Vaccine prioritisation and mental health

We systematically searched English language websites in the UK and other countries (see list of sources below) to identify and synthesise available recommendations on vaccine prioritisation and mental health. The findings are presented in the full table below in a question-and-answer format, with the clinical question, guidance extracted and links to the original sources of evidence.

The key findings extracted from the tables presented in the following pages are the following:

In the UK:

1. Patients with a severe mental illness – defined in the Green Book (UK government information on vaccines and vaccination procedures) as ‘schizophrenia, bipolar disorder or any mental illness that causes severe functional impairment’ – should be offered the vaccine after those who are over 65 years old (priority group 6).
2. Those with severe mental illness are not defined as clinically extremely vulnerable (priority group 4) and therefore will not be offered the vaccine along with adults aged 70 or over.
3. Patients in older adult mental health services will be offered the vaccine based on their age rather than any mental illness, as over 65 years old is a higher priority.
4. Priority group 6 also includes the following: 1) adults who provide regular care for an elderly or disabled person; 2) younger adults in long stay nursing and residential settings; which may include some more patients with a mental illness.
5. Within the category of severe mental illness, there is no specific guidance on who should be prioritised to receive the vaccine first.
6. Those with mental illness and additional risk factors for poor outcomes e.g. BAME, deprivation, overcrowding, will not be offered the vaccine sooner based on these additional risk factors. However, when offered the vaccine, the Trust/healthcare provider should make an assertive effort to ensure they receive it.
7. The UK system of prioritisation does not add risks together to give a higher priority to those with multimorbidity. Thus, a person with multiple risks such as age, mental health and physical health vulnerabilities will be prioritised only according to their single highest risk factor for prioritisation.  
8. All of the devolved nations base their recommendations on the Joint Committee on Vaccination and Immunisation (JCVI) prioritisation recommendations.

Available recommendations from America, Canada, Australia, New Zealand, Singapore and Ireland do not specifically list mental illness as a priority group.

Additional information

Search date: 21st January 2021, updated 2nd March 2021

Sources searched: Public Health England, Royal College of Psychiatrists, Royal College of Nursing, NICE, British Geriatric Society, Royal College of Physicians, Healthcare Improvement Scotland, Centers for Disease Control and Prevention, US Department of Labor, American Psychiatric Association, Massachusetts General Hospital Psychiatry, WHO, IASC (Inter Agency Standing Committee), UNICEF, WPA, Singapore Ministry of Health, Singapore Psychiatric Association, Singapore Medical Association, Health Canada (Government department), Canadian Psychiatric Association, Australian Government Department of Health, Royal Australian & New Zealand College of Psychiatrists.

Sources used: Public Health England (including the ‘Green Book’ – Immunisation against infectious disease, https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book), Royal College of Psychiatrists, Centers for Disease Control and Prevention, Health Canada, Australian Government Department of Health.

This priority list according to the Joint Committee on Vaccination and Immunisation (JCVI) is as follows:

1. residents in a care home for older adults and their carers
2. all those 80 years of age and over and frontline health and social care workers
3. all those 75 years of age and over
4. all those 70 years of age and over and clinically extremely vulnerable individuals (not including pregnant women and those under 16 years of age)
5. all those 65 years of age and over
6. all individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
7. all those 60 years of age and over
8. all those 55 years of age and over
9. all those 50 years of age and over

Note: all the devolved nations base their recommendations on the JCVI prioritisation recommendations.

Guidance for the public on the prioritisation schedule is available at: https://www.gov.uk/government/publications/covid-19-vaccination-why-you-are-being-asked-to-wait/why-you-have-to-wait-for-your-covid-19-vaccine?priority-taxon=774cee22-d896-44c1-a611-e3109cce8eae.

Note: ‘clinically extremely vulnerable groups’ are outlined at https://www.england.nhs.uk/coronavirus/publication/guidance-and-updates-for-gps-at-risk-patients/

• The shielded patient list has recently been updated following a new, data-driven risk assessment (the COVID-19 Population Risk Assessment), and now includes an additional group of patients with specific multiple risk factors which, combined, may put them at similar risk to those who are clinically extremely vulnerable to severe outcomes.
• People within this group will be prioritised for vaccination in priority group 6, if not already offered, and are eligible for further support.

