The decision to recommend only a certain type of Covid-19 vaccine for people over the age of 70 has thrown the State’s carefully-calibrated inoculation plan up in the air and revealed once again the dominant role of chief medical officer Tony Holohan.

Just over a week ago, on January 29th, the European Commission granted conditional marketing authorisation for the use of the AstraZeneca vaccine for over-18s, based on a recommendation from the European Medicines Agency (EMA).

The EMA scientific experts said the vaccine could be used in older adults, despite most participants in AstraZeneca’s studies being aged between 18 and 55. Protection could be expected, they believed, “given that an immune response had been seen in this age group and based on experience with other vaccines”.

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On the same day, Dr Holohan asked the National Immunisation Advisory Committee (NIAC) to look at the European advice and specifically address the issue of using the vaccine in older adults.

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The group immediately held a wide-ranging discussion. In their deliberations, they looked at the risks of disease and the benefits afforded by the vaccines. They discussed vaccine safety, efficacy, age-specific vaccine data and the likely length of time between injection and protection from Covid-19.

The NIAC team also talked about the potential impact on confidence and trust in the vaccination programme, something which has occupied minds in Government Buildings since the national campaign kicked off.

Wasting no time in their deliberations, the NIAC provided their advice to Dr Holohan on Monday. The next day, the chief medical officer sent this to the Minister for Health Stephen Donnelly along with his own recommendations.

Political sources have conceded that what NIAC recommended was different to what Dr Holohan would himself recommend.

The advisory group said “any currently authorised Covid-19 vaccine can be given to adults of all ages, including those aged 70 and older”. Crucially, they said the vaccination of those aged 70 and older “should not be delayed”.

“Where practicable and timely, those aged 70 and older should be given an mRNA vaccine.” Pfizer/BioNTech and Moderna are mRNA vaccines.

This is in contrast to Dr Holohan’s advice that “due to superior efficacy demonstrated by mRNA vaccines, including in older persons (albeit the data is limited) and in recognition of their particular vulnerability in terms of their increased risk of death and serious disease if they contract SARS- CoV-2, it is recommended that mRNA vaccines be administered to all those over 70 years in order to provide the highest level of protection available to this population”.

There was another element to his recommendations that would prove to be important. He told the Minister that “assurance should be provided by the HSE that vaccine supplies will be sufficient to progress this important objective in a timely fashion”.

For some in the Department of Health, the plan seemed quite simple by Wednesday: both the Minister and Dr Holohan would endorse the recommendations from NIAC.

But that evening, alarm bells were sounding in the Department of the Taoiseach. A number of sources who spoke to The Irish Times said the issues were as follows: there were “more questions than answers”, there was not enough detail on what the HSE response would be, and there was that matter of how Dr Holohan “went further” than the advisory group.

The idea of delaying vaccinations for the over-70s at a time when the NIAC said this should not happen also rankled.

Programme recast

Given the importance of maintaining trust in the vaccination programme, officials in the Taoiseach’s department believed there was little to no choice but to recast the vaccination programme so that only the Pfizer and Moderna vaccines, known as mRNA vaccines, would be given to those over 70.

Those close to Mr Donnelly say he was in close alignment with the chief medical officer on the issue. Those helping to co-ordinate the pandemic response 500 metres away in Merrion Street were aware this was a sizeable bump in the road and would result in much scrambling, both in the HSE and for the high-level vaccine task force.

Despite this, there was no public questioning of the chief medical officer despite the ramifications. There was instead a widespread feeling that after the events of Christmas, pretty much no one in Government had the appetite to push back against Dr Holohan.