How Can We Distribute a COVID-19 Vaccine Equitably?

• There won't be enough vaccine to go around when it's first approved, so who should be next in line after frontline workers?
• What are the ethical principles that we as a society should use to guide distribution?
• What recommendations are included in the framework developed by the National Academies’ Committee on Equitable Allocation of Vaccine for the Novel Coronavirus?

Opener (0:00-0:36)
Intro (0:36-2:48)
Interview part 1 (2:48-12:42)
Break (12:42-13:39)
Interview part 2 (13:39-22:55)
Ending segment throw (22:55-23:45)
Ending segment (23:45-27:23)
Outro (27:23-28:30)

• A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus
• Download the report
• Dr. Diez Roux's Public Health Challenges and Hopes for 2021

Colleen: We’re recording this on December 14th, 2020, just days after the Pfizer vaccine was approved in the United States. At this very moment, healthcare workers are getting ready to receive the very first vaccine doses… finally a welcome milestone in a pandemic that’s killed 300,000 people in the US. But vaccine supply is limited, and will be for many months. So how can we make sure those few doses are distributed in a way that’s equitable and makes sense? And after healthcare workers, who should get vaccinated next?

This question is best answered by medical and public health experts like those on the CDC’s vaccine advisory committee, which in early December recommended that the first round of vaccines go to healthcare personnel and residents of long-term care facilities. In developing these guidelines, the CDC committee also received input from the public and from four professional groups.

Today’s guest is a member of the National Academies, one of the professional groups that advised the CDC committee. Dr. Ana Diez Roux is Dean and Distinguished University Professor of Epidemiology at Drexel’s School of Public Health. She researches health inequity and the social factors that influence health, and sits on the National Academies’ Committee on Equitable Allocation of Vaccine for the Novel Coronavirus.

This committee ultimately came up with seven recommendations for vaccine distribution that they sent to the CDC. Today she shares what those recommendations are, how they were decided, and what ethical principles guided their recommendations. Note: this interview took place in late November before the CDC had officially released its COVID vaccine guidelines, so we discuss the recommendations the CDC will make in future tense. But the principles, criteria, and goals that guided those recommendations are evergreen.

Colleen: Ana, thank you so much for making the time to join me on the podcast today.

Ana: Sure. It's a pleasure to be with you.

Colleen: So, before we dig into how a vaccine for COVID-19 should be distributed, can you give me an idea of roughly what percentage of the U.S. population the vaccine will cover when it is available?

Ana: Well, the truth is we don't know for sure. What we do know is that it's very likely that the quantities initially available will be limited and so, will only cover a small proportion of the population, maybe 10%, 15%, if that. And gradually, as production scales up, we'll be able to expand the number of people that we can give the vaccine to. And so, this is why it's very important for us to have a thoughtful strategy and a plan for how the vaccine should be rolled out when it's available so that it really maximizes the benefits of the vaccine for the society. And also, importantly, I think, you know, that it's distributed in a way that is equitable and fair.

Colleen: In the preface to the report, I was surprised and really pleased to see this statement. And I quote, "In embarking on our task, the committee started with equity. Inequity has been the hallmark of this pandemic both locally and globally." And it goes on to talk about racism, poverty, and bias. So, can you tell me how this played out in the development of the framework?

Ana: Yes. The committee really began by identifying the fundamental principles that we should use as a society to guide the distribution of the vaccine, and it identified three ethical principles. One is that, obviously, we want to seek the maximum benefit for all. The second principle is the principle of treating everyone with equal respect and recognizing that every person has equal dignity, worth, and value. And last but not least, to your point, the key ethical and moral principle of addressing health inequities.

As we know, the pandemic has made very visible these inequities in health that characterize many, many diseases, not just COVID-19, but certainly, in the case of COVID-19 that has been very clear that the risk of acquiring the disease and of having severe disease and dying of the disease is not equally distributed. And it's concentrated in groups that have historically been disadvantaged, discriminated, and have had a number of factors that place them at higher risk. And so, we've seen increased higher risk among black Americans, Native Americans, and Latino populations. And so, the committee felt very strongly that the allocation of the vaccine needed to address these inequities explicitly in one way or another.

Colleen: So, walk me through the framework.

Ana: So, the committee identified initially the guiding principles, the ethical principles that I mentioned earlier, and in addition, some procedural principles that have to do with fairness, transparency... so, explaining very clearly what it is that we're doing and why, and also basing the distribution on evidence. And so, using these overarching principles, the committee identified an overarching goal, which is to reduce morbidity and mortality, as well as the negative societal impact resulting from COVID-19. So, it's really about balancing reducing morbidity and mortality, and also reducing transmission, and also reducing the societal impact that comes from the fact that people are not able to work, for example.