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• The JCVI advises that the first priorities for any COVID-19 vaccination programme should be the prevention of COVID-19 mortality and the protection of health and social care staff and systems. 
• Secondary priorities include vaccination of those at increased risk of hospitalisation and at increased risk of exposure, and to maintain resilience in essential public services.
• Using data from the first wave in the UK, the overall risk of mortality for clinically extremely vulnerable younger adults is estimated to be roughly the same as the risk to persons aged 70 to 74 years.
• Thus, the JCVI advises that persons aged less than 70 years who are clinically extremely vulnerable should be offered vaccine alongside those aged 70 to 74 years of age. (There are 2 key exceptions to this, pregnant women with heart disease and children.)
• There is good evidence that certain underlying health conditions increase the risk of morbidity and mortality from COVID-19. When compared to persons without underlying health conditions, the absolute increased risk in those with underlying health conditions is considered generally to be lower than the increased risk in persons over the age of 65 years (except for the clinically extremely vulnerable).
• Thus, the JCVI advises offering vaccination to those aged 65 years and over followed by those in clinical risk groups aged 16 years and over.

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Definitions of ‘clinically extremely vulnerable’ do not include any mental health conditions (except for adults with Down’s syndrome). Therefore, those with severe mental illness are not defined as clinically extremely vulnerable (priority group 4) and will not be offered the vaccine along with adults aged 70 or over.

However, some mental health patients may meet criteria because they have another condition or comorbidity listed as ‘clinically extremely vulnerable’:

People with the following conditions are automatically deemed clinically extremely vulnerable:

• solid organ transplant recipients
• people with specific cancers:
• people with cancer who are undergoing active chemotherapy
• people with lung cancer who are undergoing radical radiotherapy
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments that can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months or who are still taking immunosuppression drugs
• people with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD)
• people with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell disease)
• people on immunosuppression therapies sufficient to significantly increase risk of infection
• problems with your spleen, e.g. splenectomy (having your spleen removed)
• adults with Down’s syndrome
• adults on dialysis or with chronic kidney disease (stage 5)
• women who are pregnant with significant heart disease, congenital or acquired
• other people who have also been classed as clinically extremely vulnerable, based on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions

NHS England and NHS Improvement and NHS Digital are proceeding with making shielded patient data available to mental health providers so they can optimally support patients of all ages recently and currently under their care.

Although those who are clincially extremely vulnerable have been advised to reduce their overall contact with others where at all possible, attendance at health care appointments (which would include attendance for vaccination) is still allowed.

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• Those with severe mental illness – defined as ‘schizophrenia, bipolar disorder or any mental illness that causes severe functional impairment’ – are included in priority group 6 and should be offered the vaccine after those who are over 65 years old.
• Those with mental illness and additional risk factors for poor outcomes e.g. BAME, deprivation, overcrowding, will not be offered the vaccine sooner based on these additional risk factors, however when offered the vaccine the trust/healthcare provider should make an assertive effort to ensure they receive it.
• Of note, the JCVI (Joint Committee on Vaccination and Immunisation (JCVI) guidance discusses in the ‘Green Book’ mitigating inequalities (specifically for those from minority ethnic or BAME groups), recognises that multiple social and societal factors contribute towards increased risk from COVID-19, but does not allow for extra prioritisation either formally or by clinicians.

Updated guidance relevant to those with severe mental illness, intellectual disability, inpatients and carers in priority groups 5 and 6 is contained at :  https://www.rcpsych.ac.uk/about-us/responding-to-covid-19/responding-to-covid-19-guidance-for-clinicians/covid-19-vaccination/guidance-for-adults-with-smi-and-id

Intellectual disability:

