Who should get the first vaccine doses?

With this past Monday’s announcement from the University of Oxford and the pharmaceutical company AstraZeneca, three COVID-19 vaccine candidates have now demonstrated clinical trial results which could land them Emergency Use Authorization from the Food & Drug Administration (EUA from the FDA, for short). Pfizer, the first vaccine manufacturer to release its trial results, applied for EUA on November 20. The FDA advisory committee will meet on December 10 to review this application, and vaccines could start shipping out as early as December 12.

These dates are incredibly exciting—December 12 is only three weeks away. But that first vaccine shipment will likely include 50 million doses, at most. Since two doses are required for a patient to be protected against COVID-19, this means up to 25 million people will be able to get vaccinated. That represents just 7.6% of the country’s population. So, who will get vaccinated first?

As per usual in America’s fractured pandemic response, the answer to this question will largely depend on state and local public health authorities. Still, national guidances and data on health disparity allow us to see who should get the vaccine first—and evaluate our local public health authorities when the doses start rolling out.

Earlier this week, the Advisory Committee on Immunization Practices (ACIP) released a report which aims to help local authorities make these decisions. The ACIP is a group of medical and public health experts affiliated with the Centers for Disease Control and Prevention (CDC), which develops recommendations on how vaccines should be used among U.S. residents. The committee has been considering COVID-19 vaccine ethics since April, through a Work Group which conducted literature reviews and presented its findings to the rest of the team.

The ACIP recommends that four ethical principles guide COVID-19 vaccine distribution:

1. Maximize benefits and minimize harms. The first people to get vaccinated should be those who, when they are healthy, are better able to protect the health of others in their community. This includes healthcare workers, other essential workers, and people with preexisting health conditions who would likely need to be hospitalized if they became sick with COVID-19.
2. Promote justice. Americans of all backgrounds and communities should have an equal opportunity to be vaccinated. The ACIP recommends that public health authorities work with external partners and community representatives to help make vaccines available (and attractive) to everyone—both when vaccine supply is limited and when everyone is able to get inoculated.
3. Mitigate health inequities. People of color, especially Black Americans, Native Americans, and Native Hawaiians/Pacific Islanders, have been disproportionately impacted by COVID-19 in the U.S. The legacy of systemic racism in this nation’s healthcare system and economy, as well as disparities in testing availability and care, have contributed to these inequitable outcomes. Vaccine distribution must directly address such inequities by prioritizing racial and ethnic minorities, low-income communities, rural communities, and other marginalized groups.
4. Promote transparency. All the decisions that public health authorities make about who gets the vaccine, when, and how must be communicated clearly to the public. Furthermore, communities should be invited to participate in the decision-making process whenever possible. This kind of transparency helps promote trust in both the vaccines and the people who administer them.

The ACIP’s recommendations are also laid out more practically in two tables at the end of the report. The first table poses essential questions for public health authorities to consider for each ethical principle, while the second applies these principles to four key groups who will be prioritized in the first round of vaccinations: healthcare workers, other essential workers, adults with high-risk medical conditions, and adults over the age of 65.

Dr. Uché Blackstock, the founder of Advancing Health Equity, critiqued the recommendations on Twitter for failing to specifically call out the role of systemic racism in shaping how COVID-19 has impacted Black communities. Still, these principles are a good start in providing us reporters and community members with a framework for watching how our public health authorities distribute vaccines.

The federal government will simply be sending vaccine doses to states based on their overall populations rather than taking the ACIP’s recommendations, according to NPR’s Pien Huang. So, it will be entirely up to states and more local public health departments to prioritize justice, equity, and transparency. What tools should public health departments use in order to apply these principles?

In a webinar last week on vaccine distribution, STAT News reporter Nicholas St. Fleur suggested turning to the CDC’s Social Vulnerability Index. Social vulnerability, as the CDC defines it, measures a community’s ability to recover from events that are hazardous to human health. These events can include tornados, chemical spills, and—of course—pandemics. CDC researchers have calculated the social vulnerability of every Census tract in the U.S. based on 15 social, economic, and environmental factors such as poverty, lack of vehicle access, and crowded housing.

The most recent update of this index was released in March 2020 based on analysis of 2018 Census data. Here’s what it looks like, mapped by Esri’s Urban Observatory:

Here’s the interactive map, and here’s the CDC page where you can download all the underlying data for this index. I highly recommend zooming in to your state and looking at which areas are ranked most highly—if COVID-19 vaccines are distributed equitably, these are the communities that should get priority.

St. Fleur also recommends checking out how your state, city, or county defines essential workers, as these distinctions may vary from region to region. In New York, for example, essential workers include teachers, pharmacists, and grocery store workers. In Texas, essential workers include law enforcement and the Texas Forest Service. The Kaiser Family Foundation report which I featured in last week’s issue compiles links to draft COVID-19 vaccination plans for every state, some of which include these definitions.

I anticipate that vaccine distribution and reporting will continue to be a major topic for this newsletter in the coming months. Questions and topic suggestions are always welcome; you can drop me a line at betsyladyzhets@gmail.com, on Twitter, or in the comments.