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Vaccination priorities

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 freeflyer 11 Jan 2021

The best vaccination priorities could be vital in our battle against the virus. Are the current set the right ones?

I appreciate I'm potentially arguing with the specialist groups assigned to find the 'best' solution, references below, and I'm also aware that vaccination isn't an instant protection.

For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach? Supposing instead you go for targeting the groups most likely to affect the spread of the disease:

Hot spot areas, most likely also to be the poorest and least able to cope.
'Critical' workers - those still working and able to spread the disease.
Teachers
Children in education
Super-spreaders. Why criminalise them when you can vaccinate them.

Paranoia says they may actually be doing this anyway, using logistics to control the supply to the right places and the official advice as a smoke-shield. Only joking (partly).

Links to the official advice:

JCVI - UK Joint Committee on Vaccination and Immunisation:

https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020/annex-a-covid-19-vaccine-and-health-inequalities-considerations-for-prioritisation-and-implementation

and an American discussion paper is here, saying much the same thing:

https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-10/COVID-Chamberland.pdf

 jkarran 11 Jan 2021
In reply to freeflyer:

> For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach? Supposing instead you go for targeting the groups most likely to affect the spread of the disease:

Presuming by ethical reasons you mean reducing excess mortality, that's not the only reason to focus on the oldest and the sick first, keeping them well reduces healthcare burden and the risk of damaging overload. I think that policy almost unquestionably (old, sick plus health and social care workers first) made sense with the old variant as we were able to maintain some semblance of social and economic normality living with it while we waited.

I think to get through this crisis moment with the new varient it probably still makes sense, bringing the hospital load and deaths under control is top priority. Any opening of society now enabled by diverting vaccines from the old would likely also lead to higher prevalence in the old and more severe healthcare overload even sooner.

Once the prevalence/hospitalisation ratio can be increased a bit (by having vaccinated the most at risk of illness) and we have a care capacity buffer back we could look at diverting some doses to those at risk of transmission and of most serious harm from lockdown. Using vaccines to safely re-open schools would obviously be worth consideration.

I doubt we'll see much divergence from the oldest down strategy in reality. I think once the wave III death rate is under control there will almost inevitably be another premature experiment in unlocking education and the economy followed by a significant 4th wave of deaths, mostly in the older working age band but by then hopefully we'll be done with making it up as we go along. Either way, by then it should be a race between getting the vaccine to the 40-60yo group and tinkering with tiers to bring deaths under control.

Hopefully this all stays under review but I doubt we'll do anything radical.

jk

Post edited at 15:56
In reply to freeflyer:

> For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach?

I think it's actually those most likely to die are targeted first.  Largely this is age related but others (care home workers, medical workers, clinically vulnerable) are also high up the list. 

Maybe a switch as you propose to restricting spread once the top for levels (88% of deaths from these groups) are done?

 thetwin 11 Jan 2021
In reply to freeflyer:

You can’t include children as none of the trials had any of them given the vaccine. 

In reply to freeflyer:

Over here they're doing 'oldest down' with both doses as originally recommended, then when they get to level 3 / 4 they will consider going down the UK route with a longer gap between doses in order to vaccinate a higher percentage of the population. By the time they get to that point they'll have better data on the dose gap effectiveness.

In reply to freeflyer:

> For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach? Supposing instead you go for targeting the groups most likely to affect the spread of the disease:

> Hot spot areas, most likely also to be the poorest and least able to cope.

> 'Critical' workers - those still working and able to spread the disease.

> Teachers

> Children in education

> Super-spreaders. Why criminalise them when you can vaccinate them.

The problem is that no-one knows who these people will be.  I don't think a policy of allowing people liable to party the vaccine first will go down well.

I think trying to target those most likely to spread is inherently difficult because there will be so many of them.  Perhaps a better target is those who need to stay healthy for the good of the nation. For example healthcare workers are high up the list so they can keep the NHS working. It would make sense to treat teachers the same way as every teacher off work affects tens if not hundreds of students.  There's also the cost-effectiveness to consider, and the likelihood of a 'bad outcome' - young people with medical conditions are down the list because they're still not as likely to have a bad outcome as an older person without.  The priority list has been compiled using data from about 30 million people I believe, so is statistically sound.

