Because initial COVID-19 vaccine supply will not meet demand, rationing will be inevitable. That raises ethical and logistical questions about how policymakers and health systems will make allocation decisions.
In addition to addressing the logistical complexity of vaccine distribution, many public health leaders are seeking to address inequities and focus their efforts on vulnerable groups. But questions remain about ordering priorities. When will outpatient clinics that serve homeless populations get doses? What about incarcerated populations? School teachers?
A Dec. 5 story in the New York Times notes that “Health care workers and the frailest of the elderly — residents of long-term-care facilities — will almost certainly get the first shots, under guidelines the Centers for Disease Control and Prevention issued on Thursday. But with vaccination expected to start this month, the debate among federal and state health officials about who goes next, and lobbying from outside groups to be included, is growing more urgent. It’s a question increasingly guided by concerns over the inequities laid bare by the pandemic, from disproportionately high rates of infection and death among poor people and people of color to disparate access to testing, child care and technology for online schooling.”
As part of a Dec. 4 online seminar on vaccine distribution and social justice, Nicole Lurie, M.D., M.S.P.H., strategic advisor to the CEO of the Coalition for Epidemic Preparedness Initiatives, noted that the first available vaccine has substantial cold chain requirements and will be in short supply — there is likely to be a lot less available initially than we anticipated there would be. “What that means is that the vaccine will be distributed to a fixed number of locations that are capable of high throughput for phase 1A populations. It is going to be really complicated,” said Lurie, who previously served as assistant secretary for preparedness and response at the Department of Health & Human Services. In that role, she led the HHS response to numerous public health emergencies, ranging from infectious disease to natural and man-made disasters.
Lurie stressed that there has not been adequate planning for vaccine distribution. Information systems have not been set up. There may be enough doses for only 6 percent of front-line workers in phase 1a. “How do you figure out who those people are? Who decides?” she asked.
Lurie noted that we are looking to Congress to pass a bill to provide financial relief to state and local governments to run a vaccination campaign. Money has to go from the federal government to states and local government to hire vaccinators and the work force to pull this off. “It is not straightforward,” she said. State and local governments need to convene to approve spending the money. That can take a long time and you can’t spend money you don’t have. In past administrations, she said, there were strong partnerships with governors and mayors, and they planned for months to create a consistent framework at the federal level and have state and local governments adapt as needed. “We are way behind in all those efforts,” she said. “If money is not made available, it puts us further behind.”
The four-part seminar series is co-hosted by Ariadne Labs, Boston College, the Harvard Chan School of Public Health, the International Society for Priorities in Health, MIT, O’Neil Institute/Georgetown, the University of Pennsylvania’s Department of Medical Ethics and Health Policy, and the Leonard Davis Institute of Health Economics.
Caroline Johnson, M.D., deputy health commissioner for the City of Philadelphia, described the city’s work to prepare for a situation where there is a large demand and a limited supply. Planning for distribution started in the summer, she said. The city convened an advisory committee made up of people from healthcare provider organizations and community-based organizations to talk about getting vaccines into high-priority groups, with healthcare workers at the top of the list. The first step was cataloging how many of these workers there are and how to access them.
Health systems will have to grapple with equitable ways to distribute within certain physical locations such as emergency departments rather than by job descriptions.
“We thought hospitals and healthcare systems would be interested in standardizing on prioritization,” Johnson said. “But as it turns out, they wanted to make internal decisions based on the needs of different facilities, so we have not established what the sub-prioritization groups should be. Most health systems are comfortable determining within their own agencies.”
Philadelphia also plans to set up clinics early in the communities of color hit hardest by the virus and to partner with groups that serve communities of color to promote vaccination, she said.
Michelle Fiscus, M.D., medical director of the Vaccine-Preventable Diseases and Immunization Program in the Tennessee Department of Health, described the challenge of planning for distribution across the diverse parts of the rural state, including using a social vulnerability index to identify regions of high need as well as overcoming hesitancy about taking the vaccine. Because of the cold chain requirements, rural areas of the state will have to wait for the Moderna vaccine, she said.
She said they were taking the time to micro-plan at the county level to protect the most vulnerable populations. “I don’t know how many plans we have crumpled up and thrown away as changes have come down,” Fiscus said. “It feels like it happens on a daily basis. But I think it is possible to plan for the unknown and create a safe harbor to promote health for every Tennessean.”
Atul Gawande, M.D., founder and chair of Ariadne Labs, began his talk by thanking local public health officials and calling them heroes, saying he could not understate the burden they have been under. They have inadequate staff and computer systems while having to scale up testing and tracing programs, do case reporting, and coordinate with hospitals. “Now we are asking them to lead on making sure vaccine distribution runs smoothly.”
Gawande said other advanced countries have advantages over the United States. For instance, in the U.K., everyone has insurance coverage and most people have relationships with physicians. “The U.K. has a flu list of the most chronically ill already identified. They can use that. Not us. We don't have any of those systems.”
He said a key to success will be demonstrating to the public that a vaccine system is working and equitable, “and that bus drivers can get prioritized ahead of bankers. If we're going to demonstrate a working and equitable vaccine allocation, we need a fair system and one simple enough for the public to understand."
