Update: On Dec. 1, the Advisory Committee on Immunization Practices (ACIP) voted 13-1 to recommend giving the first Covid-19 vaccines to both healthcare workers and residents of long-term care facilities. Individual states will likely follow that recommendation, though they are not required to.
If a coronavirus vaccine is approved, it will take months before there are enough doses for everyone. Even in the US, which has lined up the ability to purchase more than 1.5 billion doses of several vaccine candidates, demand will inevitably exceed supply, forcing the US government to grapple with how to fairly distribute those shots.
The first recipients are fairly uncontroversial: Healthcare workers directly interacting with coronavirus patients. But who comes next?
The next tier of distribution broadly depends on whether the US chooses to prioritize recipients’ personal risk or potential to spread the disease. Currently, several panels of US healthcare experts are developing plans to guide these tough decisions.
A risk-focused approach tends to emphasize protecting groups such as the elderly, who are more likely to suffer the worst effects of coronavirus. Immunocompromised people, such as those who have diabetes, would fall in the same category.
“Given the impact of the virus on the elderly and immunocompromised, I would love to see a push to protect this population,” says Lydia Dugdale, professor of medicine and director of the Center for Clinical Medical Ethics at Columbia University. “Ideally, they would be vaccinated at the same time as front-line doctors and nurses.” This strategy could also factor in the spread of disease by prioritizing the elderly and immunocompromised in certain regions above others: By first focusing on the states with the worst rates of contagion, says Dugdale, it could serve those at the greatest risk of exposure and greatest risk of harm.
Alternatively, vaccines could first be given to those more likely to act as vectors for the virus. Harald Schmidt, a professor of medical ethics and health policy at the University of Pennsylvania, argues that potential “super-spreaders,” such as bus drivers and supermarket employees, should come before other healthcare workers who may have little contact with coronavirus, including neurosurgeons and office-based employees.
Home environments are just as important to consider, he adds. Lower paid workers are more dependent on public transport and can be more likely to live in crowded housing, and so the government could best vaccinate super-spreaders by prioritizing those who have both high-risk jobs and live in less wealthy neighborhoods.
More than mere risk
Whether the government focuses on the most vulnerable or those spreading the disease, some global health experts are making a serious argument for prioritizing vaccine recipients based on race.
Latino and Black Americans are more likely to work jobs that don’t permit them to work from home, such as transport and service jobs that create greater risk of spreading coronavirus. And Black and Latino people face significant personal risk, being twice as likely to die from coronavirus as white people.
Questions of if and how vaccine priorities should consider race have sparked the most debate within the Advisory Committee on Immunization Practices (ACIP), a panel currently drawing up plans, according to the New York Times. At an ACIP meeting in July, Dr. Sharon Frey, a professor of infectious diseases at St. Louis University, said the disproportionate impact of coronavirus on Black and Latino people must be taken into account. “I think it’s very important that the groups get into a high tier,” she said. “Maybe not an entire group, but certainly to address people who are living in the urban areas in these crowded conditions.”
Dayna Bowen Matthew, dean of the George Washington University Law School and an ACIP consultant on vaccine distribution, told the Times that racism should be directly addressed in vaccine distribution plans. “It’s racial inequality—inequality in housing, inequality in employment, inequality in access to healthcare—that produced the underlying diseases,” she said. “That’s wrong. And it’s that inequality that requires us to prioritize by race and ethnicity.”
Prioritizing people based on race carries downsides. “On the one hand, it could be seen as a commitment to justice, to prioritizing the protection of those who have been especially hard hit by Covid-19,” says Dugdale. “On the other hand, given the history of medical experimentation on vulnerable groups, such a campaign could be met with distrust.” Such a decision could also be challenged legally.
Instead, Dugdale and Schmidt suggest focusing on other factors that could help address the racist impact of coronavirus. Vaccines could be dispensed in zip codes where large numbers have coronavirus, or city centers with more crowded living conditions, or gig economy employees, says Dugdale. Alternatively, vaccines could be dispensed according to area deprivation index, which considers income, education, employment, and housing quality, argues Schmidt.
From theory to practice
Prioritization sounds complicated in theory, and is even more complex in practice.
Doctors have already had to create hierarchies of need for the coronavirus drug remdesivir. The University of Pittsburgh implemented a weighted lottery, where health care and emergency medical workers were given priority alongside those from economically disadvantaged areas, reports the New York Times. Those with a lower chance of survival, such as those with other illnesses including advanced cancer, had the lottery weighted against them.
Adding to the complications: There are currently several committees in the US trying to figure out who will get a vaccine first.
Vaccine priority guidance developed by the Centers for Disease Control and Prevention (CDC) in response to the 2009 H1N1 pandemic is being used as a coronavirus distribution template by the CDC’s Advisory Committee on Immunization Practices (ACIP). This plan currently puts “front-line inpatient and hospital-based health care personnel caring for the sickest persons” at the front of the line.
But in July, the National Academy of Medicine also created a panel to decide who should get a vaccine first. Members of the ACIP coronavirus vaccine distribution panel told STAT they weren’t sure if their plans would be used by the government or how their proposals would work with the National Academy Panel.
And Operation Warp Speed (OWS), the federal group dedicated to accelerating vaccine deployment, also announced it would focus on distribution of the vaccine. That led to concerns among vaccine delivery organizations that OWS could create its own prioritization system.
A OWS spokesperson denied this, telling Quartz that vaccine prioritization falls under policy, and OWS does not focus on policy. “The prioritization of any Covid-19 countermeasure will be a policy decision made by subject matter experts who are seeking input from several external parties including medical ethicists,” said a spokesperson.
There’s no easy solution. Healthcare experts at ACIP and the National Academy have been debating the question among themselves, and no decision will be uncontroversial. But when there aren’t enough vaccines for all, someone must inevitably come first.