JIM THOMAS: Deciding just who gets the vaccine first

Friday, Dec. 4, 2020 -- This is the first time that vaccines will be waiting for us rather than the other way around. The current prediction is that injections will begin in late December. There won't be enough for everyone at the beginning. Who should get the vaccine first? That depends on what we want most.

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EDITOR'S NOTE: Jim Thomas is a professor of epidemiology and ethics at the Gillings School of Global Public Health of the University of North Carolina, Chapel Hill.

Vaccines for COVID-19 are nearly here. Even as we wait for their final approval, vials of vaccine are being shipped around the country.  This is the first time that vaccines will be waiting for us rather than the other way around.  The current prediction is that injections will begin in late December.

There won’t be enough for everyone at the beginning. So, who should get the vaccine first?  That depends on what we want most.

Do we want to minimize the number of new cases? Then we should vaccinate first those who are the most likely to get infected or transmit to others.  These would be people who frequently come into contact with others in enclosed spaces.  This could include prisons, nursing homes, and farmworkers. It could also include college students who get infected on a crowded campus then carry the infection home during breaks.
Do we want to minimize the number of deaths? The risk of death from COVID is 90 times higher in people aged 65-74 than it is among the college aged (18-29). To reduce deaths, we would start with the elderly.
Do we want to correct for inequities? Although we have mixed feelings about isolating at home, the ability to do so and to avoid infection has been a luxury not available to everyone.  People with manual labor jobs cannot “phone it in” as others have.  Those jobs are often for low pay, such as housekeeping on college campuses, and held by racial or ethnic minorities.  The risk of infection among Latinx people in North Carolina is four times the risk among others.
Or do we want to keep society functioning? We need clinicians to care for those with infection and to vaccinate the uninfected.  With the surge we are currently experiencing, hospital staff are getting infected or exposed, putting them in isolation or quarantine rather than in the hospital wards.  Some small hospitals are at risk of having no physicians on duty.  A vaccine could help them stay on the job to care for others.

Each of these goals has value but we can’t have them all at once. How do we decide among them?

We gather advisory groups with a diverse representation of life experiences and areas of expertise to propose various perspectives and argue towards a consensus. The National Academy of Medicine was the first to propose a vaccine allocation framework. The North Carolina Department of Health and Human Services followed with a draft plan soon afterwards, and asked the N.C. Institute of Medicine to convene a group to provide feedback. (I am in this group, but I do not speak for it.)
The different plans are consistent on many of their priorities and with earlier guidance available on the Pandemic Ethics Dashboard. They single out health care workers at risk of getting infected and long-term care (LTC) facility staff as those to get vaccinated first. Many LTC staff are minorities. With the care givers secured, the next priority includes LTC residents, thus protecting those most vulnerable to infection and most likely to die if infected. Next in line are those who can’t avoid crowded settings, such as teachers, farmworkers, and the incarcerated.

We can see in these choices that the rich and powerful are not at the front of the line. Rather it is those who are most at risk of infection or death, which includes high-risk low-income workers who are often minorities.

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