Report: Coronavirus vaccine shouldn't be first-come, first-served

Coronavirus vaccine shouldn't be first-come, first-served when initial doses become available, and the focus should be on saving the most lives and reducing illness, according to a report released Tuesday.

The report by the National Academies of Science, Medicine and Engineering said available doses should first go to a "jump-start" group that includes front-line health care workers at the highest risk of being exposed to the virus. Paramedics, firefighters and police also would get priority.

A vaccine probably would be in scare supply when it first became available – with enough doses for only 3% to 4% of the U.S. population – so those at highest risk of sickness and death should be at the front of the line. 

Next on the priority list should be people of all ages with underlying conditions that put them at significantly higher risk of becoming severely ill or dying from COVID-19, according to the draft report, titled "Preliminary Framework for Equitable Allocation of COVID-19 Vaccine." Older people living in care facilities or crowded settings would be in that category.

Francis Collins, director of the National Institutes of Health, and Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, created the committee, which is made up of doctors, ethicists, public health officials and scientists. The public is being asked for comment on the draft report through Friday,

The committee was tasked with looking at the ethical and fairness questions associated with distributing a lifesaving vaccine in the middle of a pandemic.

Though people of color, specifically Black, Hispanic and Native American communities, have been hit hardest by the pandemic, the committee said there has been no evidence this was biologically based but instead reflected systemic racism. For that reason, the recommendations focus on underlying causes instead of specific racial or ethnic categories.

The committee is one of several making recommendations about who should get the vaccine first when it becomes available. Last month, the Johns Hopkins Center for Health Security issued its own report, recommending that front-line health workers and first responders should be in the first tier, as well as people at greatest risk and their caregivers.

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The most important recommendations would come from the CDC’s Advisory Committee on Immunization Practices, which has been working since April to craft recommendations.

Since 1964, the United States has relied on the CDC panel to decide who gets vaccines first. As soon as the Food and Drug Administration licenses a new vaccine, the advisory committee offers guidelines on how it should be distributed, to whom and when.

The committee met last Wednesday for public discussion and has a meeting scheduled for Sept. 22 at which is it expected to propose recommendations.

A four-phase approach

The National Academies panel proposes a four-phase approach, based on the presumption that when a vaccine first becomes available, only 10 million to 15 million courses of vaccine will likely be immediately available.

Most of the candidate vaccines require two doses, 21 to 28 days apart, so 10 million to 15 million courses means 20 million to 30 million doses. That’s enough to vaccinate 3% to 5% of the U.S. population.

In Phase 1, high-risk health care workers and first responders would be the first to get vaccinated. After them would come anyone with health conditions that make COVID-19 more dangerous for them, as well as older adults

When more vaccine is available, Phase 2 would begin. That would include workers in industries essential to the functioning of society who are also at high risk of exposure because they can't work from home. That includes people who grow, pack and sell food, deliver mail, work in pharmacies, drive buses, trains and fly planes, as well as teachers and school staff.

It doesn't include the estimated 37% of American workers who can telecommute and are therefore not at high risk of contracting COVID-19

Also in the Phase 2 group should be all older adults who didn’t get a vaccine in Phase 1, people in homeless shelters and group homes, and people in prisons.

In Phase 3, when the vaccine would be more plentiful, young adults, children and essential workers who didn’t get vaccine in Phase 3 would have the chance to be immunized.

Finally, in Phase 4, when there would be ample vaccine, it should be available to everyone in the United States who didn’t get vaccinated in the earlier phases.

The committee acknowledged that as much of a third of the American public may decline a free, FDA-approved COVID-19 vaccine, but said it believed that if the vaccine is made available equitably and it’s clear who’s getting it first and why, more people may come to trust it.

Some groups have called for a different allocation, including schoolchildren and nonessential workers who are none the less important for the economy.

The committee rejected that argument.

“While the non-trivial effects of an economic downturn or an online semester can at least be partially reversed, death is the most irreversible outcome.”