In reply to freeflyer:

> For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach? Supposing instead you go for targeting the groups most likely to affect the spread of the disease:

> Super-spreaders. Why criminalise them when you can vaccinate them.

The problem is that no-one knows who these people will be.  I don't think a policy of allowing people liable to party the vaccine first will go down well.

I think trying to target those most likely to spread is inherently difficult because there will be so many of them.  Perhaps a better target is those who need to stay healthy for the good of the nation. For example healthcare workers are high up the list so they can keep the NHS working. It would make sense to treat teachers the same way as every teacher off work affects tens if not hundreds of students.  There's also the cost-effectiveness to consider, and the likelihood of a 'bad outcome' - young people with medical conditions are down the list because they're still not as likely to have a bad outcome as an older person without.  The priority list has been compiled using data from about 30 million people I believe, so is statistically sound.

In reply to thetwin:

> You can’t include children as none of the trials had any of them given the vaccine. 

It doesn't deter them from insisting that all vaccinators do Safeguarding children level 1 module. I've bashed through that several other rather vaguely relevant modules this morning. You could be forgiven for not realising there's a health emergency. Thirty years in the NHS and they pretend they don't know who I am........

In reply to freeflyer:

NHS and carers first along with anyone going in to hospital to stay and people in care homes.  Followed by key workers, school kids and teachers followed by at risk people in descending order of risk, the rest of the working population, the unemployed.

My reasoning, the NHS look after us and need to be fit to do so, same with care home workers. Key workers keep the lights on, the water flowing and food on the shelves. Kids need to learn and teachers have to be there. Now we have critical people sorted move to the general at risk. Once they are sorted target the younger employed, someone needs to be paying tax to pay for all this. Finally the unemployed. Yes it's probably stigmatising them but the unemployed can stay home whilst working folk need to work for the good of the economy. 

In reply to freeflyer:

They should maybe think about allowing people and businesses to buy unlicensed vaccines.   The Chinese have a vaccine and several more under development, there's a Russian one.  Just because those guys haven't bothered to file with the UK regulators doesn't mean their product is no good.  Large businesses could easily afford a few hundred quid a dose to keep key employees safe so why not let them and get more people vaccinated faster.

 elsewhere 11 Jan 2021
In reply to freeflyer:

> For ethical reasons, age has been chosen as the basic priority. Is this actually the best approach? Supposing instead you go for targeting the groups most likely to affect the spread of the disease:

A GP can identify elderly and clinically vulnerable easily and arrange vaccination appointments. It's practical. There's masses of evidence for this policy.

Do you know who the super spreaders are? Do you have evidence for this?

Do you have evidence that super spreaders are responsible for 1%, 10% or 90% of new infections?

The vaccines haven't been tested on children.

Vaccination is assumed to reduce transmission. It's not proven.

 Si dH 11 Jan 2021
In reply to freeflyer:

Several problems with any proposed move to an infection-control strategy rather than death/severe illness-control strategy;

1) we would need to vaccinate far more people to reduce case load through herd immunity effects than we do to reduce deaths through targeting vulnerable people

2) we don't really know with much confidence where the biggest spread happens anyway. You suggest education, but the main spread is between kids and they can't have the vaccines anyway. Workplace vaccination may well be more effective. Equally, you suggest hot spot areas, but these move around very rapidly, unless you mean an entire region or city region, in which case that's loads of people. FWiW at a local level hotspots are often affluent areas as well as deprived areas, there is a link to deprivation but it's fairly loose.

3) we don't actually know for certain that the vaccine prevents infection or transmission anyway, and if so with what efficacy. We only know the efficacy with which it prevents disease.

Post edited at 18:10
 Mark Edwards 11 Jan 2021
In reply to freeflyer:

Those with the deepest pockets? Someone thinks so.

https://www.bbc.co.uk/news/uk-england-55593210

Surely that has to be criminal (unless they are Tory donors)?

 SDM 11 Jan 2021
In reply to Dax H:

Sounds like the perfect way to guarantee the short term unemployed become long term unemployed!

It would need an exemption for people who have recently lost jobs due to covid if you want them to be able to stop being a burden on state finances and to start contributing to them again.

