Far too often during the COVID-19 pandemic we have seen decisions driven by political ideology rather than science, leading to the United States having some of the worst outcomes in dealing with COVID worldwide. As we approach decisions on how to allocate a vaccine, once one becomes available, we need to have an approach driven by science.
The problem begins at the top with President Donald Trump continually making promises about how soon a vaccine will be available to everyone, contradicting his scientific advisers. The goal is to have a vaccine available to everyone, but that may take time. In the interim, we need to prioritize who gets the vaccine as limited amounts become available.
As a state representative and with my interest in medicine, science, public health and health policy, I have been appointed to a number of commissions studying health-care issues. I am currently chair of the Therapeutic Cannabis Medical Oversight Board and vice chair of the State Health Improvement Plan Advisory Council.
Recently I was asked by an individual serving on the State Disaster Medical Advisory Committee for my opinion about a 115-page public draft document exploring a framework for vaccine allocation, prepared for the Centers for Disease Control by a National Academy of Sciences committee composed of experts in infectious disease, public health, epidemiology, economics and bioethics. The issues I discuss here are not my musings but are some of the concerns raised by the NAS committee.
Difficult choices will need to be made for allocating a tightly constrained supply of vaccine, perhaps initially only enough to vaccinate 4 percent of the U.S. population. As the supply increases, allocations will be incrementally phased in. This means that some persons or groups of persons will receive it earlier than others. The plan has to be flexible to accommodate changes in knowledge.
The report begins with a review of previous vaccine allocation efforts and lessons learned from them. The NAS committee adopted guiding principles of a program which maximizes benefits, with equal regards for all citizens, while trying to mitigate health inequities. The program would use fair, non-discriminatory guidelines, which are evidence based and decided and administered with transparency.
The goal is to “maximize societal benefit by reducing morbidity and mortality caused by transmission of the novel coronavirus.” This would be achieved by prioritizing 1) those most at risk of acquiring infection and serious outcomes, including death; 2) those in roles considered to be essential for societal functioning; and 3) those most at risk of transmitting the coronavirus to others.
How do we achieve the goal of maximizing societal benefit by reducing morbidity and mortality caused by transmission of the novel coronavirus? It is difficult to determine the most effective vaccine allocation to both reduce death and reduce transmission. Though decreasing the spread of infection will ultimately save lives, when the amount of vaccine is limited, is it more important to save lives or more important to decrease the spread of infection?
Concerns about fairness of rationing arise when age is involved. In this case age is not used as a criterion of allocation alone, but as a predictor of heightened risk of acquiring infection, risk of severe outcomes of infection and the risk of transmission.
Preventing spread may require vaccination of younger people who are less likely to die or become severely ill but may be more likely to spread the disease. Saving lives would require vaccination of the elderly who are more at risk for severe disease and death. Even if saving lives is the priority, given the age difference in mortality, is it more important to save the lives of fewer young people who have many years to live, or more older people with not as many years left?
The NAS committee recommends that Phase 1 would include high-risk workers in health care and first responders, people at significantly higher risk for death or living in congregate and overcrowded settings. Phase 2 would include critical workers and teachers, people at moderate risk, or in group homes or prisons and those who work there. Phase 3 would include young adults and children and workers in essential industries. Phase 4 would be everyone else.
I hope that ultimately when decisions are made, politicians will stay out of the way and let the decisions for vaccine allocation be made by scientists, physicians, and bioethicists using public health criteria.
Jerry Knirk, a Democrat, represents Freedom in the New Hampshire State House.