Who should get the vaccine next?
After a very tough year, last month we received good news about vaccines that will protect against COVID-19. Pfizer and Moderna submitted applications to the Food and Drug Administration for authorization to market vaccines that may prevent COVID-19 in 95% of those who take them. The FDA authorized Pfizer’s vaccine Friday and could authorize Moderna’s as soon as late this week.
A Centers for Disease Control advisory committee recommended this month that the first vaccine doses be given to health care workers and residents of longterm care facilities, health care workers because they care for everyone else and long-term care facility residents because they account for almost 40% of COVID-19 deaths. This recommendation was expected and it reflects sound judgment.
Now comes the hard part: deciding which groups will get the vaccine next. This will be the most important and most difficult coronavirus challenge that the Biden administration will face. The decision needs to be fair, transparent and designed to protect the largest number of persons without regard to income or social status.
The answer will literally decide who lives and who dies since the vaccine will be in short supply until late spring or summer. In our view, this decision should be based on the simple principle that those who have the greatest risk of dying from COVID-19 should be the next to be vaccinated.
Applying this principle, people who live or work in high-risk, high-transmission communities must be given priority. Giving vaccines as soon as possible to these people will save a disproportionate number of lives because they are more likely to get the coronavirus. Many work in crowded conditions, including factories, meat packing plants, public safety jobs and agriculture. Others live in close quarters. Many are essential workers.
This population is diverse and mobile, presenting implementation challenges, but the need is clear. Migrant agricultural workers have a three-fold higher risk for infection than the general population in one study. American Indians and Alaska Natives have a 3.5 times higher infection rate. While difficult to measure, the infection risk amongst the homeless is high. And prisoners should also be prioritized, having a 4 times higher infection rate than the general population and greater than 8 times in some states.
These groups lack political power and they are usually the last to get society’s most important benefits. Some in these groups will not want the vaccine – at least not initially. And some members of the historically privileged will question why these at-risk communities should be given priority.
But if the guiding principle is saving lives, the vulnerable groups we have identified must be given priority for two reasons. First, members of these groups, who have already withstood a significantly greater burden of the virus, are more likely to be saved by a COVID-19 vaccine because they are more likely to be exposed. Second, giving these groups priority will slow transmission and benefit the entire community since these individuals often have social connections to many others who could be exposed.
Just as there was no room for missteps or delays in developing the vaccine, it is critically important that we make the best and most equitable public health judgments in deciding how to prioritize its distribution. The best way forward across an incredibly complex landscape is to center vaccine distribution plans to curtail transmission and deaths which calls for giving priority to persons who live and work in high-transmission communities.
William B. Schultz was general counsel of the Department of Health and Human Services from 201116, and was deputy commissioner for Policy of the Food and Drug Administration from 1994-1999. Dr. Regan H. Marsh is the senior technical lead for Partners In Health’s US Public Health Accompaniment Unit, an emergency physician at Brigham and Women’s Hospital in Boston, and on the faculty at Harvard Medical School.