• From 24 February 2021, all people on the GP Learning Disability Register for COVID-19 vaccination are eligible for vaccination (priority group 6) (https://www.gov.uk/government/news/jcvi-advises-inviting-people-on-learning-disability-register-for-vaccine). This includes adults with severe and profound learning disabilities, and those with learning disabilities in long-stay nursing and residential care settings (Down’s syndrome are included in group 4).
• Adults with less severe learning disabilities are not currently prioritised.
• However, GP systems do not always capture the severity of someone’s disability. GPs can also use GP Learning Disability Registers and SNOMED codes (which describe the impact of learning disability although there is variation in how these are applied). In addition, GPs should use clinical discretion so that all people who meet the severe and profound learning disability definition are on the register.
• The NHS is asking key stakeholders, voluntary and third sector partners to encourage people who have a severe and profound learning disability to come forward to their local GP, so that they can be assessed and if appropriate, added to the list to be vaccinated.
• GPs should also use the vaccination visit to offer people with a learning disability their annual health check and to book them in for their flu vaccine.

Severe mental illness

• NHSE/I is encouraging GPs to take a similar approach to that outlined above for learning disabilities, for those with severe mental illness i.e. working in partnership with secondary care mental health services and VCS partners to ensure appropriate outreach mechanisms are in place.
• Information for people with severe mental illness and their carers is at: https://equallywell.co.uk/wp-content/uploads/2021/02/Covid-19-Vaccine_Severe-Mental-Illness.pdf

Adult carers

• NHSE/I recognise the difficulties in identifying people in this group. The third sector are helping to identify people through public campaigns, and eligible unpaid carers are being asked to contact their local authority so they can be prioritised for vaccination through the National Booking Service.
• Local vaccination centres should also prioritise invitations to carers aged 16 and 17 flagged within their systems to align with their known allocations of Pfizer/BioNTech vaccine. The Pfizer/BioNTech vaccine is the only currently authorised vaccine under Regulation 174 which can be used for individuals aged 16 and 17.

Inpatient settings

• As part of priority group 6, all adults over 16 who are inpatients in Mental Health, Learning Disability and Autism settings are eligible for the COVID-19 vaccine from the week commencing 15 February 2021.
• Some patients might have already been offered the vaccine in earlier cohorts.
• In most areas, patients should be able to access the vaccine directly from their inpatient service provider (including the independent sector).

Multiple occupancy/shared community settings

• The Green Book Chapter 14a (https://www.gov.uk/government/publications/covid-19-the-green-book-chapter-14a) states: “Many younger adults in residential care settings will be eligible for vaccination because they fall into one of the clinical risk groups (for example learning disabilities). Given the likely high risk of exposure in these settings, where a high proportion of the population would be considered eligible, vaccination of the whole resident population is recommended.”
• The proposed definition for inclusion of such settings is “a closed community with substantial facilities shared between multiple people, and where most residents receive the kind of personal care that is CQC regulated (rather than help with cooking, cleaning and shopping)”.
• This would include CQC registered care homes (excluding older people’s care homes who were included in Cohort 1) and those identified as part of the Mental Health Services Dataset (MHSDS) as well as Learning Disability settings sites which are not in the MHSDS and Special residential colleges and supported living.
• Shared student accommodation, detained estates (including prisons and immigration removal centres) are excluded within this definition. The COVID-19 Vaccination Programme is addressing vaccination within detained estates separately in conjunction with Health and Justice teams. 

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• Patients in older adult mental health services will be offered the vaccine because of their age rather than any mental illness.

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Priority group 6 will also include the following:

• adults who provide regular care for an elderly or disabled person
• younger adults in long stay nursing and residential settings

which may include some more patients who also have a mental health difficulty.

Those with mental health difficulties not meeting criteria for severe mental illness may also have priority because of another risk factor or physical comorbidity.

(The other categories for priority group 6 are:

• chronic respiratory disease, including chronic obstructive pulmonary disease (COPD), cystic fibrosis and severe asthma
• chronic heart disease (and vascular disease)
• chronic kidney disease
• chronic liver disease
• chronic neurological disease including epilepsy
• Down’s syndrome
• severe and profound learning disability
• diabetes
• solid organ, bone marrow and stem cell transplant recipients
• people with specific cancers
• immunosuppression due to disease or treatment
• asplenia and splenic dysfunction
• morbid obesity

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There is no specific guidance provided.

