Covid-19 vaksine

Ikke la vaksinasjonsstrategi bli politikk

Det er vektigere grunner til å gi Folkehelseinstituttet ansvaret for vaksinasjonsstrategien enn å gi Norges bank ansvaret for renteutviklingen.

Stadig oftere kommer politikere og selvutnevnte epidemiologer på banen og krever endringer i vaksinasjonsstrategien. Noen mener det er feil å starte med eldre sykehjemspasienter, de skal jo dø snart likevel. Andre mener at det er liten grunn til å prioritere helsepersonell. Kan hende det ville vært fornuftig å vaksinere mest der det var mest smitte? Mye tyder på at vaksinerte i mindre grad smitter andre. Dette er et argument for å prioritere ald ersgruppene med mest smitte, dvs. unge voksne. Blant arbeidere som bor i brakkerigger og de som deler soverom, er risikoen for smitte stor. Det samme gjelder mennesker med utviklingshemning som bor tett på andre og har et hav med tjenesteytere som bistår. De fleste diagnosegruppene synes å mene at deres diagnose er for lavt prioritert. Mange av argumentene som fremføres for å endre vaksinasjonsstrategien appellerer og har substans. Problemet er at hvis en følger alle argumentene, så vil en prioritere alt.

Stol på Folkehelseinstituttet, men ikke tro på dem

Jeg stoler på Folkehelseinstituttets (FHI) forslag, ikke fordi de er riktige, men fordi de er best. Det er alt for mange forhold som påvirker alvorlige forløp av Coronasmitte til at noen greier å tenke seg til en god løsning. FHI forsøker å samle kjente forholdene som en vet eller antar påvirker alvorlige utfall i en stokastisk modell. Ulike vaksinasjonsstrategier anvendes på ulike smittesituasjoner og resulteten viser hvilke strategier som vil fungere best i de ulike situasjonene.

Styrken med slike modellberegninger, er at en får vurdert alle argumentene samlet. Men modellberegninger trenger slett ikke å være sanne. Men en modell er en forenkling og forskningen på feltet er særdeles mangelfull. Den eldste forskningen på Covid-19 er drøyt ett år gammel, dvs. at det finnes lite forskning, forskningsresultatene er ferske og i liten grad etterprøvd. Det er nok mulig å finne over 1000 diagnoser som kan medføre økt risiko for alvorlige utfall av Covid-19 smitte, svært få av diagnosene er undersøkt mht. risiko ved smitte. Mange har flere diagnoser og det finnes millioner av ulike diagnosekombinasjoner. Effekten av kombinasjoner av diagnoser er det kanpt forsket på. Bo- og livssituasjonen til folk, vet vi kan være avgjørende, men en vet ikke helt hvordan og hvor mye. I hvilken grad folk følger opp smittevernrådene er selvsagt også avgjørende. En modell makter ikke å ta fange opp alle forholdene som kan påvirke, derfor er det viktig å sjekke at forhold som en vet eller tror kan påvirke, blir ivaretatt.

En bør stoler på rådene fra FHI fordi de bygger på alle vanlig fremførte argumenter. Ingen jobber mer på feltet enn FHI og ingen har flere fagfolk på feltet enn FHI. FHI har overhode ikke full oversikt over feltet, men ingen har bedre oversikt. Rådene fra FHI er det beste. Men heller ikke FHI sitter med faciten. Mye er ukjent og mye kan være uteglemt fra FHIs beregninger, en bør derfor ikke tro at FHI besitter sannheten. En på FHIs anbefalinger som de beste, men være kritisk til dem.

Alternativet til å bygger på rådene til FHI, er å åpne for politikere, selvoppnevnte eksperter, interessegrupper og sjarlataner. En slik situasjon vil føre til at de mektigste kommer først i vaksinekøen.

NFUs innspill til vaksinasjonsstrategi

NFU har ved flere anledninger spilt inn forhold som er av bekymring med hensyn til utviklingshemmedes plass i vaksinasjonskøen. Det siste innspillet var et brev til helse- og omsorgsminister Bent Høie. NFUs argumentasjon er blant annet:

Norsk Forbund for Utviklingshemmede (NFU) er bekymret for våre medlemsgrupper. Diagnosemanualen ICD-10 inneholder flere tusen diagnoser. Ingen har kjennskap til alle og kun noen av de mest utbredte diagnosene er blitt undersøkt med hensyn til risiko for alvorlige forløp ved smitte av COVID-19. Blant de sjeldne tilstandene er kompetansen innen helsevesenet svakest. Folks livssituasjon synes også i begrenset grad å inngå i simuleringsmodellene til FHI, selv om den kan påvirke sannsynligheten for å bli smittet.

Det er lite forskning på utviklingshemmede og Covid 19. Imidlertid finnes empiri som viser økt risiko for alvorlige forløp1. Diagnosen utviklingshemning dekker en svært heterogen gruppe, både helsemessig og med hensyn til kognitivt funksjonsnivå og reaksjoner.

Mange med utviklingshemning har underliggende sykdommer som tilsier forhøyet risiko for alvorlige utfall. Det er nok adskillig vanligere enn i den øvrige befolkningen å ha et knippe av diagnoser som hver for seg tilsier moderat økt risiko. Hvordan risikoen samlet sett er, finnes det heller ingen dokumentasjon på, men det er ikke urimelig å anta at knippet av diagnoser samlet sett kan utgjøre en vesentlig økning i risiko.

Ulike sjeldne diagnoser er såpass utbredt at det å ha en sjelden diagnose er relativt vanlig. I gjeldende prioriteringer er f.eks. Downs syndrom nevnt som en tilstand med relativt stor risiko for alvorlige utfall. Som lekmann, ville jeg forventet at Edward Syndrom og mange andre av de sjeldne diagnosene hadde en vesentlig større risiko for alvorlige utfall.

Nedsatt kognisjon er i seg selv en risikofaktor. En blir mindre i stand til å forstå og etterleve smittevernregler og anbefalinger.

Selve livssituasjonen til mennesker med utviklingshemning vil medføre en større sannsynlighet for smitte enn for de fleste andre. De fleste voksne bor i bofellesskap og er avhengig av tjenesteytere. Dem er det mange av. Mange ansatt har småstillinger og det er utstrakt vikarbruk. Tjenesteyterne vil i hovedsak bli vaksinert etter aldersgruppe og mange tjenesteyter, spesielt vikarer, er unge. Noen få personer med utviklingshemning vil vise såpass store reaksjoner på eventuelle vaksinasjonsforsøk, at fordelen med vaksinasjon kan bli mindre enn konsekvensene av å vaksinere. I slike tilfeller vil vaksinasjon av tjenesteyterne kunne være den eneste beskyttelsen.

Konsekvensen av smitteverntiltakene er større for mennesker med utviklingshemning enn de fleste andre. Som følge av smittesituasjonen er de fleste fritidsaktivitetene stengt og dagtilbudene er ofte redusert. Mange har fint lite å ta seg til og har hatt lite å ta seg til lenge. Reaksjonene på en slik tilværelse kan være uheldige, både for den enkelte med utviklingshemning, psykisk helse og miljøet rundt vedkommende.

Beklageligvis kan vi ikke vise til grundige empiriske undersøkelser som tallfester konsekvensene, men utfordringene eksisterer og er større enn for mange andre.

NFU håper at statsråden kan bidra til at forholdene knyttet til mennesker med utviklingshemning blir ivaretatt på en god måte ved revisjonen av vaksinasjonsstrategien og at vi ikke drukner i hensynet til mektigere interesser med kraftigere stemme.

Jens Petter Gitlesen

2 mars 2021

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