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Editor's Comment
COVID-19

Vaccination Priorities for 2021

  • 1Deputy Editor, JAMA Health Forum
  • 2Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee

Due to an astounding confluence of human ingenuity and transnational cooperation, millions of health care workers will receive an initial dose of a vaccine for the novel coronavirus by the end of 2020. It’s a hopeful end to a traumatic year, especially for those who have been on the front lines of a global pandemic.

But over the past week, my health professional colleagues receiving with relief their first vaccine dose have turned to ask the same question: “when and how can my parents be vaccinated?” Unfortunately, the answer to this question seems to be the same as the answer to all too many questions in health care: it depends on where you live.

Even the initial images of vaccination display differences across jurisdictions in how policy makers will allocate scarce vaccine resources. In the United Kingdom, where the first dose of the Pfizer-BioNTech vaccine outside of a trial was given, persons living in a “care home for older adults and their carers” were prioritized first, before “all those 80 years of age and over and frontline health and social care workers.” In the United States, an African American nurse from hard-hit New York was the first face of the vaccine rollout that prioritized frontline health care workers concurrent with older adults in residential facilities. As a practical matter of rapid dissemination, initial doses of the Pfizer-BioNTech vaccine were shipped to hospitals with ultralow temperature storage so that they could vaccinate their workforces. Administration to long-term care facility residents and staff is following quickly behind in the United States through a partnership with pharmacies.

The initial images concord with areas developing allocation priorities and deployment plans through different policy-making processes and with different priorities. The United States, not surprisingly, has a web of processes for national vaccine prioritization—yet states have the final say. The National Academies of Science, Engineering, and Medicine (NASEM)—a private organization—created an initial set of recommendations with expert input, including from ethicists.1 The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) has made preliminary recommendations for prioritization as the vaccine approval process progressed.2 Most states are following the ACIP guidance, at least for the initial phases, but some are not. Notably, some are prioritizing those with high-risk conditions above those in older age groups, some are further segmenting within the initial priority groups, and some are treating special populations, like the incarcerated or the homeless, differently.

Similarly, European countries announced plans that vary with respect to how they are treating different age groups, residents of long-term care facilities, and those with comorbidities. The UK has plans to roll out the vaccine by sharply defined age groups, while other countries are working out approaches that target those with medical vulnerabilities. And in China, where virus transmission is low, those accepting risk during the pandemic, such as diplomats and vaccine makers, received the first doses; people in important industries, those interacting with imported goods, and overseas travelers might be prioritized next.

Another area of congruence, though not consensus, around the world, is how to allocate vaccines in ways that increase equity. The NASEM explicitly called its work a “Framework for Equitable Allocation” and recommended the use of a social vulnerability index to guide prioritization within each phase and population group. The World Health Organization similarly supported mitigating health inequities. Yet in the United States, there is concern that an explicit consideration of race could be overturned by the courts.3 It may be that dissemination strategies, as much as explicit criteria, will determine whether vaccine receipt is equitable.4

Of course, one thing we’ve learned from this pandemic is that to fight it, we have to adapt to changing scientific knowledge and information about human behavior. Discussions of age criteria have been conducted in the absence of real knowledge about how well mRNA vaccines work in older adults. There is still uncertainty about whether vaccinated people can still transmit the virus; if this was known for certain, we might prioritize essential workers or younger people to break chains of transmission faster.5 Likewise, we need to be cognizant that marginalized groups disproportionately affected by the virus might be more hesitant to be vaccinated.6 Innovative strategies, informed by social science, to increase vaccine acceptance are needed.7 In other words, all of us in the health policy sphere will need to continue drawing on the wells of flexibility and perseverance we’ve tapped in 2020 into 2021 and beyond if we hope to help defeat this pandemic.

Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Buntin MB. JAMA Health Forum.

Correction: This article was corrected on January 7, 2021, to fix a sentence in which “incarcerated” had been incorrectly written as “incarnated.”

