Why Have People With Asthma Been Removed From the Covid-19 Vaccine Priority Groups in the UK?
Last week I received my first Astrazeneca Covid-19 vaccine dose. I was filled with a mixture of gratitude, fear I would for some reason be refused, and guilt that so many other people with asthma in my position were still waiting with no hope in sight for their first dose coming before the rest of their age groups.
Being left unvaccinated with the rest of the under 50s for the next few months is a particular concern of many with asthma in the UK. When lockdown ends next month and many are left exposed to Covid again they will be in the position of having to self shield (if lucky) or many will have to go out to jobs that will potentially expose them to Covid.
Some people with asthma noticed in late December that the JCVI (Joint Committee on Vaccination and Immunisation) had omitted many with asthma from the priority groups in their green book guide for what order people should receive the Covid vaccine in terms of risk/vulnerability.
Asthma UK, in several tweets and posts to their Facebook page, assured people with asthma from late December through mid February that the Department of Health and Social Care had told them anyone on steroid inhalers/those who normally receive a flu jab, would be in group 6, after the 65+ age group and more severely vulnerable groups, but before our healthy, same age group peers.
When the JCVI guide was updated again in mid-February, it doubled down on excluding all but the most severe cases of asthma. Anyone who hasn’t had at least three courses of oral steroids in the past three months or been hospitalised because of their asthma (technically at any point but many GP’s are reportedly interpreting this to mean recent hospitalisations only for some reason. Even those who were hospitalised as children like me may not have access to those records anyway).
This effectively removed a large majority of people with asthma from the priority groups, as well as creating sub categories of asthma not previously recognised by the NHS.
Many have pointed out that this criteria overlaps with the severe asthma already covered in group four, and modest estimates have this tightening of group six’s asthmatics eliminating anywhere between one and one point eight million people with asthma from the Covid vaccine priority groups.
My moderate, not particularly well controlled asthma, which requires two steroid inhalers and a reliever inhaler for me to function daily, had been classed as clinically vulnerable without quite meeting the shielding criteria by the NHS throughout the Covid pandemic.
Like many people with asthma I self-shielded anyway, fearing Covid might be bad news for someone who struggles to breathe at times due to allergies, pollens, dust, any number of things that aren’t a patch on the coronavirus and its often lethal attack on the respiratory system.
Distressingly the UK government has now announced they intend to lift this basic protection of shielding when lockdown eases. For many unvaccinated people with asthma that have so far been left out of the vaccine rollout, this is genuinely a terrifying prospect and will remove their protected status with their employers.
In a study by The Lancet published March 4, 2021, younger Covid patients with asthma were found to have a much higher risk of being hospitalised, requiring oxygen and other breathing assistance with Covid symptoms than their non asthmatic peers.
They write
“We found that the proportion of people with asthma admitted to hospital with COVID-19 (8.6% aged <16 years, 20.9% aged 16–49 years, and 12.2% aged>50 years) was considerably higher than the national prevalence of asthma, which is around 7% for each age group”
They further say
Patients with asthma aged 16–49 years and those aged 50 and older were significantly more likely to receive critical care, non-invasive ventilation and oxygen than patients without asthma after adjusting for age, sex, ethnicity, obesity, smoking and comorbidities”
Ok, so maybe the JCVI/UK government simply didn’t have all of the facts about asthma, one might argue. Except this is far from the first study to indicate people with asthma are at greater risk from Covid.
An earlier Lancet review of several studies suggested women with asthma as a sub-group are particularly vulnerable to severe illness and hospitalisation from Covid. A King’s College study warned that the greater risk of long Covid in those with asthma must be considered.
In May of 2020 Rush University Medical Center found younger Covid patients with asthma need more time on ventilators.
“Our findings suggest that younger individuals with asthma may require extra attention, as they could develop a sustained pulmonary failure with Covid-19 infection, leading to prolonged medical ventilation”
Rush EDU also concluded that
New data suggests that asthma is associated with longer time on ventilators for hospitalised younger patients with Covid-19 aged 20–59 who also had asthma needed a ventilator to assist with breathing for five days more on average than non-asthmatic patients with Covid-19
Inevitably cases will rise again after lockdown ends in the U.K., and should people with asthma be infected at a higher rate after being forced back into work unvaccinated it could be very bad indeed for people with asthma as well as the NHS.
