Most of us are excitedly anticipating the arrival of new vaccines against the novel coronavirus that causes COVID-19. With Food and Drug Administration emergency use authorization of the first two vaccines and the very promising efficacy and safety data on which the EUAs are based, we can hope to prevent many thousands of deaths and begin to return to more normal life over the course of the coming year.
But it will be a long time before there is enough vaccine for everyone who wants and needs it. In a culture where threats of "rationing" have been enough to stymie many innovative health policies, we now find this term widely used in public discussion about allocation of the early and limited vaccine doses. Of course we have to ration, because there are so many people at risk and so little vaccine.
But who should be first? Authoritative national bodies such as the National Academy of Medicine and the Centers for Disease Control and Prevention have issued clear opinions about the ethical guidelines for vaccine allocation, and it appears most states and regions are adopting these general frameworks. There appears to be wide agreement that "healthcare personnel" should be the first group to be vaccinated.
The CDC and the independent Advisory Committee on Immunization Practices, or ACIP, define healthcare personnel as "paid and unpaid people serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials." CDC guidelines include a wide range of healthcare workers, and the actual decisions will be made at the local level. It is easy to say "put healthcare workers first," but the decisions about relative priorities may not be obvious.
We see vivid images of hospitals and especially intensive-care units in the news about COVID-19. Doctors and nurses are working hard in those tough environments, but so are respiratory and physical therapists; and the people who clean the rooms, transport patients, transport bodies or work in the morgue when a patient dies. There are many nonclinical workers who may be at risk of encountering contagion, such as intake workers in emergency departments, urgent-care centers and laboratory settings who are wearing only minimal protective gear, i.e., a mask and perhaps gloves.
Less visible are the many people outside of hospital settings to be considered in these ethical frameworks. Almost 10 million people each year receive care in nursing homes, assisted-living residential settings, hospices and at home. At least 1.5 million staff are involved in direct care, but this doesn't even include administrative staff, food and environmental services workers, and an unmeasured but critically important cadre of volunteers.
In addition to nursing home workers, there are many personal care workers who face the same challenges of public transportation, family demands and child care that are faced by minimum-wage workers in other sectors of the economy. They are exposed to contagion by the nature of their work and by the struggles of their daily lives, and if they become infected they are at risk for worse outcomes.
Of all these millions of workers, who should receive priority in these first critical months?
The ACIP based its priorities on four ethical principles: Maximize benefits and minimize harms; mitigate health inequities; promote justice; and promote transparency. The first three would all seem to point in the direction of more emphasis on workers who are in the community rather than in the hospital. Their numbers are greater, and their potential to expose others is greater because they do not have the elaborate protective gear used in hospitals. The third principle, promote justice, invokes the notion of fairness—that people who are most disadvantaged in confronting this risk should receive special consideration.
While all healthcare workers deserve our respect and admiration, and it would be ideal if all could be vaccinated right away, tough decisions must be made. And the minimum-wage workers face much more difficult personal challenges than the traveling nurses who are earning twice normal pay and staying in hotels.
A rigorous approach to mitigating health inequities and promoting justice would take into account not only the risk of infection but the risks of the devastating consequences to minimum-wage workers who have no support for child care, no options except for public transportation, and family members who face exposure in their own work. These workers do not have the public face of hospital workers rightly honored in the media, but the risks to themselves and their families may be just as great or greater.
For both lower-paid workers in healthcare settings and essential workers in the community, the question should be how to apply first three principles of the ACIP framework. And because of the far fewer resources that lower-paid workers bring to their risk of contracting COVID-19—and its outcomes for them—we should consider elevating our assessment of their need and ensure that we rapidly extend vaccination beyond traditional health settings to most essential workers in the community.
We applaud all the ACIP principles, especially their commitment to transparency. We all wish that everyone who needs it could be vaccinated immediately. But we are faced with deciding who "needs it the most," and that deliberation is worth some reflection. The specifics of these decisions will be interpreted and implemented at the state and local levels. If we endorse the ACIP ethical principles of mitigating health inequities and promoting justice, we should include consideration of the social determinants of risk as we select the first in line for the vaccines.