Once the most vulnerable are sorted, I would like to see priority given to the remainder based on their required levels of social interaction for work i.e:

1) people who cannot work without high levels of interaction first,

2) people with a requirement for some social interaction,

3) people who can work with limited/no interaction (people who can work from home or outside with distancing),

4) the retired and long term unemployed

In reality, I know this wouldn't work because too many employers would try to abuse the system to give their employees priority. Just like many employers are abusing the current rules and guidance by forcing workers in to the workplace who have no need to be there.

In reply to freeflyer:

My guess would be that it's better to target those who, statistically, are more likely to require hospitalisation, certainly now as we rapidly approach critical resource usage in hospitals. So that means the elderly and those with compromised health. It ought to also mean hospital workers, so that that critical resource isn't eroded, and to minimise spread within essential, non-covid, hospital care, and care workers to reduce spread in care homes.

In reply to tom_in_edinburgh:

WTF???? What happened to your 'thou shalt not step outside the trial protocol' line?

How can you be ok with unlicensed vaccines after all the lively debate we've been having?

Post edited at 18:34
In reply to Deleated bagger:

> Thirty years in the NHS and they pretend they don't know who I am........

'They' probably don't know who you are, because 'they' probably aren't the NHS...

 Stuart William 11 Jan 2021
In reply to freeflyer:

Someone was saying something similar to me the other day. My initial thoughts were that the current order mainly focuses on those most likely to be hospitalised and those working in healthcare, with the goal of preventing health services being overwhelmed. It seems to me that bumping the most vulnerable down the list would only work if you also then refuse them medical care if they do get covid in order to protect the health service from being overwhelmed. That’s not a particularly palatable option to my mind. Even more so since we don’t know that the vaccines prevent transmission, so vaccinating the greatest spreaders potentially makes no difference to the risk posed to anyone else or to the pressure the healthcare system is facing. 

Post edited at 18:43
In reply to SDM:

When I said unemployed I meant long term unemployed. 

We need to keep people working in critical industries to keep the services working and we need to get as many people back to work as possible to pay for all this. If the government are correct in what I read earlier that everyone will have the opportunity to be jabbed by August (I think it was August) then let the vulnerable shield for a bit longer whilst we get the country up and running again. 

 girlymonkey 11 Jan 2021
In reply to freeflyer:

I think if we knew that the vaccine prevents spread, then there would be grounds for looking at changing the priorities. As it is, we don't know if it does yet, but we do know it has a really good protective effect against severe illness. 

On these grounds, we should stick to doing the most vulnerable first. If at some stage the evidence becomes clear that the vaccine is highly effective at stopping the spread too, I think we should be open to changing the priority list then

 freeflyer 11 Jan 2021
In reply to freeflyer:

We appear to be doing much better than the rest of Europe however:

https://www.bbc.co.uk/news/world-europe-55575756

Interesting to note the degree of anti-vax opinion, especially in France and Sweden. Weird in fact. I find it very hard to understand why anyone would not want to get vaccinated.

And Putin has not yet had Sputnik V. I might be with him on that

In reply to Longsufferingropeholder:

> WTF???? What happened to your 'thou shalt not step outside the trial protocol' line?

If we aren't going to follow the protocol anyway what's the point in the process?

If the Chinese have done their process and injected a few million people there's more data on their vaccines than these vaccines anyway.  Why should I trust the people in London more than the people in Beijing? Maybe ten or twenty years ago there would be a reason but these days the Chinese are pretty good.

All I'm saying is that if we are in the corner cutting to get more vaccine supply business then just licensing the Chinese vaccine(s) by accepting their process rather than making them go through ours is one way to get a lot more vaccine fast.

I'm not saying the NHS should buy it.  I'm saying we shouldn't actively prevent people who want to buy it in order to get vaccinated faster than the NHS would get to them by making it illegal to import. 

Why not?  More people get vaccinated faster,  which reduces R and the number of people needing treatment in the NHS.  It costs the NHS nothing.  Taking some people out the NHS queue will mean they can actually get to others faster.

> How can you be ok with unlicensed vaccines after all the lively debate we've been having?

