Priority Vaccination for Prison and Homeless Populations

Written by Ben Davies

Last week brought the news that an additional 1.7m people in the UK had been asked to take additional ‘shielding’ measures against COVID-19, following new modelling which considered previously ignored factors such as ethnicity, weight and deprivation. Since many of this group have not yet been vaccinated, they were bumped up the priority list for vaccine access, moving into group 4 of the government’s vaccine plan.

Two other groups, however, have not yet been incorporated into this plan despite appeals from some quarters that they should be. First, new figures reinforced the sense that the virus is disproportionately affecting prisoners, with one in eight of the prison population having had COVID-19, compared with roughly one in twenty in the wider population (in the United States, the prison figure has been estimated to be one in five).

Second, some GP groups and local councils have offered priority vaccination to homeless residents, despite their not officially qualifying for prioritisation on the government’s plan. There have also been calls for the government to incorporate this into national plans, rather than being left to more local decision-making.

This debate raises several ethical issues. There are many groups who need access to vaccines as a matter of urgency, and so any call to add more individuals to priority groups must be considered carefully: expanding a group may mean that some existing members of that group (e.g. the very elderly or those with chronic conditions) have their vaccinations delayed, with potentially serious consequences.

Yet there is a good case for prioritising both homeless and prison populations. Both are extremely vulnerable groups in general, and the evidence suggests that they have increased vulnerability to COVID in particular. Members of both groups will find social distancing difficult, albeit for different reasons.

Consider now the more specific factors attaching to each group. Individuals who are homeless are also particularly vulnerable to being missed even if they qualify under existing criteria, such as severe underlying illness, since many are not registered with a doctor. Homeless people are in general more likely to suffer from underlying health conditions.

Turning to prisoners, government ministers have insisted that they should be prioritised in line with falling into pre-existing categories. Yet even if prisoners do not qualify for priority vaccination on grounds of individual need, they may qualify on public health grounds. As Oxford’s Professor Seena Fazel noted in November, prisons are at particular risk of serious outbreaks, with distancing extremely difficult to practice, and many staff not able to source PPE. Even those who (wrongly) regard prisoners as undeserving of protection from serious illness should recognise that they are not closed systems, with staff providing potential community links for any surge of infection. Additionally, attempts to control outbreaks often leave prisoners confined to cells in ways that damage their health, including stories of serious sanitation issues for those without in-cell facilities.

With respect to the decision to vaccinate homeless residents, there is a separate ethical question of whether local councils or medical professionals are right to ignore national guidance, even if it is flawed. Of course, if the national guidance were completely unethical (say, advocating prioritising Conservative party donors), then ignoring it would be justified. But where guidance is generally justified, but has flaws, one might think that there is a case for sticking with it. After all, there would be considerable scope for abuse if every local council started making its own priority lists.

This ignores the possibility of independent justification. Local groups should not have carte blanche to set their own vaccination priorities – justification is needed for deviations from guidance that is overall reasonable. Yet such justification is often available; in particular, such groups will have knowledge of more local factors that may affect the case for prioritisation. And we must also be wary of taking the ‘easy’ route for distributing surplus vaccines of simply offering them up to patients who can get to surgeries or hospitals by the end of the day. While such measures may be justified to avoid waste, they should not be Plan A when there are other more vulnerable, harder to reach patients who have not been vaccinated.

It is easy to call for more groups to be prioritised for vaccination in ways that misunderstand how prioritisation must work: not everyone can be a priority. The case for prioritising homeless and prison populations, though, is a strong one.

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