a medical doctor drawing vaccine from a vial in a syringe in a gloved hand with selective focus on vaccine.

Bioethics Forum Essay

Ethics Supports Seeking Population Immunity, Not Immunizing Priority Groups

Public health officials, policy makers, and national, state and local health system administrators have strived to determine the most ethical and effective way to triage a scarce resource:  vaccinating the population for the coronavirus. Given the limited supply of vaccine, current distribution guidelines seek to protect those most at-risk—either at-risk of serious illness if they become infected (the elderly or chronically ill) or at-risk of being infected (health care and other essential workers). Considerations of fairness, reciprocity, and societal well-being  support protecting those whose work on behalf of others places them at increased risk. Reducing the risk of infection for those most likely to become severely ill may not only protect them from harm, but also reduce the risk of overwhelming health care systems with the need for intensive care.

However, implementing these guidelines necessitates considerable administrative work (sometimes taking weeks) to identify people meeting established criteria for early vaccination, schedule appointments, and then confirm the occupational and/or health status of individuals presenting for vaccination. This is creating a bottleneck that has resulted in doses stuck in freezers, not in arms of those eager for vaccination, as well as either wasted doses or vaccination outside of the guidelines in order to avoid such waste. Recent reports indicate less than half the available vaccine has been administered. Requirements of implementation are thus delaying achievement of the guidelines’ own triage goals. The ethical priorities of equity, reciprocity, and protection of those at highest risk are not being met. Moreover, implementation challenges siphon much needed resources away from achieving the overarching goal of vaccination: creating enough immune people to end the pandemic.

There have been some calls for a more pragmatic approach eschewing micromanaging distribution and instead focusing on speed and access. While there are indeed practical considerations supporting a more logistically streamlined system, we believe there are, more importantly, ethical reasons to prefer an approach that vaccinates more people more rapidly.

The gap between available and delivered vaccine represents the squandered opportunity to save lives—both the lives that might have been protected by inoculation with doses remaining in freezers and those that may be saved by reducing the spread of coronavirus. Though studies have not yet determined that being vaccinated reduces one’s risk of transmitting the infection, this is a reasonable speculation. Greater infectiousness has been associated with higher viral load and with more severe Covid-19 symptoms. Thus, it is reasonable to proceed with vaccination programs on the assumption that among those vaccinated, the vaccines substantially reduce infection by Covid-19 and reduce viral load in those infected. These effects will amplify the impact of any vaccination program.

Acting more quickly to achieve herd immunity, or a level of population-wide immunity necessary to have major impact on disease spread, would reduce the risk of infection faced by everyone, including those meeting the criteria to be in those earliest vaccination groups who have not yet been vaccinated, as well as those in the next group, and the next. It would benefit those who cannot receive the vaccine for medical or other reasons. Even antivaxxers would benefit—population immunity benefits all.

While it is ethically admirable to protect those most at-risk for being infected or for suffering serious illness or death, pursuing those goals directly has proved counterproductive, delaying maximum vaccine delivery and costing a significant number of lives. Achieving the goals of protecting those most at-risk and those who place themselves in harm’s way for others’ benefit (essential workers) can be better achieved indirectly by seeking to achieve population immunity as rapidly as possible.

Approximately 70% of the population—or more, depending upon whose calculation you note—must acquire immunity. That means we need something like 200 to 250 million people to have had either the vaccine or the disease (presuming that the disease confers immunity). If a million people were vaccinated a day, it would take well into the fall to achieve population immunity. With more than 4,000 deaths a day, that is too long. We must go faster. We need to vaccinate 3 million a day to have significant impact in three months. The delay in achieving population immunity puts huge swaths of the public at continued risk. This is an ethical as well as public health concern.

There is a huge number of people who want the vaccine, but do not meet the criteria to receive it yet. Giving these people access will dramatically increase—and meet—demand for vaccine and advance the ethically prioritized goal of achieving population immunity. Removing criteria-based barriers to access, and the administrative work to ensure criteria fulfillment, would speed the process and benefit the populace. Policy or guidelines embracing an open access approach would be fairer than the current practice of than having some get vaccinated just because they are nearby when doses have been thawed and will otherwise go to waste. The reduced administrative burden of an open access approach would reduce variation between jurisdictions, which currently results in, for example, a 65-year-old qualifying for vaccination in one state but not in another.

