Considerations underlying Prioritisation of COVID-19 vaccine recipients

The scale and rampant spread of COVID-19 has generated a huge challenge for the world. While vaccine candidates are racing through the trial process, countries are gearing up to administer the early vaccines to their populace. It is obvious that initially no country will have enough vaccine supply to vaccinate everyone. In India, we will require about 2 billion doses to vaccinate the more than 1.3 billion people. No freshly approved vaccine will be available in that supply and manufacture can only be ramped up over time to cater to this demand. Thus, initially vaccine demand is going to outstrip supply, necessitating a mechanism of prioritising vaccine recipients.

Several methodologies have been proposed to prioritise vaccine recipients — such as frontline workers first or those with co-morbidities or over the age of 65 years to be vaccinated first. There is universal consensus that healthcare workers be prioritised within the first phase of vaccination. However, there are differing views on which group would accompany HCWs in this phase. Each methodology has its own set of pros and cons and will have champions and detractors. There is no universally correct or right method to prioritise and it will be up to our elected officials to make this hard decision. But a principled decision communicated transparently to the public can help alleviate public anxiety.

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A schematic to show how vaccine demand and supply trajectories may play out

The choice of prioritisation method can rely on 5 considerations:

1. Non-discriminatory — It should not be discriminatory to any social, economic, demographic, or ethnic group

2. Evidence based — the chosen vaccine should have been shown to be effective in the prioritised group. For example, if the vaccine has demonstrated effectiveness in age group 16–60 years, the prioritised group should also fall within this age demography.

3. Prioritised group should be a small, identifiable group — the decision to prioritise will be made by the Union government and this group should be easily identifiable to those eventually administering the vaccine. Ambiguity in the prioritised group can lead to disputes and potentially impact law and order situation at the administration site. For example, healthcare workers are a small group who can be identified through the association number or hospitals/clinical setups they are working with. Prioritising those with hypertension, on the other hand, can be tricky because we don’t have a database of people afflicted with the condition. There is also no certain way for the vaccine administrators to identify people with hypertension, since a one-time blood pressure test is not confirmatory to chronic hypertension. A doctor’s note may be essential to certify the condition, but putting in such a condition could lead to unintended consequences such as generation of fake letters. It would be most prudent to avoid any such ambiguity in the first phase of vaccination. Similarly, the target population should be small, so that enough doses can be secured to vaccinate everyone in one phase.

4. Saving lives and economic revival — this is an obvious principle, but its practical application is complicated by the lack of data on the virus. We are still exploring which demographies are more vulnerable to the severe form of the disease, if these demographies can be effectively vaccinated and how long the immunity last. On the other hand, economic revival would need persons who may be outside the vulnerable group to get exposed to the virus as they carry out their work. Balancing these two requirements is going to be tricky and will be further complicated by the positive externalities of certain occupations.

5. Positive externalities — Vaccinating certain groups of people will have positive externalities for the society. For example, vaccinating a healthcare worker benefits not only her, but all potential patients in her care. Vaccinating a logistic worker delivering essential services ensures continued services to the population. Thus, vaccinating a single person carrying out an essential service will indirectly benefit a larger population.

The policymaker may choose to apply any or all of these considerations in their decision making process. It is important that they convey the reasons behind their chosen prioritisation method, to make it more acceptable to the public. Such communication can prepare sections of the population to either get the vaccine (if they are prioritised) or await their turn. Prioritisation demands that a large group of people will not be able to get the vaccination even after it becomes available and therefore, this group deserves to know why they have to wait.

Prioritisation should not be used as a tactic to delay ramping up supply of the vaccine. India needs to actively invest in increasing vaccine supply and look to vaccinate a majority of its population by the end of 2021.

Finally, prioritisation can be useful only in combination with other measures including social distancing, usage of masks and delivery of social support services to the needy. The peaceful and smooth completion of the first phase of vaccination can be achieved if those not prioritised feel safe from the virus.

COVID-19 vaccination is going to be a major implementation challenge, riddled with some very difficult decisions. However, this challenge can be allayed by reasoned decision-making, transparent communication and effective implementation. There is no right way to tackle COVID-19, but it is important that there be acceptance of the way the policymakers choose to follow.

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