Risk of COVID-19 death in adults who received booster COVID-19 vaccinations: national retrospective cohort study on 14.6 million people in England
Authors: Ward Isobel , Robertson Chris , Agrawal Utkarsh , Patterson Lynsey , Bradley Declan T. , Shi Ting , Lusignan Simon de , Hobbs Richard , Sheikh Aziz , Nafilyan Vahé 
Published: July 2023

Importance

The emergence of the COVID-19 vaccination has been critical in changing the course of the COVID-19 pandemic, with estimates suggesting vaccinations have prevented millions of deaths worldwide. To ensure protection remains high in vulnerable groups booster vaccinations in the UK have been targeted based on age and clinical vulnerabilities.

Objective

We sought to identify adults who had received a booster vaccination as part of the autumn 2022 campaign in England yet remained at increased risk of postbooster COVID-19 death and compared to non-COVID-19 risk.

Design, Setting, and Participants

We undertook a national retrospective cohort study using data from the 2021 Census linked to electronic health records. We fitted cause-specific Cox models to examine the association between health conditions and the risk of COVID-19 death and all-other-cause death for adults aged 50-100-years in England vaccinated with a booster in autumn 2022. Our total population was 14,644,570 people; there were 6,800 COVID-19 deaths and 150,075 non-COVID-19 deaths.

Exposure

Sociodemographic characteristics (sex, age, ethnic group, region), disability, body mass index, and diagnosis of a health condition defined from QCovid2.

Main Outcomes and Measures

The primary outcome of this study was COVID-19 death. The secondary outcome was all-cause non-COVID-19 deaths.

Results

Having learning disabilities or Down Syndrome (hazard ratio=5.07;95% confidence interval=3.69-6.98), pulmonary hypertension or fibrosis (2.88;2.43-3.40), motor neuron disease, multiple sclerosis, myasthenia or Huntington’s disease (2.94, 1.82-4.74), cancer of blood and bone marrow (3.11;2.72-3.56), Parkinson’s disease (2.74;2.34-3.20), lung or oral cancer (2.57;2.04 to 3.24), dementia (2.64;2.46 to 2.83) or liver cirrhosis (2.65;1.95 to 3.59) was associated with an increased risk of COVID-19 death. Individuals with cancer of the blood or bone marrow, chronic kidney disease, cystic fibrosis, pulmonary hypotension or fibrosis, or rheumatoid arthritis or systemic lupus erythematosus had a significantly higher risk of COVID-19 death relative to other causes of death compared with individuals who did not have diagnoses.

Conclusions, and Relevance

We identify groups who are at increased risk of postbooster COVID-19 death relative to non-COVID-19 deaths. Policy makers should continue to priorities vulnerable groups for subsequent COVID-19 booster doses to minimise the risk of COVID-19 death.

Funding

National Core Studies–Immunity, National Core Studies–Data and Connectivity, Health Data Research UK, and the Medical Research Council.

Key Points

Question:What health conditions are associated with increased risk of postbooster COVID-19 death in adults who received a COVID-19 vaccination in autumn 2022?

Findings:Certain groups were found to be at overall higher risk of postbooster COVID-19 death (e.g., learning disability or Down Syndrome) and certain groups were found to have significantly higher relative risk of COVID-19 death compared to other non-COVID-19 causes (e.g., cancer of the blood or bone marrow).

Meaning:This work has implications for prioritisation of vaccination booster doses worldwide. We highlight which groups with health conditions are at elevated risk of postbooster COVID-19 death.