I don't think the UK process is any better than other countries.  In fact I think it is probably worse than a fair few including the EU and US.   The way the sh*t is hitting the fan I would seriously think about paying a couple of hundred quid to get a vaccine blessed by the Chinese regulator next week rather than one blessed by the UK regulator in August.   If I was Facebook or Google or Amazon I'd seriously think about spending 10 or 20 million to vaccinate my staff and keep my business running if I had the option to buy some vaccine on the open market in another country.

Post edited at 04:16
In reply to freeflyer:

> Interesting to note the degree of anti-vax opinion, especially in France and Sweden. Weird in fact. I find it very hard to understand why anyone would not want to get vaccinated.

They aren't as scared because they aren't in such a disastrous situation.  Maybe this new variant will put them there in a few weeks.

 Richard Horn 12 Jan 2021
In reply to tom_in_edinburgh:

My vaccine will be available at £20 a pop for anyone willing to try it (I bunged China a few quid and they said it was ok)

In reply to Richard Horn:

> My vaccine will be available at £20 a pop for anyone willing to try it (I bunged China a few quid and they said it was ok)

I find it strange that people are so negative on a Chinese vaccine. Maybe it's because I work in electronics and am used to dealing with engineers all over the world but I don't have an expectation that things are shit because the were designed in China.  Ten or twenty years ago that would be reasonable but they've caught up.   

They did a better job of handling the first wave of Corona than we did.  Why - apart from nationalism/xenophobia/racism should I assume their vaccine is not safe or effective because it hasn't been blessed by some guy in London.  The guys in Beijing are probably just as smart or smarter.

In reply to freeflyer:

There's no proof at all that the vaccine stops or reduces spread.  Therefore we need to probably assume that it doesn't, even if it might do.

Therefore the priorities make sense - the people most likely to die of it first.  NHS staff because they will get high viral loads dealing with patients, the rest by age/condition.

We will see over time if it does reduce or stop spread by changes in the caseload (based on randomised testing), if it proves that it does then this can be reconsidered.  But the highest priority as things stand is to stop people needing hospital treatment (and dying).

Post edited at 13:31
 Richard Horn 12 Jan 2021
In reply to tom_in_edinburgh:

The point was not about Chinese competence, incidentally I also work in electronics and have worked with Chinese companies. China is not an open society though, I have also worked with people from HK who are very much less than impressed by the Chinese state - and in fact they seemed scared to even talk about it even though they were in the UK at the time. Anyway that wasnt really the point I was trying to make... 

What I was trying to highlight is if you start lowering the standards around regulation then there will be a free-for-all for those of low moral fibre to make an absolute killing selling fake vaccines - a tank of saline drip and some convincing looking packaging and you've got yourself a product and millions of quid in your pocket. Look how many contracts were dished out willy-nilly in desperation for PPE which turned out to be completely useless when it arrived. I think it would destroy trust in the vaccine process... 

In reply to Richard Horn:

> What I was trying to highlight is if you start lowering the standards around regulation then there will be a free-for-all for those of low moral fibre to make an absolute killing selling fake vaccines - a tank of saline drip and some convincing looking packaging and you've got yourself a product and millions of quid in your pocket. Look how many contracts were dished out willy-nilly in desperation for PPE which turned out to be completely useless when it arrived. I think it would destroy trust in the vaccine process... 

Looking at this from a personal perspective it could be the Autumn before the NHS offer me a jag  (I live in Scotland and they are called jags not jabs!).  That's 6 or 7 months.  With this new variant there's a pretty strong chance of catching Covid before the NHS vaccinate me.  I can't quantify it with hard maths but it looks like way over 50%, I don't see them locking down hard for that length of time.   The risk if you stay within the system is pretty high and I'd think seriously about spending some money and taking a calculated risk to get a different vaccine faster.

If I was a large business with the resources and it was legal procuring a bunch of vaccine for my employees would be almost a no brainer.   

Post edited at 14:24
 jkarran 12 Jan 2021
In reply to Si dH:

> 2) we don't really know with much confidence where the biggest spread happens anyway. You suggest education, but the main spread is between kids and they can't have the vaccines anyway.