“Pubs will soon open, wahay!” we see people our age that have no fear of Covid ravaging their already constricted airways and scarred lungs rejoice, and many unvaccinated people with asthma despair. I am not using the term figuratively, there are endless heart-breaking social media posts from unpaid carers, frontline workers, parents afraid of their children bringing it home, teachers petrified of catching it.
We feel vulnerable, up until just over a month ago we were classed as such by the NHS. Only now many people with asthma have been cut loose completely, having failed to meet the strict criteria for deserving the vaccine with other priority groups. Why the UK government decided to place such a virtually unachievable high bar for those with asthma is mysterious, as the science falls apart pretty quickly on deeper inspection.
I believe the only reason I was given the vaccine ahead of my age group is that I plead with my g.p. that I have a couple of other health factors that placed me in a grey area for qualifying for priority vaccination, one being that I am in long term remission/considered cured from Non-Hodgkin’s Lymphoma (blood diseases definitely fall in group 6, but as with my asthma it still wasn’t quite enough to place me in any priority vaccine group according to the first GP I asked).
I think it’s ridiculous that I should have to rely on being a cancer survivor to be made a priority when my respiratory disease is prone to chest infections that often require oral steroids even with a common cold.
I have no assurances that I have been placed in any priority group in the future, like many others with asthma who have been able to finesse a vaccine out of their GP or who have been lucky enough to have a GP who didn’t know about the change in priority groups to asthma and won what some are referring to as a “postcode/GP lottery”.
It has created far more work for GP’s, when a simple Flu jab = Covid jab policy would have saved practices the time and hassle of dealing with (understandably) frightened people with asthma and other flu jab qualifiers who have fallen through the JCVI net.
Asthma UK and the JCVI both made mention of “GP discretion” when the priority groups were announced, which has resulted in a mix of some GP’s willing to bend “the rules” and others saying their hands are tied.
Asthma, ALL asthma, was classed as clinically vulnerable right up until a few weeks ago, when the NHS removed that page from the Covid information section of their website.
Asthmatic vs. healthy airways, an even playing field with Covid according to the UK government and the JCVI.
Moving The Goalposts
Please note from the screenshots below how the parameters for asthma shifted over the course of two weeks on the gov.uk site. It initially read “the vaccine will be offered to…breathing problems like asthma (using steroid inhaler often)”, which some people presumed/hoped meant we might still be included, only for them to slice and dice which asthma is “severe” enough in line with the JCVI’s published guidelines.
This is how it appeared before the section on who is clinically vulnerable was removed:
Make it make sense?
I feel, and I don’t think I am alone here, a sinking “not enough life boats” sensation the more I learn about this decision and the careless danger we have been placed in.
Asthma UK has voiced some objections to the decision, but have never publicly questioned why the dramatic change in what they were told would happen or made any public demands to for our priority to be reinstated into priority group 6 as they claimed they were promised. They have expressed concern and a need for “clarity” which has so far resulted in zero movement from the JCVI.
It’s all a bit underwhelming from what is meant to be our main charity advocate. Smaller asthma charities like the Aberdeen Asthma and Allergy Foundation have meanwhile voiced unreserved support for our cause:
Removing so many asthmatics has meant the government has been much quicker to meet its targets of vaccinating “all” of the vulnerable groups first, as they have unflinchingly boasted for the past week.
It has put the hopes of the majority of people with asthma being given any kind of priority for the vaccine in the future in peril to have this decision be so unchallenged by anyone with any power.
Tory MP’s reply to the letters sent by concerned people with asthma with cut and paste messages that ignore all of the science presented here. Other MP’s might make sympathetic noises but no one has raised this in parliament. Keir Starmer, Nicola Sturgeon and other politicians all have bigger fish to fry than listening to our fears for our health, it would seem.
