How should people of color be prioritized for a Covid-19 vaccine?

AAs the United States moves closer to approving a Covid-19 vaccine, a difficult decision emerges as a central question: Should people in hard-hit communities of color be given priority access, and if so, how should it be done?

Frontline health workers, the elderly and those with chronic illnesses that make them particularly vulnerable to Covid-19 are likely to be in the lead, but public health experts are also being supported to make efforts individuals to administer the vaccine quickly. to blacks, Latin Americans, Hawaiian and Pacific Islander Indians and Native Americans – who have experienced higher rates of serious illness and death from the coronavirus.

“Having a racial preference for a Covid-19 vaccine is not only ethically acceptable, but I think it’s an ethical imperative,” said Lawrence Gostin, professor of global health law at Georgetown University. “The reason is both because of the historic structural racism that has resulted in extremely uneven health outcomes for all kinds of illnesses, and because Covid-19 has had such a disproportionate impact on the lives of people of color.

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Legal objections to any framework that uses race and ethnicity to determine vaccine allocation and how it might be interpreted in courts, however, raise concerns. For example, a forensic review would not allow healthcare workers to skip a white person in the queue for a vaccine in favor of a person of color, as Gostin recently wrote in the Journal of the American. Medical Association. He also noted that legally, a public health agency probably couldn’t distribute vaccines to geographic locations purely on the basis of race.

“I am concerned that if explicit racial priority were given to the Covid-19 vaccine, we could be involved in lawsuits that would really compromise the implementation of the vaccination process, and also risk being overturned by the Supreme Court, in particular with its new conservative majority, ”Gostin told STAT.

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There are also fears that some groups, especially blacks, are reluctant to be among the first to get vaccinated, given the history of abuse of black patients in medical research.

“The other challenge you face when you say, ‘We want African Americans to step in first’ is that we don’t want people to feel like guinea pigs,” said Georges Benjamin, executive director of American Public Health. Association. “We have to be very careful. We don’t want to give people the impression that they are experienced. “

The Immunization Practices Advisory Committee, which provides immunization advice to the director of the Centers for Disease Control and Prevention, will not make a decision on who should be vaccinated and whether to give preference to communities in the area. color, until a vaccine is approved.

The group will be guided in part by a framework released last month by the National Academies of Science, Engineering and Medicine, which calls for taking an equitable approach to vaccine allocation. (Other frameworks that fuel ACIP’s discussion of vaccine distribution were created by the Johns Hopkins Bloomberg School of Public Health and the World Health Organization’s Strategic Advisory Group of Experts.)

The recommendations of the National Academies are divided into four phases and set a goal to ensure that each step of the process takes into account the disproportionate impact on public health and the economy of the virus on older people and communities of color.

“We are making sure that we prioritize the communities that have borne the greatest burden of this pandemic,” said Helene Gayle, president and CEO of the Chicago Community Trust and co-chair of the National Academies report.

Across all phases, national academies say geographic priority should be given to communities that are high on what the CDC calls the Social Vulnerability Index, which identifies communities most at risk and in need of assistance during disasters like hurricanes. The index takes into account poverty, unemployment and health insurance rates, among other socio-economic, demographic, housing and transport vulnerabilities.

“We wanted to make sure there was real consideration in getting it to people most at risk, especially communities of color, who are often higher on this scale of social vulnerability,” Gayle said.

The first phase described by national academies would include frontline health workers like those in hospitals or nursing homes and first responders who are at high risk of contracting the virus. Vaccinating these workers would allow them to continue providing essential care, especially to the elderly who are at greatest risk of contracting or dying from Covid-19, according to the report. According to the Centers for Medicare & Medicaid Services, 63,600 deaths among their residents – more than a quarter of deaths in the United States – and some 800 nursing home staff have died from Covid-19, according to the report.

“An equity lens must ensure that even in these categories we focus on the types of workers who are often overlooked and fall through the cracks of our system,” said Kirsten Bibbins-Domingo, epidemiologist at the University of California, San Francisco, who reviewed the report. “These workers are disproportionately low wage workers. These are disproportionately workers from communities of color. “

Bibbins-Domingo said taking a fair approach to this first phase would mean making sure it’s not just doctors who get the vaccine.

“It is the health worker, the public health worker, the home health worker who will come and take care of my mother, then go to work in a retirement home, then go to work elsewhere. ‘worried who will not have priority. for vaccination and absolutely should be, ”she said. The report states that 27.8% of nursing home workers are black, while among home care aides, 29.7% are black and 17.5% are Latino.

But she said it would be a challenge to ensure fair distribution. It will be up to state, local and tribal health agencies to determine who belongs to each priority group and how to provide it to them.

“It will likely be enforced by the way we distribute vaccines to health care organizations for them to give to their employees,” Bibbins-Domingo said. “And the question will be whether these low-paid healthcare workers, the contract workers, will actually get the vaccines they need.”

The CDC released a revised version of its Covid-19 vaccination booklet in October, which was influenced by the National Academies report and designed to help states, territories, and local health officials develop distribution plans vaccines. The manual suggests that jurisdictions make plans that “ensure equitable access to immunization” and lists under-represented racial and ethnic groups as critical populations who may be at increased risk of acquiring Covid-19.

But Howard Koh, a professor at the Harvard TH Chan School of Public Health and former assistant secretary of health in the Department of Health and Human Services under the Obama administration, noted that the National Academies and ACIP guidelines no. ‘were just guidelines.

“Once all of this guidance and insight and analysis has been put in place, it is ultimately up to government officials to lead and coordinate the distribution,” Koh said. He stressed that national guidelines and principles are not necessarily followed at state and local level, highlighting what happened after the spring shutdown. “Each state has reopened its doors using its own standards. Even though the CDC issued guidelines, they were not implemented and no one was held accountable, ”he said.

Another challenge is that some of the vaccines need to be stored in extreme cold conditions, including the one from Pfizer which is probably the first approved and needs to be stored at minus 94 degrees Fahrenheit. This would limit where they can be stored and what communities, such as Native American populations in rural areas, have access to them.

While the National Academies panel prioritized those most at risk, Benjamin warned his plan could be misunderstood if the public message is not correct.

“If you just say, ‘We want to access this zip code, or that zip code or communities of color’ without doing it at risk, then you run the risk of stigmatizing those populations and giving people a vaccine that they do not need. them, ”he said.

“If you’re healthy, just because you’re African American doesn’t mean you have to put yourself on the front lines,” Benjamin said. “If you’re African American, a bus driver, and you have chronic illnesses. Absolutely.”