And so, balancing these different criteria, the committee proposed a series of phases that would be gradually implemented. The first phase includes sort of a jumpstart phase where the vaccine would initially be distributed to high-risk healthcare workers and first responders. And then in a second phase to people of all ages who have underlying conditions that place them at higher risk of severe disease as well as older adults living in congregate settings or crowded settings that we know have been very vulnerable to this disease. So, that's the first phase, and that would probably be 5% to 15% of the population.

In a second phase, the distribution would be broadened to include teachers, K through 12 teachers, and school staff, and childcare workers so that children can go back to school. Also, critical workers in high-risk settings, food supply, public transportation, etc., who are essential to society and who are at significantly higher risk of exposure. And also people of all ages with comorbid conditions that place them at moderate risk, as well as people in homeless shelters, prisons, jails, and staff, and older adults in general. And in a third phase, the vaccine would be distributed to young adults and children. Although we should note that the trials that are currently underway do not include children, so we'd have to wait for results in children. Workers and other occupations important to the functioning of society that were not included in the prior phases.

And then in the fourth phase, it would really be everyone living in the U.S. And within each of these phases, the committee also recommended that the distribution prioritize access for geographic areas that are socially vulnerable as defined using a variety of different indices that can be used to target neighborhoods that are socially vulnerable because of socio-economic conditions, because they include race or ethnic groups at higher risk, because of the kinds of occupations and jobs that people have, etc., because of poverty, because of crowding, etc. So, within each phase, the committee recommended that those vulnerable neighborhoods be prioritized.

Colleen: Ss part of the framework process, I noticed that there was space for public comments, and some of the comments critique the focus on individual risk factors over population groups. For example, one commenter suggested that Native Americans and Alaska natives be designated as a high-risk population and have that group included in the highest risk category. So, how did the committee handle those comments and ultimately finalize the framework in the way that it did?

Ana: Yes. This is a very important question. First, I should say the committee had...there was an extensive process through which we obtained public comments, both written and through open meetings, and all comments were recorded and the committee had conversations about the comments that we received because we really wanted to hear what people thought and how they reacted to the preliminary version of the framework that was distributed. So, in thinking about how to capture these inequities by race, and ethnicity, and social, and economic factors as well that we have seen for COVID-19, the committee really tried to capture the underlying causes of these differences that have to do with people's working conditions, with the kinds of jobs that they have, with the kinds of neighborhoods that they live in.

And so, we tried to capture those in the framework itself by prioritizing people who work in essential jobs, many of whom tend to be lower-income and belong to race or ethnic groups that have higher risk in this pandemic. By also prioritizing people with underlying conditions, which we know are related to social conditions. And that's why they tend to be higher in certain race or ethnic groups because the structural racism and inequality are drivers of these underlying conditions themselves. And we also try to capture the inequities in addition to prioritizing certain groups in the framework, also through the use of the social vulnerability index or some similar index to target communities and neighborhoods at particularly higher risk.

The committee decided not to include a race-ethnic category within the framework specifically because we really wanted to get at these underlying drivers and build them into the framework. We were also, you know, concerned that there could be mistrust in communities if we said that the vaccine should be targeted at a particular race or ethnic group, given the long history of mistreatment by the medical community of many of these populations. We were concerned that people would feel targeted in a way that would discourage them from wanting to take the vaccine because they would feel targeted. And we also wanted to have a framework that addressed social determinants broadly. And so, that's why the committee chose to go down this path where we were really trying to capture the underlying structural drivers of these inequities rather than labeling a particular group.

[Break]

Colleen: You raise a really interesting issue, which is the issue of public trust and confidence in a vaccine. We're developing multiple vaccines at warp speed and there may be...I'm assuming there likely will be more than one vaccine. How can people be confident that the vaccine is safe and effective, and how do we handle more than one vaccine?

Ana: Yeah, this is a critical issue. And, you know, as we know, for many very valid historical reasons, there is distrust among many communities, certainly African American community, Native American community, Latino or Latina community, of medical research for very good reasons because of the long history of abuse and mistreatment and lack of information. And in addition, because there's the sense that the vaccine approval process is being done very, very quickly, that we could be cutting corners to try to get a vaccine quickly for political reasons that has not been accurately tested.

And so, it's very, very important that the scientific community and I think all scientists who have been speaking about this have emphasized this point, that we ensure that the process that we're following to test and approve a vaccine follows the most rigorous scientific standards. And then, and this is something that the committee talked quite a bit about, any vaccine allocation strategy needs to be accompanied by a very deliberate and planned and well-funded strategy to engage communities in the process of distributing the vaccine and also very clear communication to everyone about the benefits and the risks of any vaccine.