As I understand it for ethical (and to a degree, cost) reasons hardly any drugs/interventions get trialed in and licenced for children. They just get treated as small adults when the likely benefit of intervention outweighs the likely risk of settling for the next best approved option (often nothing). Is it actually true children can't have the covid vaccines?

jk

 jkarran 12 Jan 2021
In reply to tom_in_edinburgh:

> They should maybe think about allowing people and businesses to buy unlicensed vaccines.   The Chinese have a vaccine and several more under development, there's a Russian one.  Just because those guys haven't bothered to file with the UK regulators doesn't mean their product is no good.  Large businesses could easily afford a few hundred quid a dose to keep key employees safe so why not let them and get more people vaccinated faster.

But because they haven't been trialled effectively we don't know they are safe or effective. I have unlicenced 'vaccine' on tap here, hot and cold if you've got the money.

jk

In reply to jkarran:

> But because they haven't been trialled effectively we don't know they are safe or effective. I have unlicenced 'vaccine' on tap here, hot and cold if you've got the money.

https://www.bbc.co.uk/news/world-asia-china-55498197

Says they started to vaccinate people on emergency use authorisation in July and have already administered 4.5 million doses of three different vaccines.  Seems like plenty to get a good idea on safety.

The regulator in Beijing has approved their vaccine and they are saying 79% effective.

With our own government going off-piste and approving protocols outside the trials I'm not sure there's much reason to cast aspersions on the Chinese regulatory process.

 neilh 12 Jan 2021
In reply to tom_in_edinburgh:

Has it really gone off piste approving? There were emergency protocols in place before hand. Thats just your anti governement on anything messaging.

The difference is of course that both the Chinese and Russsians have not published their info for anybody else to have a look at.That is the real question mark.

In reply to neilh:

> Has it really gone off piste approving? There were emergency protocols in place before hand. Thats just your anti governement on anything messaging.

Pfizer are pretty clear that lengthening the delay between first and second dose is not supported by their clinical trials or approved by them.     Approving it anyway is off-piste by any standards.

In reply to neilh:

> The difference is of course that both the Chinese and Russsians have not published their info for anybody else to have a look at.That is the real question mark.

From the BBC article:

"Earlier this month, the United Arab Emirates became the first other country to roll the Sinopharm vaccine out to the public, saying it was 86% effective in a phase-three trials. Bahrain then followed suit, allowing adults to register online to receive the jab for free.

On Thursday, within hours of the Sinopharm vaccine being approved in China, Pakistan announced a 1.2 million dose purchase deal with the company.

media captionHow will the new Pfizer vaccine work?

Singapore has also signed advance purchase agreements with vaccine makers including Sinovac, as well as Moderna and Pfizer-BioNTech.

Shipments of Sinovac have arrived in Indonesia and Sinovac is also known to have secured other deals with Turkey, Brazil and Chile."

Seems to me that they have injected millions of people in China starting quite a few months ago and they've also sold it to multiple other countries.    I think there's an element of English exceptionalism creeping in to assume the product is too risky because the people in London haven't approved it.

The main thing is that 'too risky' needs to be balanced against the risk of catching Covid before the NHS gets around to vaccinating you.   The new variant changes the balance of risk quite considerably.

In reply to tom_in_edinburgh:

> I find it strange that people are so negative on a Chinese vaccine.

Possibly because the Chinese supply chain is riddled with fakes?

Like baby milk formula being formaldehyde?

If I'm buying some cheap electronics from Banggood, it's not really a problem if it doesn't work. A vaccine that I inject is a differnet matter.

 thetwin 12 Jan 2021
In reply to jkarran

> As I understand it for ethical (and to a degree, cost) reasons hardly any drugs/interventions get trialed in and licenced for children. They just get treated as small adults when the likely benefit of intervention outweighs the likely risk of settling for the next best approved option (often nothing). Is it actually true children can't have the covid vaccines?