People with asthma normally receive the flu jab every year to protect us from the dangers pneumonia poses to our health, and yet the UK government have with little pushback negated the heightened risk of hospitalisation, death and long Covid in anyone with asthma based on cherry picked data that it could be argued best suited their aim to streamline vaccine targets.
In the U.S.A., some states initially attempted to side-line people with asthma from receiving vaccine priority in a similar way, but states like Massachusetts, New Jersey and West Virginia to name a few have reconsidered being so hasty to remove those with asthma. They are respecting the CDC advice to treat asthma cautiously when it comes to Covid.
By comparison, the UK government cutting most people with asthma so drastically from the Covid vaccine priority groups sets them apart from most countries.
Many of the touted “Asthma is less vulnerable to Covid than we thought” news headlines we see are based largely on studies that were over reliant on the promising effects certain steroid inhalers have had on fighting Covid symptoms. While it’s possible some people with asthma were able to manage milder strains of Covid symptoms with the luck of having the right inhalers handy (certainly not a given), this remains unproven.
It is worth noting that the JCVI removed asthmatics at least in part due to the Oxford Budenoside study, which was carried out on 146 healthy people with NO UNDERLYING LUNG DISEASE. Clinical recovery was one day shorter than the usual care arm.
Furthermore, a recent study from the European Respiratory Journal seems to call much of this presumption of inhaled corticosteroids improving asthma Covid outcomes into SERIOUS question:
In the COPD population, an unadjusted model showed that ICS prescription was associated with an increased risk of death (hazard ratio (HR) 1.53, 95% CI 1.22–1.93). Adjusting for age, sex and comorbidities did not alter this signal (HR 1.39, 95% CI 1.10–1.76).
In the asthma population a single variable model showed a similar increase in risk of death (HR 1.36, 95% CI 1.01–1.84) for low- or medium-dose and high-dose ICS (HR 2.30, 95% CI 1.64–3.23). This excess risk was not evident after confounder adjustment for age, sex and comorbidities in the low or medium dose ICS group
The main study used by the JCVI to judge asthma’s Covid mortality rates excluded the fact that many if not most of us were shielding when it was conducted almost a year ago. The British Medical journal called using these studies to make decisions on health outcomes without factoring in shielding “problematic”.
Following on from that, priority group 6 was not intended to be based solely on mortality rates, in fact JCVI doctor Professor Wei Shen Lim said that for group 6 “we’ve been asked specifically to look at how we can reduce the risk of severe disease- hospitalisation and people dying.”
Asthma is a respiratory disease: Covid systemically attacks the various systems of the body and this includes the respiratory system. According to the British Medical Journal:
Respiratory failure due to covid-19
Covid-19 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which primarily targets the respiratory tract, causing widespread inflammation in the lungs in severe cases. Approximately 14% of all people with covid-19 develop severe respiratory disease with T1RF, and a further 5% will become critically unwell,2 many of whom will require intensive care.56
I mention this specifically as Professor Anthony Hardin, deputy chair of the JCVI, when recently interviewed on Radio 5 live with Stephen Nolan about asthmatics being cut from the vaccine priority groups, called Covid “mainly a vascular disease”, downplaying the severe effect it can have on the lungs and respiratory system, and the WHO classification of Covid as Severe Acute Respiratory Syndrome.
Further contributing to the confusion, the vaccine minister Nadhim Zahawi stated that all asthmatics who take inhalers are on the priority list, only to retract the next day. Boris Johnson similarly misspoke about our inclusion in the priority groups, but never bothered with a retraction or apology. This was only picked up on by the Wharfedale Observer.
People with asthma being given false hope and having our lack of priority undermined by incorrect government statements that the press at large doesn’t bother to hold to account is another demoralising issue we have dealt with.
When even mild, young asthmatics have serious long Covid issues that have exponentially worsened their daily asthma symptoms (on top of the long Covid effects), this indicates that we are a vulnerable population now in grave danger of overwhelming an already beleaguered NHS.
