10 Ways to Decide Who Gets the COVID Vaccine

The United States is about three weeks away from distributing hundreds of thousands of doses of the new COVID vaccines. The logistics of the largest and fastest vaccination operation in human history are daunting. Our biggest challenge is that millions of Americans face above average risks from the virus, and there will not be enough doses of the vaccine for all of these people in the first round. The first group of high-risk people who come to mind are frontline healthcare workers who have close contact while caring for patients infected with COVID. The second big group is people with high blood pressure, heart conditions, diabetes, and obesity have much greater risks of both hospitalization and death if they get it. While they are a small portion of the total population, 45% of all COVID deaths have occurred in nursing homes and other group care settings for the elderly. Additionally, adults over 65 have a generally higher risk that continues to increase with age. When all of these people have a justifiable reason to be the first ones to be vaccinated, how do we decide who gets it?

This is a global issue and countries all over the world are trying to figure out how to prioritize the allocation. Possible approaches boil down to these ten concepts:

1. Importance to fighting COVID (first responders, health care, government officials, military)
2. Risk of exposure (health care workers, first responders, teachers, retail workers, transportation workers)
3. Risk of death/hospitalization (elderly, people with multiple pre-existing health conditions)
4. Risk of spreading to others (college students, business travelers, workers with high customer interaction)
5. Inability to self-manage risk (nursing home patients, people with disability, prisoners, homeless)
6. Targeted geographic areas (hotspots, rural areas with limited access to health care)
7. Reverse age order (over 90, 85–89, 80–84, 75–79, and so on)
8. Random lottery (birthday, last name letter)
9. First come, first serve (line-up to get it on Monday at 8am — just like the next iPhone or concert tickets)
10. Most accessible populations to administer quickly (all of the employees working at a large business, all of the students on a campus)

Each of these concepts is distinctly different and bring both pros and cons. There are both ethical and practical questions associated with any decision. Elderly people in nursing homes have the highest risk for death, but they are also a very difficult population to administer a vaccine to because the vaccine needs to be transported to them and it must be stored at extreme low temperatures using specialized equipment. Healthcare workers have the most frequent contact with infected patients, but they also have the best personal protective equipment and sanitation available. These risks bring up many difficult questions such as:

• A 50-year-old person who exercises, eats well, and has no pre-existing conditions can have serious complications, and even death, from COVID. Should an 50-year-old unhealthy person be prioritized ahead of a healthy person when may risk factors are connected to lifestyle choices?
• If irresponsible behavior by young people and college students is a major vector for spreading COVID to other populations, should young people be vaccinated ahead of other to slow the spread?
• Healthcare systems, along with state and local governments who are leading the vaccination effort, are already overtaxed after months of the COVID response. Should the vaccine distribution be done in the most efficient way possible so that it reduces additional strain on these organizations?
• When there are so many competing risk factors, is a randomized lottery system the most fair method of allocation?

None of these questions have right or wrong answers…they don’t even have simple answers. Picking only one of the ten options for the vaccination strategy is critically important because there is a short timeframe for distributing millions of doses. We need to figure out how to do this in the next 3 weeks! Using formulas that weigh different levels of risk across multiple categories will create an extremely complex allocation plan. How does the risk to a 72-year-old grocery store cashier differ from that of a 51-year-old teacher with heart disease and diabetes? What if that teacher only teaches remote classes and the cashier is at work every day? How would it even be possible to identify those differences when looking at aggregate data for entire states and counties? It’s not.

Example of complex vaccine planning

Any approach that is selected is going to have some downsides. It is ultimately up to each state to decide how to distribute the vaccine. What is important is having a clear and simple methodology for COVID vaccine distribution that can be consistently messaged by the government and then understood, supported, and followed by all of our citizens.

David Riedman is Ph.D. student in Sociology at the University of Hawai’i and an expert in critical infrastructure protection, homeland security policy, and emergency management. He was a volunteer firefighter for 18 years and is a co-founder of the Center for Homeland Defense and Security’s Advanced Thinking and Experimentation (HSx) Program at the Naval Postgraduate School.