In it's June meeting, ACIP held preliminary discussions about what new tiers might look like, Schaffner said, keeping in mind that officials will need to know how many doses are available and who responds well to the vaccine. Among those considered for the top tier were high-risk medical, national security and essential workers. Below that might be other health care and essential workers along with people age 65 and older, those who live in long-term care settings and those at high medical risk for severe COVID-19. Those groups include 122 million people.
Future discussions will likely focus on how to slice the various categories.
John Zurlo, an infectious diseases doctor at Jefferson Health, said he would prioritize health care workers most likely to have direct contact with COVID-19 patients and people who live in settings like nursing homes and assisted-living facilities. Low-wage workers with a lot of exposure to the public would also be high on his list, as well as those with conditions like obesity, diabetes and heart disease that raise the risk of hospitalization from COVID-19. The elderly would get priority over the young.
Caplan's list is similar to Zurlo's, with a priority tier that includes first responders, health-care workers and nursing home staff and residents, but he would also add representatives of groups that were not well studied in clinical trials. Then he'd start looking at hot spots. Maybe Houston will need the vaccine more than Boise. He'd want to make sure that key foreign locations are under control so travelers don't reintroduce the virus.
Because Black and Latino people have been more likely to become seriously ill with COVID-19 and to die of it, members of ACIP have discussed whether some racial groups should get preference for the vaccine.
Schmidt says race must be considered. Minority groups are at higher risk in part because they have higher rates of chronic medical problems, but socioeconomic conditions like crowded homes, low-wage jobs without sick leave and the need to take public transportation make things worse. Black and brown workers also often toil in essential businesses like hospitals, nursing homes and grocery stores.
"We have to understand that social justice will loom large in allocating vaccine," the Penn bioethicist said. While legally, governments could not prioritize by race, they could by "social deprivation," a measure that combines income, education, employment, and housing-quality data to rank neighborhoods.
It's clear, he said, that the vaccine should not be dispensed on a first-come-first-served basis. That would help the "well connected and better off."
Schaffner thinks that prioritizing essential workers and those with risk factors will benefit nonwhite Americans. "I don't like vaccine allocation by race," he said. "I think doing it by risk is much the better method."
Should political leaders jump the line? Bresnitz thinks that should be on the table. "We don't want our leadership to be decimated," he said. One could make a case, he said, that career government workers may sometimes be more important than elected officials.
Caplan said we can assume that not everyone will follow the rules. There will inevitably be a black market. "There will be people buying access," he said. "This is America."
It's a safe bet that no one, save possibly those critical health care workers, will be completely satisfied with the eventual rationing scheme.
Bresnitz tells friends and family not to think a vaccine will change everything -- it will be a while before their effectiveness is proven. "Whatever vaccines we have," he said, "it is not going to obviate the need for continuing to practice social distancing and hygiene and even mask wearing."
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