Vaccinating vulnerable people with asthma before their healthy peers is common sense, backed by many scientific studies, but the UK government has yet again taken another short cut to ease their path to reopening society, placing the economy above human life as it has done time and time again.
It has not worked out well so far, over 130,000 deaths and counting is a shocking record compared to many other countries who took a zero Covid approach and have had a far more successful outcome protecting the lives of their citizens.
People with asthma are fairly used to our illness being largely invisible. It’s something we manage ourselves, for the most part. Whether it be judging if a wheezing spell will pass without an inhaler, running out of breathe doing everyday activities or pushing our limits with exercise, we try our best to just get on with it, until we can’t.
We would LOVE to be healthy people, to not have asthma, and so many of us downplay it. I don’t take my inhalers in public if I can help it, I try everything my doctor tells me to try to improve my condition but alas, I remain a person with asthma.
We are Leonard in The Big Bang Theory, we are nerds who are the easy butt of the joke according to most film and television portrayals of asthma. Many of us probably faced some form of discrimination or mockery growing up as kids with asthma (my own nemesis was always the dreaded gym teacher forcing me to run until I had an asthma attack).
Our illness is often undermanaged by our medical care (reportedly very few people with asthma received an annual asthma review this year, yet the government confidently bandies about categorisations for asthma as if it’s an incredibly well managed condition and not the sliding scale, good one day/week/month, bad the next lived reality of many).
The UK has the worst death rate for asthma in all of Europe, according to the British Medical Journal:
The analysis of official figures from the Office for National Statistics, released by the charity Asthma UK on 9 August, shows that more than 1400 adults and children died from asthma attacks in 2018, an 8% increase since 2017. Overall, more than 12 700 people have died from asthma in England and Wales in the past decade. Deaths increased by 33% during 2008–18.
A grim but not unreasonable question is how many people with asthma will have preventable Covid deaths labelled merely “underlying condition” as a reason should we not receive vaccine protection from Covid in a timely manner.
The phrase “mild asthma” has been leaned into heavily by both government and press in dismissing the million plus of us who require steroid inhalers to breathe not quite as well at the best of times, and much worse at the worst times, than people who don’t have a chronic respiratory illness.
Mild, moderate and severe asthma often all intersect. Of course some people with very mild asthma don’t require inhalers very/as often as some of us, but even they have shown a higher propensity to develop much more serious asthma and long Covid symptoms. There is nothing “mild” about ANY form of asthma when dealing with Covid.
Asthma isn’t something that should be dismissed as a risk factor for Covid because a few studies (which didn’t factor in shielding) indicate not as many of us died or contracted serious Covid as predicted, nor should we have been cut because there were simply too many of us to get through before the desired lockdown end target dates.
The Association of Respiratory Nurse Specialists agree that all people with asthma should be prioritised for the vaccine:
It is unethical and medically reckless of the UK government and the JCVI to stand by this decision. People with asthma did our bit, we shielded, stayed safe and avoided seeing friends and family for a year. Sadly many of us won’t be protected much longer when our shielding status is taken away from us.
In an analysis of what constitutes medical ethics, an author at the British Medical Journal wrote about these four aimed core principles:
The four prima facie principles are respect for autonomy, beneficence, non-maleficence, and justice.
It is inaccurate to suggest that these principles are equally applied to everyone, but they should be the aim now of all times, surely.
The UK government has either successfully convinced the media that all vulnerable people have been protected with the vaccine, or the lives of people with asthma are simply not considered valuable enough to investigate this obviously medically shaky, politically expeditious decision more closely.
This clearly misjudged decision to exclude us from the Covid vaccine priority groups cannot stand. Will anyone be held accountable here if this goes horribly wrong? They unjustly cut not only asthmatics, but those with CFS/ME and other rare diseases as well. It has had a traumatic effect on those of us with asthma to have been made to feel our lives are so undervalued.
Why won’t the UK government and the JCVI protect people with asthma by offering us the Covid vaccine along with all of the other vulnerable groups? We deserve and would appreciate a thoughtfully considered answer.
We are #AsthmaticsAtRisk on Twitter.
All of the research, graphics and data compiled here was a group effort.