In the UK, the JCVI does consider this area, although not specifically focussing on mental health. They note that while the evidence indicates that age has the highest absolute risk, studies have also shown that there are several other factors that are associated with elevated incidence or adjusted risk ratios, such as male sex, black, Asian, and minority ethnic (BAME) groups, people with multiple comorbidities and deprivation.

They consider specifically the example of those from BAME groups and whether they should be further prioritised, and conclude that:

• It is paramount that prioritisation and roll-out of the vaccine do not reinforce negative stereotypes and further increase experiences of stigma and discrimination.
• In the context of low trust among some groups, being given early access to the vaccine on the grounds of belonging to a certain community may feel like exploitation rather than inclusivity.
• Many of those from BAME groups might be prioritised through other routes (eg as health or social care workers.

Therefore, those from BAME groups do not receive extra prioritistion on this factor alone.

Those with comorbidity (eg within mental health or across both mental and physical health) are not considered for extra prioritisation in this guidance, but are considered in relation to access and uptake of the vaccine (vaccine uptake/hesitancy table currently in development).

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1. De Hert and colleagues in World Psychiatry (1^st November 2020) argue that those with severe mental illness should be prioritised because of they have a 2-3 x higher mortality rate than the general population, 10‐20 years reduced life expectancy, and increased rates cardiovascular diseases, type 2 diabetes mellitus, respiratory tract diseases and obesity, which all confer increased risk of morbidity and mortality from COVID‐19. Severe mental illness is also correlated with environmental variables which are risk factors for COVID‐19 infection (e.g. socioeconomic deprivation, working in unsafe environments, overcrowded settings, homelessness, institutionalization and confinement) in addition to system factors which act as barriers to the recognition and management of physical diseases. Recent studies have shown that people with severe mental illness are at a heightened risk of morbidity and mortality from COVID‐19.
2. Siskind et al (JAMA Psych, 15 Dec 2020) outline the challenges even if those with severe mental illness are prioritised. Historically, this group has a low uptake of preventative healthcare programmes, including the influenza vaccine (uptake may be as low as 25% in the US). These will need to be addressed on an individual level (e.g. health education, addressing negative beliefs) and a systems level (e.g. holding vaccination clinics in parallel with mental health clinics, planning of services and registers of those needing vaccination) (vaccine uptake/hesitancy table currently in development).

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General guidance on the legal position in relation to testing for COVID-19 in the context of reduced mental capacity is available at https://www.39essex.com/rapid-response-guidance-note-testing-for-covid-19-and-mental-capacity/.

Guidance on the possible use of the Mental Capacity Act in this setting is at https://www.gov.uk/government/publications/coronavirus-covid-19-looking-after-people-who-lack-mental-capacity/the-mental-capacity-act-2005-mca-and-deprivation-of-liberty-safeguards-dols-during-the-coronavirus-covid-19-pandemic-additional-guidancea.

A guide to capacity assessments in general is here (https://www.39essex.com/mental-capacity-guidance-note-brief-guide-carrying-capacity-assessments/) and a user friendly guide to COVID-19 swab testing here (http://flipbooks.leedsth.nhs.uk/LN004794.pdf).

COVID-19 vaccination in the context of reduced capacity to consent is covered in the guidance at  https://www.gov.uk/government/publications/coronavirus-covid-19-looking-after-people-who-lack-mental-capacity/the-mental-capacity-act-2005-mca-and-deprivation-of-liberty-safeguards-dols-during-the-coronavirus-covid-19-pandemic-additional-guidancea:

• Healthcare professionals offering a COVID-19 vaccine should take all practicable steps to support the person to make the decision for themselves.
• Planning should happen in advance and information should be provided about the vaccine, the likely side effects, what administering the vaccine will involve, and when it will happen. These actions should be recorded.
• Where it has been established that the person lacks capacity to consent, an individual best interests decision should be taken in line with the best interest checklist in section 4 of the Mental Capacity Act. This means that the decision-maker must consider all the relevant circumstances, including the person’s wishes, beliefs and values, the views of their family and what the person would have wanted if they had the capacity to make the decision themselves.
• The decision maker should make a record of their best interests decision.
• Where appropriate, the person’s advocates or those with power of attorney for health and welfare should be consulted. If there is a deputy or attorney with relevant authority then consent must be sought from them to be able to make a decision.
• Decision makers may want to consider the benefits of vaccines to the individual’s health and potential alignment with a decision the person may have taken themselves if they had the relevant capacity.
• Consideration should also be given to the possibility that receiving the vaccine may not be in the individual’s best interest e.g. where administering the vaccine would be significantly traumatic, or where the decision to receive a vaccine would not be one the individual would make, if they had capacity.

