Vaccination against Covid-19: priority for the most vulnerable

The elderly, the chronically ill and those who care for them will be the first to be vaccinated.

Number of doses available, methodology of clinical trials, efficacy according to target populations … The unknowns surrounding Covid-19 vaccines remain numerous, but this does not prevent the authorities from getting involved in the preparation of the upcoming campaign, even before the marketing authorizations (AMM) are issued.

The High Authority for Health (HAS) itself has deviated from its habits to start developing recommendations long before having all the cards in hand. Because these vaccines, which were only recently a “hypothesis”, now represent “A real glow at the end of the tunnel”, launched Monday the Pr Dominique Le Guludec, president of the college of the HAS, by presenting the opinion on the populations which will have access in priority to the vaccination. Health authorities must be ready “Upon arrival” vaccines, so make decisions “Before having all the data” of the problem.

The “Red string” chosen by the members of the Technical Committee on Vaccinations (CTV), responsible for drawing up the recommendations, has the merit of simplicity: “Protect in priority the most vulnerable and those who care for them, summarized Dominique Le Guludec. Those whose experience has taught us that they pay the heaviest price ” to the epidemic. Because if the preliminary data disseminated by the manufacturers indicate an excellent protection against the serious forms of the disease, one ignores however all of their capacity to prevent the infection by the SARS-CoV-2, therefore the contagiousness.

Reducing the number of hospitalizations and deaths seems within reach of vaccines, but ending the epidemic with them remains much more uncertain. Another unknown is the effectiveness in older people, whose immune system is less effective. The results of the “Public consultation on the implementation of vaccination which ends today, said Pr Elisabeth Bouvet, president of the CTV. All this is very evolving, and little by little we will see the rest of the vaccine strategy take shape ”. Decisions will come back anyway in fine to the government. Making vaccination compulsory is not currently a preferred option, the HAS preferring to take the“Membership” of the population thanks to the virtues of transparency on the efficacy and potential risks of vaccines.

“A third of the deaths took place in nursing homes”

Two types of priority audiences have been defined after analysis of the scientific literature and data collected by Public Health France. On the one hand, those who are at risk of severe disease because of their age and / or their state of health. Regarding age “It is difficult to fix a ‘cut-off’, noted Professor Daniel Floret, vice-president of CTV, but we know that the risk increases linearly from age 50 ”. As for co-morbidities, “A certain number are consensus *. Others less, but they can be integrated as and when “ the arrival of new scientific data. Second priority audience, the people most exposed to the virus, starting with “Medical and paramedical health professionals, medical auxiliaries, stretcher bearers, social workers and personal services personnel”, listed Daniel Floret.

Three first phases of vaccination will target these two types of public. Without real surprise, the residents of nursing homes and elderly patients in long-stay services as well as the staff of these establishments themselves presenting an increased risk of a serious form of the disease (over 65 years of age and / or presence of comorbidity) will be the very first guests to be vaccinated. “For this phase, we will probably have a very limited number of vaccine doses and we will not be able to vaccinate many people”, justified Elisabeth Bouvet.

Accommodation for the elderly has therefore been deemed a priority, because their residents have two types of risk: a much greater vulnerability to the virus, and a significant risk of being infected because they live in places where it circulates. . “We know that in these establishments there have been many cases, clusters and a considerable number of deaths: it is estimated that a third of the deaths in France have occurred in nursing homes”, pleaded Elisabeth Bouvet. The fragility of their residents also forced them to transform into strongholds to which neither families nor certain caregivers such as physiotherapists had access. Even more damaging the chances of very fragile people.

Once vaccination has been offered to those most at risk and to the personnel who take care of them, workers who are not necessarily at risk but deemed essential to the country’s activity can be integrated into phase 3, but “It is not for HAS to define the essential sectors, Daniel Floret slipped. It is a political, not scientific, datum that will be defined by the government. ” These first three phases will respectively concern 840,000, then 14.9 million and finally 17 million people, and they should follow each other fairly quickly, said Daniel Floret. But all of this is “Conditioned by the supply of vaccines”.

Phases 4 and 5 on the other hand will be “Probably later”. They will make it possible to expand access to vaccination, starting with those who work in conditions that increase the risk (contact with the public, closed environment, difficulties in applying barrier gestures, etc.) or who live in conditions that make them particularly vulnerable (residents of psychiatric hospitals, prisons, hostels, precarious public, etc.) and those who care for them.

Gradually, the rest of the population can then be vaccinated. Pregnant women are not currently concerned, because in addition to an unrecognized increased risk at least in early pregnancy, “We always hesitate to vaccinate them with vaccines that we do not know very well”, notes Daniel Floret. Another public not targeted by these recommendations, those under 18, for a legal reason: clinical trials have not yet included them, future MAs will therefore be issued for adults only. If the youngest are considered low risk and not very contagious, “It is a problem for adolescents with comorbidity”, agrees Daniel Floret to the Figaro. But the laboratories will end up carrying out tests on the pediatric population: the regulations oblige them to do so.

* The comorbidities justifying a priority in access to vaccination as listed by the HAS are: obesity from a body mass index greater than 30, chronic respiratory diseases in particular COPD and respiratory failure, high blood pressure, heart failure, diabetes, chronic kidney disease, recently treated cancers, having had an organ or stem cell transplant and Down’s syndrome.


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