Friday, 5 Mar 2021

Opinion | The Line for a Coronavirus Vaccine Is Forming

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On Monday, Moderna became the second drugmaker, after Pfizer, to apply to the Food and Drug Administration for emergency approval of its coronavirus vaccine. If the companies get it, Americans could start receiving their first shots as early as next weekend — both vaccines require two, spaced several weeks apart — with enough doses for some 20 million people by January.

That could mark the beginning of the end of the U.S. epidemic, but only just: By many estimates, herd immunity will require inoculating upward of 200 million Americans, a manufacturing challenge that will take Pfizer and Moderna at least until April or May to meet. While supplies of the vaccine are still scarce, who should get priority? Here’s what people are saying.

Who gets the ‘jump start’?

The United States is on the precipice of a very grim winter, with the Covid-19 death toll threatening to nearly double the 250,000 mark it surpassed just weeks ago by the spring, as Donald McNeil Jr. reports for The Times. With so many lives on the line, modelers have suggested that distributing vaccines in a tiered way — based on age, risk level or essential worker status, for example — could help avert tens of thousands more deaths than a uniform distribution would.

In October, a panel at the National Academies of Sciences, Engineering and Medicine released recommendations for what those tiers should look like: Health care workers would be at the very front of the line, in what the panel calls the “jump-start phase.” An advisory committee within the Centers for Disease Control and Prevention voted on Tuesday to officially adopt that recommendation, while also moving residents of nursing homes and other long-term care facilities from the second tier to the first.

Together, these two groups account for some 24 million people. There is relatively broad consensus among public-health experts that prioritizing them is the right decision, but it is not without controversy. Top officials in the Trump administration are reportedly pushing to have adults 65 years old and older precede health workers because of the high death rate in that age group. Dr. Ezekiel Emanuel, a medical ethicist at the University of Pennsylvania, has also questioned prioritizing health care workers because, as he told Scientific American, proper personal protective equipment can significantly drive down their risk.

But the C.D.C. committee has so far been steadfast in its support for giving health care workers first priority. Depending on how the White House reacts to the recommendation, the mixed signals coming from Washington may risk confusing the state authorities who will have final say over their distribution plans, as Helen Branswell reports for Stat.

Who should get to go next?

The National Academies framework places people of all ages with two or more conditions that put them at significantly higher risk of severe disease or death from Covid-19, like cancer and diabetes, in the second tier.

But after this population, deciding who’s next in line arguably becomes even more complicated. One reason for that is while the first vaccines appear to at least stop most people from developing severe disease, we do not yet know if they stop people from spreading the virus — a key secondary benefit that, while possible and perhaps even likely, is not assured.

If the vaccine does block transmission, some epidemiologists have suggested, the middle phase of the vaccination drive should prioritize younger adults because they pose a higher risk of spreading the virus. A similar logic has been applied to flu vaccinations since 2009, when epidemiologists showed that better protection against the swine flu could have been achieved by vaccinating those most likely to transmit it instead of just those most vulnerable.

With the coronavirus, “college students and young adults are significant transmitters and also less likely to suffer complications,” Kim Tingley writes in The Times Magazine. “Given these dynamics, if a future vaccine proves to be effective for all ages and is widely available, saving the most lives could mean prioritizing the vaccination of children and young adults — even though they’re among those Covid is least likely to harm.”

Yet many researchers are wary of taking that gamble as long as the vaccines’ transmission-blocking abilities remain unknown. “Let’s forget about protecting the masses to protect the vulnerable,” Dr. Eleanor Riley, a professor of immunology and infectious disease at the University of Edinburgh, told Reuters. “Let’s directly protect the vulnerable.”

The National Academies seems to be taking that tack: In its framework, third priority is allocated equally to older adults, essential workers and people in homeless shelters, jails and prisons, leaving healthy young adults and children last.

What makes a vaccine rollout ‘optimal’?

Much of the discussion around vaccine priority has focused on minimizing the number of Covid-19 deaths and cases, but those will not be the only two factors in play. Dr. Anthony S. Fauci, the nation’s top infectious disease expert, said on NPR in November that the priority list will be graded according not only to risk but to the degree to which certain people, like teachers and child-care providers, are deemed “important to society.”

How one measures importance to society is, of course, a very thorny question. The National Academies framework, for its part, suggests that people should have higher priority “to the extent that societal function and other individuals’ lives and livelihood depend on them directly and would be imperiled if they fell ill.” In other words, economic and quality of life concerns will be part of the equation.

But state officials may come to different conclusions about where the right balance lies between those concerns and the need to contain the virus. In New York, for example, Gov. Andrew Cuomo announced that, in contrast to the National Academies plan, the state would prioritize teachers, transit workers and grocery store workers before the 65 and older age group. That may not minimize the number of lives lost to the virus, but it could presumably do more to relieve the strain so many parents, children and workers are facing.

Finally, public-health officials are weighing how to make the vaccine distribution fair. The National Academies framework notes that particular racial and ethnic groups, including African-Americans, Hispanics and Native Americans, have borne a disproportionate burden from the disease so far, and that redressing that imbalance is a “moral imperative.”

But doing so may be tricky in practice. For one thing, the report explains, the racial disparities in Covid-19 outcomes are a function not of genetics but of systemic racism and socioeconomic factors, such as poverty, crowded housing and an inability to work from home. “This virus has no sense of skin color,” William Foege, a former C.D.C. director who is co-chair of the National Academies panel, told Stat. “But it can exploit vulnerabilities.”

What’s more, trust in the safety of a coronavirus vaccine is especially low among Black Americans, which might best be understood as a natural reaction to “a vast history of centuries of abuse of African-Americans in the medical sphere,” the medical ethicist Harriet Washington told Undark Magazine. If prioritization of Black people for vaccination were perceived by some as a form of experimentation, it could backfire.

In part for those reasons, rather than applying discrete racial and ethnic categories to allocation phases, the National Academies framework recommends that priority be given within population groups to people who score high on the C.D.C.’s Social Vulnerability Index, which accounts for the underlying causes of health inequities.

For the time being, however, only the beginning of the vaccination line is starting to form. In the weeks and months ahead, the C.D.C. still has to vote to finalize its recommendations, which may change as the drive ramps up and, potentially, as more vaccines seek F.D.A. approval.

Whatever federal officials recommend, it will ultimately be up to state and local ones to decide the most ethical way to distribute the doses. As Ms. Tingley writes, “Models can predict what actions might lead to what outcomes, but they can’t say which is right.”

Who do you think should get a vaccine first and why? Email us at Please note your name, age and location in your response, which may be included in the next newsletter.


“When and How You’ll Get a Vaccine” [The New York Times]

“Why Obese People Should Get Covid-19 Vaccine Priority” [Slate]

“Should Millennials and Gen Z Get the Vaccine First?” [Bloomberg]

The Times answers other questions about the new shots. [The New York Times]


Here’s what one reader had to say about the last edition: Thanksgiving during a pandemic.

Evie: “Our son is hospitalized with Covid and we are so scared. We bowed out of family Zoom but I will zoom with my daughter who is out of state and staying put. In any other year, we would be making pies together. So we will FaceTime pie making. She’s doing apple and I’m doing pumpkin. A roaster chicken will be our bird of the day. And I’m thinking of a Three Sisters dish — i.e., squash, beans and corn in honor of our Native roots.

“Please send good thoughts/prayers/mojo to all those families whose loved ones aren’t here or are struggling to survive Covid. And all those who have been in line for food distribution in this terrible time.”

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