Further examples and guidance are provided at https://www.39essex.com/rapid-response-guidance-note-vaccination-and-mental-capacity/.

The first Court of Protection judgement on this issue is summarised at https://www.mentalcapacitylawandpolicy.org.uk/covid-19-vaccination-and-the-mca-the-first-court-of-protection-judgment/.

For those with dementia and their carers/health professionals, useful tips are contained at https://www.rcpsych.ac.uk/docs/default-source/members/faculties/old-age/dementia-uk—useful-tips-on-the-covid-19-vaccine-for-people-with-dementia—december-2020-(3).pdf?sfvrsn=73562f29_2.

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CDC recommends that initial supplies (Phase 1a) of COVID-19 vaccine be allocated to healthcare personnel and long-term care facility residents. Subsequently, vaccination should be offered to people in the following groups:

Phase 1b

• Frontline essential workers such as fire fighters, police officers, corrections officers, food and agricultural workers, United States Postal Service workers, manufacturing workers, grocery store workers, public transit workers, and those who work in the educational sector (teachers, support staff, and daycare workers.)
• People aged 75 years and older.

Phase 1c

• People aged 65-74 years.
• People aged 16-64 years with underlying medical conditions which increase the risk of serious, life-threatening complications from COVID-19.
• Other essential workers, such as people who work in transportation and logistics, food service, housing construction and finance, information technology, communications, energy, law, media, public safety, and public health.

Mental health conditions are not specifically listed as a priority group, nor is ethnic background, but specific occupations at risk are.

As vaccine availability increases, vaccination recommendations will expand to include more groups.

Information on the vaccination programme for each state is contained at: https://www.kff.org/other/state-indicator/state-covid-19-vaccine-priority-populations/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

Further information from the New England Journal of Medicine Vaccine Resource Center is at https://www.nejm.org/covid-vaccine.

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Health Canada states that key populations should be prioritized for initial doses of the vaccine, such as those at increased risk of exposure due to living/work settings, and those at increased risk of severe illness and death from COVID-19 (e.g. advanced age, other high-risk conditions to be determined as the evidence base evolves).

National Advisory Committee on Immunization (NACI) do not specify mental illness as a risk group, but include in the key populations for early immunisations those who are ‘at high risk of illness & death from COVID-19’.

The National Advisory Committee on immunization advises the following prioirtisation:

Stage 1

• Residents and staff of congregate living settings that provide care for seniors
• Adults 70 years of age and older, beginning with adults 80 years of age and older, then decreasing the age limit by 5-year increments to age 70 years as supply becomes available
• Health care workers (including all those who work in health care settings and personal support workers whose work involves direct contact with patients)
• Adults in Indigenous communities where infection can have disproportionate consequences

Stage 2

• Health care workers not included in the initial rollout
• Residents and staff of all other congregate settings (e.g., quarters for migrant workers, correctional facilities, homeless shelters)
• Essential workers

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The Australian Government Department of Health in collaboration with the Australian Technical Advisory Group on Immunisation (ATAGI) have provided recommendations for vaccine implementation which prioritise those:

• Who are at increased risk of exposure (e.g. health and aged care workers).
• Who have an increased risk, relative to others, of developing severe disease or outcomes from COVID-19 including Aboriginal and Torres Strait Islander people, older people and people with underlying select medical conditions (mental health is not currently specified in this group).
• Those working in services critical to societal functioning including select essential services personnel and other key occupations required for societal functioning.