> jk

That’s not true. Many drugs are licensed for use in children. There is also a lot of drug research in treatments for cancer and rare diseases in children. Children can also be enrolled in trials for covid treatments that are ongoing  

 freeflyer 12 Jan 2021
In reply to Si dH:

> Several problems with any proposed move to an infection-control strategy rather than death/severe illness-control strategy;

> 1) we would need to vaccinate far more people to reduce case load through herd immunity effects than we do to reduce deaths through targeting vulnerable people

> 2) we don't really know with much confidence where the biggest spread happens anyway. You suggest education, but the main spread is between kids and they can't have the vaccines anyway. Workplace vaccination may well be more effective. Equally, you suggest hot spot areas, but these move around very rapidly, unless you mean an entire region or city region, in which case that's loads of people. FWiW at a local level hotspots are often affluent areas as well as deprived areas, there is a link to deprivation but it's fairly loose.

> 3) we don't actually know for certain that the vaccine prevents infection or transmission anyway, and if so with what efficacy. We only know the efficacy with which it prevents disease.

Thanks very much - this was a very clear explanation. The reason for the OP was that the subject comes up fairly regularly socially (ie zoom) and I read the JCVI material but hadn't thought through the rationale in a coherent way.

It's an interesting area, because we need the vaccine take-up to be very high - both in the UK and globally - in order to get back to some normality.

In reply to tom_in_edinburgh:

New info today:

Sinovac: Brazil results show Chinese vaccine 50.4% effective
https://www.bbc.co.uk/news/world-latin-america-55642648

In reply to neilh:

> Has it really gone off piste approving? There were emergency protocols in place before hand. Thats just your anti governement on anything messaging.

Not only is the government off-piste it is going further off-piste every day.

Apparently Hancock has been telling GPs that if they have Pfizer vaccine left over at the end of the day they are not allowed to use it for second doses, they need to chuck it out.  So not only going off-piste with the protocol compared with manufacturer's advice but chucking vaccine away rather than allow it to be used according to advice.

https://twitter.com/SandraToFriends/status/1350842324608278529

And then we have this: every adult in the UK to get a first dose by September, no commitment about a second dose for every adult, and lockdown to be eased in March.

https://www.independent.co.uk/news/uk/politics/covid-vaccine-first-dose-dominic-raab-coronavirus-b1788505.html

If they start lifting lockdown in March and it could take until September until you get a vaccine from government the chance of catching it before you get the vaccine and it is effective are pretty high.

There's going to be huge pressure for private access to vaccines.  Let's remember these are Tories, private healthcare is a business opportunity for many of them and an industry full of Tory donors.

 Ian Archer 18 Jan 2021
In reply to freeflyer:

I think the flaw with vaccinating teachers is that it implies that schools open fully which has seen to spread the virus back to homes where there is often multi generation households. Some of them in the 50- 65 age group with underlying conditions who now look like they have been bumped down the priority list as shop staff, teachers and Police (I do think Police should be prioritised) may be next.

There have been cases where it looks like children have brought the virus into homes and their parents or others living with them have died from the virus. What the long term impact on the children may be of this has not been thought of.

So a fit teacher under 50 will take a vacine from a 50+ person who is more at risk because of diabetes etc. 

 colinakmc 18 Jan 2021
In reply to freeflyer:

I had been thinking round the issue outlined by the OP but I don’t see a way round the age/critically vulnerable first criterion. However when we get to the fitter under-60’s i think other kinds of front line workers should be prioritised, e.g public facing workers in shops & service industries, factory workers etc. , alongside the age pyramid.

surely someone will have a statistical model that might help with this?

 cb294 18 Jan 2021
In reply to Ian Archer:

The point about teachers is that the state, like any employer has a duty of care to reduce health risks to his employees. Witness the endless compusory H+S trainings....

There is a vaccine available in principle, vaccination is therefore state of the art for covid protection.

Thus, no employer should be allowed to force teachers (e.g. my wife) or uni lecturers (e.g. me) to provide face to face teaching without offering vaccination beforehand , as there is an established, safe alternative in online teaching. We also worked our arses off to adapt our coursework when that was the fashion of the day (obviously without being paid for the extra hours), but now we are asked to risk our health for the newest brain fart of the education ministry bureaucrats hiding in offices without student contacts or  working from home.

Obviously there are other groups that should be vaccinated with even higher priority, but until itb is our turn we should at least have the option of continued online teaching. Of course I am happy to supervise my MSc and Bachelor students in the lab in person, which obvioulsy cannot be done online, but I will not take any bullshit about "duty to our students" from bureaucrats unwilling to take the same risks.

CB


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