost mythical panacea, the Vaccine, has arrived with such alacrity that it is being hailed as the ‘second coming’.

The fact that young and fit have a first class immune system, honed over millennia of evolution, is totally irrelevant as far as this new Crusade is concerned……”God wills it”!
Those who disagree shall be condemned as ‘Blasphemers’!

LUKE LOZE
LUKE LOZE
2 years ago

The whole justification of lockdown haa been to stop the old and frail dying in huge numbers of Covid (something that seems to have failed spectacularly and unfortunately).

All this talk about life years lost is misplaced . Sure the total number of life years lost because of lockdown will vastly exceed deaths saved from Covid, but those live years are not politically expedient now.

It’s quite understandable when we’ve been presented with this question that we chose to save the lives now, not tomorrow. It’s all about how the question is put. If we asked shall we spend 10 years health budget this year on sick people with excellent results, but then nothing for 9 years, people might answer differently. Of course pro lockdowners will get angry with this question, like anyone whose moral authority is destroyed.

I’d still be inclined to give the vaccine to older groups first. By % they’re most vulnerable, anything else will get too complex. If for example obesity was chosen would people chomp their way to a 30.1 bmi, or get weighed with lead in their pockets.

Johnny Sutherland
Johnny Sutherland
2 years ago
Reply to  LUKE LOZE

The whole justification of lockdown haa been to stop the old and frail dying in huge numbers of Covid

No, it was to spread it out so the NHS could cope. Lockdowns will only ever slow things down it can’t stop it. Look at the difference between lockdown and an isolation ward and you should start to understand.

LUKE LOZE
LUKE LOZE
2 years ago

That was justification on day 1. Since then raw death numbers has become most important politically – and for a good reason.

Lockdowns as practiced in China, does appear to work – but also involves removal of even their limited freedoms. Still unable to leave the house without being tracked, disappeared if you question it and so on.

Dennis Boylon
Dennis Boylon
2 years ago
Reply to  LUKE LOZE

They don’t consider asymptomatic people as diseased. Post Wuhan they only test and contact trace the symptomatic. That is why they have been open and more free than the West since April 8th. They have had a couple short lockdowns since in symptomatic hot spot areas but for the most part they have been fine. Japan, South Korea, and Vietnam have done this the entire time. They’ve never had a hard lockdown. This is not allowed to be discussed in the West. We are supposed to only consider Australia and New Zealand. More harsher lockdown are desired by our plutocrats. It has been great for wealth concentration. By limiting the flow of money through restricting the economy they’ve been able to turn the money spigot on at the fed and blow up the financial markets. The wealthy get to buy up assets on the cheap as the rest of the country goes broke. We are living in extremely dangerous times. The so called 1 percenters are consolidating wealth and power in the West as the US empire ends. We are looking at a new age of feudalism.

Elaine Giedrys-Leeper
Elaine Giedrys-Leeper
2 years ago
Reply to  Dennis Boylon

The short-term impacts of COVID-19 lockdown on urban air pollution in China Nature sustainability July
95 out of 234 cities locked down all over the eastern half of China looking at the map. Followed by Shulan in May, Beijing in June and Xinjiang (22 million) in July – the latter information from a pal of mine who lives in Beijing.

Talking of which, everyone is obliged to have this app on their phone – if it doesn’t show green you can’t enter a building …any building.

Vietnam had a nationwide shutdown in April like everyone else and since then has had a series of local ones, all over the country, as and when required – the latest one on Jan 28 covering Hai Duong.
Plus sa change.

George Lake
George Lake
2 years ago
Reply to  LUKE LOZE

Surely you don’t believe a word the Chinese say?
In fact I’m astonished at your insouciance.

Angela Paris
Angela Paris
2 years ago

The current “vaccines” do not stop the spread nor do they stop people from catching the virus. So what is the point of taking the vaccine to stop the spread?