To be sure, appointments are still going to be needed, but creating more appointment opportunities will be possible by upstaffing with people repurposed to the sequence of tasks: vaccine distribution from the supplier, scheduling, inoculation, post-inoculation observation, and record keeping. Involving more health care professionals in moving patients through the vaccination event can enable greater parallel delivery of vaccine: more people vaccinated per hour.

By focusing on specific risk groups, the more important goal of population protection is currently being compromised. It doesn’t matter as much whether the “right people” are vaccinated as that the required percentage of the population is vaccinated as soon as possible.  What matters most—practically and ethically—in ending a pandemic is the immune status of the population, not of particular individuals. Opening access to vaccination is the practical and ethical path to achieving adequate population immunity.

Michael A. DeVita, MD, FCCM, FRCP, is director of palliative care at Harlem Hospital Center in New York City and a professor of clinical internal medicine at Columbia University Vagelos School of Physicians and Surgeons. Lisa S. Parker, PhD, is director of the Center for Bioethics and Health Law at the University of Pittsburgh and a Hastings Center fellow.

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  1. It seems to me that most of the arguments of this article are sensitive to what the effect sizes are in actuality, and especially the question of what are in fact our bottlenecks in the process of producing immunity through vaccination. We’re only 9 days into a more transparent government actor, but at this moment it seems as though the bottleneck of greatest effect size is the number of existing doses of vaccine, rather than the adequacy of our transportation/distribution_system, or the available professionals able to stick needles into arms (with others to carry out the associated non-clinical tasks), or the identification of “eligible” recipients, or the number of people who will present to be vaccinated. If we had a surplus of vaccine, e.g., for the American population, of 800 million doses, then it would indeed make less sense to fuss bureaucratically about whether those “needing” were receiving their innoculations in order of their need, if accomplishing this ordering actually delayed when even they were getting them. This doesn’t appear to be the case.

    If only 200/1000 population would experience terrible morbidity/mortality; and 100/1000 of these become infected while we are bureaucratically identifying who is eligible and administering the 100 doses/1000 that we have to the other 100/1000, that is preferable to pursuing a rapid non-discriminating approach of deploying the 100 doses randomly among the 1000, and thereby end up sparing 20 people/1000 of terrible morbidity/mortality, and subjecting 180/1000 to terrible morbidity/mortality.

  2. Excellent article and I think this is a very good approach. Enlisting the support of the DOD and military healthcare providers could drastically increase the workforce leading to mass vaccinations and herd immunity.

  3. The dynamics of COVID and vaccine availability, distribution, and inoculation are changing almost daily. While it is true that at the time of this writing doses are not readily available in many regions, in others the concern to avoid “wasting” doses by adhering to triage guidelines arises. Moreover, while the supply is likely to improve rapidly in the near future, the administrative challenges of identifying/verifying, contacting, and actually inoculating those who meet the triage criteria are likely to persist. Involvement of the national guard and many minimally trained volunteers for the administering of the vaccine will not adequately address the challenges of administering the triage criteria. Doing so requires access to patient information, skill in verifying proffered personal information, and skill in contacting and convincing those eligible to receive vaccination. In any case, our ethical point is that emphasis on maximizing the number of people with immunity is best for all those inoculated and those who are not. Whatever mechanism that reduces administrative barriers and promotes additional workers giving the vaccine is good. Barriers, however well intended are putting more people at risk for a longer period of time. Administrative efforts should be directed to ensuring that those who receive their first dose are contactable and encouraged to receive their second, in accordance with evidence-based recommendations to achieve adequate population-wide immunity.

  4. “. . . COVID and vaccine availability, distribution, and inoculation are changing almost daily.” True. And it would be entirely reasonable to have criteria for administering vaccine to change dynamically across locations as well as time in response to such differences. I do not agree that while triage is NOT the limiting factor, and supply remains the limiting factor, to abandon criteria when/while these are not slowing delivery, to consume vaccine in inoculating those less likely to experience serious illness. “. . . our ethical point is that emphasis on maximizing the number of people with immunity is best for all those inoculated and those who are not.” This point simply not true if/while inoculating numbers of some people actually precludes inoculating others who are remarkably more vulnerable if infected, the latter to instead obtain the “trickle down” benefit, likely but still not demonstrated or quantified, of vaccination reducing transmission of the virus in the population to which the vulnerable are exposed. This is policy in advance of the data. If, and when or where supplies outstrip the capacities to ascertain triage considerations, the calculus would be different.

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