Their prioritisation groups are:

Phase 1a

• Quarantine and border workers
• Frontline health care worker sub-groups for prioritisation
• Aged care and disability care staff
• Aged care and disability care residents

Phase 1b

• Elderly adults aged 80 years and over
• Elderly adults aged 70-79 years
• Other health care workers
• Aboriginal and Torres Strait Islander people > 55
• Younger adults with an underlying medical condition, including those with a disability
• Critical and high risk workers including defence, police, fire, emergency services and meat processing

Phase 2a

• Adults aged 60-69 years
• Adults aged 50-59 years
• Aboriginal and Torres Strait Islander people 18-54 
• Other critical and high risk workers

Phase 2b

• Balance of adult population
• Catch up any unvaccinated Australians from previous phases

Phase 3

• < 18 if recommended

Mental health conditions are not specifically listed as a priority group, but specific ethnic /cultural groups are specified.

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Guidance is that vaccines will start to be delivered in the second quarter of 2021. Three broad groups are included for initial prioritisation, but the order of these groups will depend on the situation at the time – whether low/no community transmission OR Clusters and controlled outbreaks OR widespread community transmission.

The 3 priority groups are:

Group 1

• Border and managed isolation & quarantine workforce
• Health workforce at highest risk of exposure to COVID-19
• Household contacts of the above two groups

Group 2

• High risk frontline health workforce
• High risk frontline public sector and emergency services

Group 3

• People in the community, including older people and those with underlying conditions
• At risk health and social services workforce

Mental health is not identified as a specific priority group.

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Vaccination will be prioritised to start with groups who are at greater risk and hence most in need of COVID-19 vaccination, including healthcare workers and COVID-19 frontline workers, as well as vulnerable groups at greater risk of severe disease from COVID-19 infection, such as the elderly.

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This is the provisional order in which people in Ireland will be vaccinated against COVID-19:

1. People aged 65 years and older who are residents of long-term care facilities (likely to include all staff and residents on site)
2. Frontline healthcare workers
3. People aged 70 and older
4. Other healthcare workers not in direct patient contact
5. People aged 65-69
6. Key workers (Vaccination Programme)
7. People aged 18-64 with certain medical conditions *
8. Residents of long-term care facilities aged 18-64
9. People aged 18-64 living or working in crowded settings
10. Key workers in essential jobs who cannot avoid a high risk of exposure
11. People working in education sector
12. People aged 55-64
13. Other workers in occupations important to the functioning of society
14. Other people aged 18-54
15. People aged under 18 and pregnant women

* Medical conditions include: Chronic heart disease, chronic respiratory disease, Type 1 and 2 diabetes; chronic neurological disease, chronic kidney disease, body mass index >40, immunosuppression, chronic liver disease.

Mental health diagnoses are not included as a priority medical condition.

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COVID-19 vaccination and prioritisation strategies in the EU/EEA are outlined at https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-vaccination-and-prioritisation-strategies.pdf.
The EU advises prioritising vaccination for people whose health makes them particularly at risk for severe COVID-19, but leaves it to member states to decide which medical conditions get prioritised.

A recent review of EU guidance (https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00046-8/fulltext) found that:

• 8/20 countries explicitly mentioned psychiatry or mental illness in their national vaccine strategy documents.
• Several countries prioritised institutional residents, which can include people with severe mental illness.
• 4 countries (Denmark, Germany, the Netherlands, and the UK) had some form of higher vaccination priority for outpatients with severe mental illness. Latvia, Romania, Spain, and Sweden prioritised outpatients with disabilities, possibly including severe mental illness. The Czech Republic and Sweden specified behavioural or mental problems interfering with pandemic regulation adherence as priority indication.

The WHO have issued a framework for guiding prioirtisation, including six core principles that should guide distribution:

• Human Well-Being
• Equal Respect
• Global Equity
• National Equity
• Reciprocity (honour obligations of reciprocity to those individuals and groups who bear significant additional risks and burdens of COVID-19 response for the benefit of society).
• Legitimacy (use transparent processes that are based on shared values, best available scientific evidence, and appropriate representation and input by affected parties).

and twelve objectives that further specify the six principles.

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