Jonathan Patrick
Jonathan Patrick
2 years ago

A bit late in the game to be bringing up QALYs. If you do the math in terms of cost per QALY of our fight against COVID you will quickly find that it is astronomically high – easily 10x the typical thresholds of $50,000 per QALY used in most cost benefit analyses of health interventions. It would be a bit strange to suddenly take an interest in QALY as the appropriate measure!

Dennis Boylon
Dennis Boylon
2 years ago

Or just stop paying attention to all this nonsense and get on with our lives?

Russ Littler
Russ Littler
2 years ago

NO, we should be vaccinating journalists and politicians first, waiting six months to see how many die, or are irreparably damaged, and then given to those who want it.

George Lake
George Lake
2 years ago
Reply to  Russ Littler

Plus their wives and children.

Russ Littler
Russ Littler
2 years ago
Reply to  George Lake

no one should be penalized for another persons crime. Why persecute innocent people?

George Lake
George Lake
2 years ago
Reply to  Russ Littler

The larger the target audience, the better the experiment surely?

You can’t make an omelette etc!

George Lake
George Lake
2 years ago
Reply to  George Lake

..

Tom Jennings
Tom Jennings
2 years ago

There is a management principle with the shorthand of KISS(Keep it Simple Stupid) that is coming into play. There is a solid correlation between age and covid lethality. Age has the merit of being both demonstrable and readily verifiable through government furnished ID. I believe there is general agreement that minimizing covid deaths is a good thing. Once you get past age, things start to get hard.
Complexity is the enemy of KISS. Quality Adjusted Life Years(QALY), Body Mass Indexes(BMI), social justice objectives, etc. can be advocated for but will necessitate a long walk in the woods to sort out what we should do. My guess is that governments that vaccinate based on age will be well on their to inoculating their populations while woke immersed governments will still be sorting out the rules.

Warren Alexander
Warren Alexander
2 years ago

If I recall correctly, Indonesia has decided to vaccinate its young people first.

Michael Cowling
Michael Cowling
2 years ago

I would argue that part of the problem is that decisions are made by bureaucrats rather than doctors. Most doctors I have talked to are well aware of quality of life issues, and I believe that before the NHS many of the decisions on the allocation of resources within hospitals were made by doctors. Now there are bands of managers who make decisions based on the data that they have, but this data doesn’t and probably can’t include all the factors that those at the front line see and used to use in their decision making.

Justin Perry
Justin Perry
2 years ago

Whatever the moral and scientific arguments are for having prioritised differently for the initial vaccine roll out – politically they had no choice but to reduce risk of hospitalisation and death.
At the moment, most, if not all of the reduction in cases, hospitalisation and death is from lockdown, so if we had vaccinated 15m 20 and 30 somethings, at this point in time there would not be much apparent difference. Imagine though, that in a month’s time, when restrictions start to ease, infection numbers start to rise. With old people vaccinated, even infections going up should not translate into hospitalisation and death. However, if none of the old had been vaccinated, the opposite would be true – and what government would want to preside over that?
Having said this I think there is a case for reversing priority if and when a ‘new variant booster’ is needed in the autumn.
Provided that existing vaccines do protect against severe disease, enliven with new variants, the old might get infected but they won’t die. If the young get the new variant shot first, this should reduce the spread of the variant (more infection is in the young) and help limit further mutation. There is even a case for delaying the second dose in the young until the new vaccine is ready. The old won’t die and they can get their boosters in the autumn. This keeps both infection rates and deaths at tolerable levels and avoids another lockdown.
I apprecytbat a lot has to go right for this to work, but as a concept, I think it’s worth considering.

Kathy Leicester
Kathy Leicester
2 years ago

This is the “F*&^ you, you’re old!” system. Nice.

Normals went about business many months ago, as much as they could. We prefer our immune systems.

Let the soys argue over killing the elderly so the children can get the jib jab.

Helen Barbara Doyle
Helen Barbara Doyle
2 years ago

I completely agree about lifting lockdown too early before 50-70 year olds have been vaccinated.

If cases soar the % of that group who catch it will increase so the current 12% of deaths from that cohort will turn into quite a large number.

We have come this far, let’s wait another 2-3 weeks and do it properly.