Corresponding Author: Melinda B. Buntin, PhD, Vanderbilt University School of Medicine, Department of Health Policy, 2525 West End Ave, Suite 1200, Nashville, TN 37203 (buntin.jhf@vumc.org).

Conflict of Interest Disclosures: None reported.

References
1.
Stephenson  J.  National Academies report advises on allocation priorities for a COVID-19 vaccine.   JAMA Health Forum. Published online October 13, 2020. doi:10.1001/jamahealthforum.2020.1288Google Scholar
2.
Bell  BP, Romero  JR, Lee  GM.  Scientific and ethical principles underlying recommendations from the advisory committee on immunization practices for COVID-19 vaccination implementation.   JAMA. 2020;324(20):2025-2026. doi:10.1001/jama.2020.20847PubMedGoogle ScholarCrossref
3.
Schmidt  H, Gostin  LO, Williams  MA.  Is it lawful and ethical to prioritize racial minorities for COVID-19 vaccines?   JAMA. 2020;324(20):2023-2024. doi:10.1001/jama.2020.20571PubMedGoogle ScholarCrossref
4.
Lurie  N, Experton  B.  How to leverage the Medicare program for a COVID-19 vaccination campaign.   JAMA. Published online November 19, 2020. doi:10.1001/jama.2020.22720PubMedGoogle Scholar
5.
Persad  G, Peek  ME, Emanuel  EJ.  Fairly prioritizing groups for access to COVID-19 vaccines.   JAMA. 2020;324(16):1601-1602. doi:10.1001/jama.2020.18513PubMedGoogle ScholarCrossref
6.
Lewis  JR.  What is driving the decline in people’s willingness to take the COVID-19 vaccine in the United States?   JAMA Health Forum. Published online November 18, 2020. doi:10.1001/jamahealthforum.2020.1393Google Scholar
7.
Volpp  KG, Loewenstein  G, Buttenheim  AM.  Behaviorally informed strategies for a national COVID-19 vaccine promotion program.   JAMA. 2020. Published online December 14, 2020. doi:10.1001/jama.2020.24036PubMedGoogle Scholar
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    3 Comments for this article
    EXPAND ALL
    Murphy Strikes Again
    Michael Mundorff, MBA, MHSA | integrated healthcare system (retired)
    In the USA, initial allocation of vaccine doses is based on overall population. So Utah, which has far and away the highest proportion of children — for whom administration of the vaccine is not prioritized — of any state, will get more than its fair share of the allotment. Meanwhile Florida, the third-most populous state and where one in five residents is 65 or older, will get less. And so on. This is no way to run a pandemic.
    CONFLICT OF INTEREST: None Reported
    Keep it Simple, Fair, Efficient via Random Lottery
    Daniel Waxman, MD, PhD | University of California, Los Angeles
    Prioritization schemes based upon occupation are logistically unworkable and will lead to unacceptable delays and unnecessary divisiveness. At this point, with large outbreaks happening everywhere, nearly every person in the U.S. has a legitimate argument for prioritization. Society should focus on using every available dose immediately, while ensuring that all members of society have equal access to vaccine. Random allocation by date of birth (not age) would avoid gaming and bickering, would be as likely to maximize public health benefit as any other plan, and would allow for efficient distribution at mass vaccination sites.
    CONFLICT OF INTEREST: None Reported
    Vaccine Information Sheets (VIS)
    Paul Nelson, MS, MD | Family Health Care, P.C. retired
    Long ago, there was a time when immunization traditions were assaulted by a variety of social phenomena intended to discredit them. Various problems occurred regarding their legitimate adverse effects. A strategy to financially respond to these legitimate adverse effects became the norm. Screening for legitimate factors to withhold certain immunizations and a standardized education process about each immunization also became the norm. With the COVID-19 immunization roll-out, there is no vaccine information sheet applying the long-standing traditions for health literacy. Instead, I received a full-color, glitzy generic hand-out that haphazardly communicated its message. An opportunity to strengthen our nation's immunization strategy and its implementation was ignored by the CDC and the vaccine manufacturers.
    CONFLICT OF INTEREST: None Reported
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