Colleen: What are some of the top-line recommendations that the committee came up with?

Ana: The framework includes seven recommendations. The first recommendation, of course, is that this framework, which as I said is based on very clear ethical and procedural principles be implemented across the United States. We do, of course, recognize that local authorities will have to operationalize this in different ways. And so, this is intended to be not a rigid but a flexible guiding framework, but that the spirit of it and the key principles should be adopted, including the principle of mitigating health inequities.

The second recommendation is that we should really take advantage of existing systems, structures, and partnerships across all levels of government to distribute the vaccine and provide necessary resources for this. So, this means not necessarily creating a completely separate parallel system, but rather take advantage of the systems that have been used historically, for example, to distribute vaccines to children very effectively. A third recommendation, and this is very important, is that the vaccine should be available with no out-of-pocket cost to anyone, to all people living in the United States, regardless of their immigration status.

A fourth recommendation is that it's very important to create a vaccine risk communication and community engagement program, because, for all the reasons that we have talked about, clear communication about the risks involved and the benefits involved with participation of communities is very, very important. And this will require a very deliberate strategy and also include a vaccine promotion campaign, which was the fifth recommendation. And then also to build an evidence base to identify what are the most effective strategies for vaccine promotion and acceptances. So, learn about what we can do to encourage people to take the vaccine.

And the last recommendation is related more to global issues. The focus of the report is primarily on the distribution of the vaccine in the United States, but the committee did recognize that it's very important to support equitable allocation of the vaccine globally. And this means that the U.S. government should really commit to engaging in global efforts around the vaccine, which means participating in international initiatives to distribute globally such as something called the COVAX Facility, which is a program that brings together governments, philanthropy, healthcare organizations to support the development and distribution of the vaccine across the world, and also to engage with the WHO, which unfortunately the U.S. has recently disengaged with.

So, the committee felt that this was very, very important, both from the point of view of the U.S. specifically, because, obviously, controlling the pandemic globally is in the interest of the United States, but also, most importantly, and fundamentally, because it's really the morally right thing for the United States to do. And the committee even suggested that the U.S. set aside a small proportion of the vaccine supply for global distribution as well.

Colleen: So, is there a way that we can be sure that the guidelines are followed?

Ana: The best way is to create consensus around this kind of approach and for many different voices to advocate for this kind of approach. There are a number of other committees. CDC has its own vaccine advisory committee that will be developing specific recommendations. So, we hope that our proposal will be considered by this committee. We hope that state territorial and local health departments will consider the committee's recommendations as well, as they develop their own specific plans. We hope that various community groups will become engaged, you know, and use and leverage this framework as a way to advocate for an approach that follows these principles about fairness, equity, and transparency in how the vaccine is distributed and talked about.

Colleen: So, do you think ultimately the framework will be effective in increasing people's trust in science again, in federal science and institutions?

Ana: I certainly hope so. We really have to think, of course, of science and public health science, in particular, as something we can all lean on as a society to support the best way forward. And I hope that frameworks like this that are based on the scientific evidence, but that are also grounded in very strong, ethical, and social principles related to fairness, and equity, and justice will motivate a greater acceptance of science as a way to, you know, inform the things that we do as a society. Of course, it's not only science, it's science plus our values, right? Our values as a society. And I think this is something that this particular framework really tried to capture. Sort of integrate evidence and science as we...you know, the information that we have right now, which, of course, is continuously evolving in the case of a disease like COVID-19, but sort of combine that with a very strong principled approach to what we should be doing together as a society to protect health and reduce health inequities.

Colleen: It's so important what you just said, I could not agree more. As I was following the development of the framework, one of...I don't remember who on the committee said this, but they said that you started with the ethical questions and then did the science rather than doing the science and then putting an ethical framework around it. And I thought that was so interesting and so important.

Ana: Yes, that's exactly the way it was, and it was a wonderful process to be part of exactly for that reason. Because it really started with a very strong foundation and our values and our ethical principles, and then sort of went from there. So, it was wonderful to be part of. Yeah.

Colleen: Yeah. That's a great model for others to use.

Ana: Yeah.

Colleen: Well, Ana, thank you so much for the work that you're doing to save lives and disseminate science-based information. We love that here. We need voices like yours front and center right now. It's been really a pleasure talking with you today.

Ana: Thank you. Thank you so much for the opportunity.

Ending segment: Cynthia Derocco
Editing: Omari Spears
Additional editing and music: Brian Middleton
Research and writing: Jiayu Liang and Pamela Worth
Executive producer: Rich Hayes
Host: Colleen MacDonald