COMMENTARY

Who in the US Should Get the COVID-19 Vaccine First -- Old, Young, Health Workers, Others?

Arthur L. Caplan, PhD

Disclosures

August 27, 2020

Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Editor's Note: Please view Dr Caplan's video, Both Sides Now, with Drs Auwaerter, Rees and Waldman as they further debate the topic, "COVID-19 Vaccine: Which Country Should Get It First?"

This transcript has been edited for clarity.

Hi. I'm Art Caplan, and I'm at the Division of Medical Ethics at the NYU Grossman School of Medicine. One issue that is becoming increasingly divisive and debated among doctors, ethicists, and policymakers is: If we got a vaccine against COVID-19, who in the United States should go first to get it?

Now, why is that an issue? Because even if we got a vaccine approved early next year, it would not be available for everyone right away. Even if you try to manufacture a vaccine in advance so you have a large amount, you still need to get needles and ship the vaccine out to different locations where people can get it. You'd need to train people to administer it, and you need to get informed consent forms and liability forms out there so that people know what they're agreeing to receive.

If you don't have all of that done, then many folks are going to say, "Don't worry about who goes first. I'm not taking this until I'm convinced that it's safe."

We've had a lot of talk about speed and warp speed and racing that isn't helpful to building trust. We want to be talking about racing and going fast and warp speed to a safe vaccine. Assuming we get that and the data come in and something looks like it's fairly effective and very safe, and we have all the distribution handled and the manufacturing handled and so on, we can assume that we might see 30 or 40 million doses.

In a country of 330 million, that leaves many folks not vaccinated. Even if a significant number of people say they don't want it, there is still going to be a lot of push to get it among people who do see the vaccine as one helpful tool in working our way out of this pandemic.

If you look at the discussion, almost everybody — including government officials, FDA officials, advisory panelists, and ethicists — says the first group that should get this is healthcare workers. They say it, although they're not always clear about why.

One idea is that you need to give it to them because they will keep the healthcare system working, and another is that you need to give it to them because they face risk and they should get rewarded for having done that — almost, if you will, a matter of reciprocity by being first to get the vaccine.

'Healthcare Workers' First?

Whichever the reason, I think there's something else that's interesting when people all agree that it's healthcare workers, which is the definition of who's a healthcare worker. You could easily get millions and millions of people designated as healthcare workers.

We normally think that it's going to be doctors and nurses who work in ERs and ICUs. If you don't vaccinate technicians, people who clean the rooms, make food, transport patients, provide security, do the laundry, and so on, you're not going to have a functioning hospital. You're not going to have a functioning ICU and you're not going to have a functioning ER.

The definition of healthcare worker, even if we say let's give it there first, doesn't answer the question completely about who's going first. Of the group I just mentioned, all of them have to be handled if you're going to keep your hospital functioning.

You also have first responders who are going to bring the patients to the hospital. At a minimum, you've got police, fire, ambulance drivers, and probably Uber drivers who are involved in transport. I think right there, if we put forward those groups broadly defined, you probably used up the initial first supply of vaccine before you even get to anybody else.

That's an interesting feature of distribution. Just defining "healthcare worker," doing it sensibly, doing it reasonably, and including first responders is probably going to wipe out your initial 10-20 million vaccine doses, particularly if the vaccine requires two doses, which some of them do.

After that, I think we get into a more interesting argument about who should go next, and I favor protecting people and saving lives. If you're going to die if you get infected, that's a reason to try to immunize those people if it provides protection against getting the virus in a way that could harm you. That probably means elderly people in nursing homes, but it also means prisoners. Prisons have been heavily ravaged in our country by COVID-19, ailments, and death.

We also have poor neighborhoods, populations where there's a lot of comorbidity, poor healthcare access. Poor minority groups, Native Americans on reservations, inner-city people, and African Americans in very poor neighborhoods may have to get a designation of going next, even though it might prioritize race, zip code, or geography. That does seem to be the reality of where the harms and the deaths are followed.

Then I think we have a third population, and this starts to become a tradeoff between the likelihood of getting sick and whether the vaccine provides any protection against spread of the disease. In other words, vaccines can help you build up enough immunity so that you don't die if you get infected. They may also protect against shedding virus and infecting others.

It's at this third level where we have to start thinking about the spread of the vaccine. We might decide that instead of trying to protect additional people at risk — say, teachers, daycare workers, or others who might legitimately make a claim — it might make more policy sense to try to do a protective ring around places like Florida, Houston, Louisiana, or Phoenix, where outbreaks are raging (if there's still raging at that time of the year) and try to contain the spread of the virus, ultimately hoping to save more lives.

If you look at who is going to get the vaccine first, it's popular to answer this with healthcare workers. I think that answer doesn't even cover all healthcare workers — broadly defined in a way that I think you have to do it — and first responders. We still may have to make choices about who in that group goes first. Even when we address that, we have to trade off saving lives vs containing the spread of the epidemic. Both strategies are valuable and I think we'll have to give some supply toward each purpose.

Now, if that debate interests you and you want to hear more about how we might decide what to do if we had vaccine supply here, took care of our neediest first, but then discussed sharing with other countries, I have an excellent debate coming up on the show that I host, Both Sides Now, with internationally renowned experts who will discuss what's ethical in the distribution of vaccine worldwide.

I'm Art Caplan at the Division of Medical Ethics at New York University's Grossman School of Medicine. Thanks for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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