Who should be first in line for COVID-19 vaccines?

Credit: University of Pennsylvania – Penn Medicine News
INOCULATION QUEUES FORM

The pandemic has forced governments to answer many tough questions and the virus is currently posing another: Who should be at the front of immunisation lines when vaccines against COVID-19 become available? This vexing decision has come into sharp relief as policymakers grapple with how best to allocate doses for scarce vaccines.

Even if in the coming months some vaccines are declared safe and effective, there will not be enough for everyone who wants a shot right away. While many individuals and groups will argue that they should be at the top of the distribution list, determining who should be given priority access to limited supplies is challenging politicians and epidemiologists.

Bio-ethicists have weighed in on the debate as the mass vaccination of almost eight billion people won’t happen overnight. It is widely believed that a phased-in approach – which must be fair and equitable – will be required. But deciding how to apportion supplies of the first batches of coronavirus vaccines – and who will follow the initial jumpstart phase and in what order – is the subject of ongoing debate.

From a health equity perspective, there will undoubtedly be disagreements over vaccine rationing, regardless of what priority ranking is introduced. Prioritisation decisions will be fraught as players (the young, the old, pregnant women, health care workers, those in front-line jobs, people of colour, individuals with pre-existing conditions, etc.) jockey to be early recipients of the drug. Some will claim that it is a matter of life and death that they receive an early jab while others will refuse immunisation all together.

Of course, for nations to distribute vaccines, they must firstly obtain supplies from vaccine manufacturers. Will manufacturers just sell their product to the highest bidders? Or will they take a global perspective and ensure that supplies are rolled out to all nations – even poorer ones? The correct course of action was outlined in a recent article by Bill Gates.

During a pandemic, vaccines and antivirals can’t simply be sold to the highest bidder. They should be available and affordable for people who are at the heart of the outbreak and in greatest need. Not only is such distribution the right thing to do, it’s also the right strategy for short-circuiting transmission and preventing future pandemics.

Though no final agreement has been reached on a single, global distribution framework for COVID-19 vaccines, two main proposals have emerged. A number of experts have argued that health care workers and high-risk populations (the over 65s) should be immunised first. In contrast, the WHO has suggested that countries receive doses proportional to their populations.

From an ethical perspective, both of these strategies are “seriously flawed” according to Professor Ezekiel J. Emanuel from the University of Pennsylvania. He states:

The idea of distributing vaccines by population appears to be an equitable strategy. But the fact is that normally, we distribute things based on how severe there is suffering in a given place, and, in this case, we argue that the primary measure of suffering ought to be the number of premature deaths that a vaccine would prevent.

Professor Emanuel led an international group of 19 health ethicists from around the world (including Australia) to develop a three-phase plan – the Fair Priority Model – for vaccine distribution. In their proposal, as noted in a news release by Penn Medicine, Emanuel and his co-authors point to three fundamental values that must be considered when distributing a COVID-19 vaccine among countries:

Benefiting people and limiting harm, prioritizing the disadvantaged, and giving equal moral concern for all individuals. The Fair Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, as well as economic destruction.

Preventing deaths is seen as the most urgent of all three dimensions and is the focus of Phase 1 of the Fair Priority Model. In Phase 2, two metrics that capture overall economic improvement and the extent to which people would be spared from poverty are proposed. Finally, in Phase 3, countries with higher transmission rates are initially prioritised.

With regard to preventing deaths, the Model begins by calculating the number of years of life that will be added in a given country by the delivery of, for example, a million vaccine doses. Peru, which has experienced high COVID-19 mortality rates and the US, where the virus has killed over 200,000 people, would likely be on the priority list.

“But take New Zealand, giving them a million doses, you’re probably not going to save but one or two people literally. So, they would be low on the priority list,” said Emanuel. The group of 19 rejects the argument that its policies would reward bad management, such as in the US, which leads the world in the number of virus deaths and cases.

“You shouldn’t penalise Americans because Donald Trump can’t seem to manage this pandemic,” he reasoned.

Emanuel and his collaborators – as outlined in the Penn Medicine release – also object to the WHO’s plan, which begins with three per cent of each country’s population receiving vaccines, and continues until every country has vaccinated 20 per cent of its citizens. While that plan may be politically tenable, it “mistakenly assumes that equality requires treating differently-situated countries identically, rather than equitably responding to their different needs,” argues Emanuel.

Health care workers and others most vulnerable are traditionally first in line for a scarce vaccine. But many are calling for geography to play a greater role this time round and to give COVID-19 vaccine priority to people where the outbreak is hitting hardest. Still, the fear remains that many nations will prioritise their own populations first. The resultant uneven scramble may see countries with the greatest need for vaccines being unable to put in place an early and critical ring of protection around their borders.

Another idea that has been floated is to give priority to “super-spreaders”. A trio of US academics believes that after taking care of essential workers, “vaccinations should be given to the biggest transmitters of the virus – mostly the young – and only then to the most vulnerable”.

One of the lessons from past pandemics is that vaccinating likely asymptomatic spreaders early can avert multiple infections with others. The academic trio note that very few of the COVID-19 super-spreaders are elderly. Rather, it is younger people who have a much greater propensity to resume social lives at school and in other venues.

While the strategy of vaccinating the young to protect the old is counterintuitive, there is ample evidence to suggest that this is the right approach. According to UK researchers, immunising those around the elderly may help protect them. It is also instructive to note that a vaccine against COVID-19 may not be as effective in older people who are most at risk of suffering complications and dying from the disease.

Clearly, there is an urgent need for international co-ordination on COVID-19 vaccines to ensure that effective treatments are widely available and appropriately distributed. With many nations likely to adopt a nationalistic approach, there is a high risk that the most vulnerable will not get the life-saving interventions that they need.

Deciding who gets first dibs will be a challenging and contentious task. Most nations are expected to adopt a tiered approach to vaccine distribution. Regardless of the allocation plan adopted, it needs to be transparent and perceived as fair by a majority of the general public.

Of course, fairness – like beauty – is in the eye of the beholder.

Regards

Paul J. Thomas
Chief Executive Officer
Ductus Consulting

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