Unclear protocol for designating ‘very high-risk’ patients

There are no clear criteria to guide redesignation of a medical condition from ‘very high-risk’ to ‘high-risk’ and vice versa, in regard to Covid-19, heard the expert advisory group (EAG) to the national public health emergency team (NPHET).

According to minutes of the EAG’s meeting on 3 November 2020, it queried the level of risk required to move medical conditions between these categories.

“It was clarified that there is no established acceptable risk criteria, and it was highlighted that this is a current gap where clarity would be beneficial,” according to minutes. “However, it was noted that it is difficult to clarify how much evidence is needed and what risk is acceptable for downgrading.”

“There was a query around whether we can make a decision to move a condition from the very high-risk group to the high-risk group without having a predetermined metric to make that decision. It was clarified that this is often based on expert medical opinion and highlighted that other countries have removed groups from their list based on new evidence.”

The risk categories were noted as having “extremely important implications for vaccine policy as they will inform vaccine allocation”. There was a need for “a clear process for when evidence emerges on risk categories and the requirement for updating categories”.

A HSE spokesperson told the Medical Independent that evidence related to risk of severe illness from Covid-19 continues to evolve. The category of ‘very high-risk’ or ‘extremely medically vulnerable’ was based on the NHS shielding guidance. The ‘high-risk’ group was developed “with HSE public health advice” and based on European Centre for Disease Prevention and Control guidance.

A review of those defined as ‘extremely medically vulnerable’ was conducted by HIQA in late 2020. The advice was not to remove any groups from this list, noting the lack of evidence in certain areas. “Work is ongoing to consider the incorporation of additional patient groups to the overarching definition of those at highest risk of severe illness from Covid-19.”