Having multiple highly effective vaccines for SARS-CoV-2 is terrific, but it is not the end of the story. Who should get vaccinated first, second, and third remains a vital question.
When vaccines first reached medical centers, some were angry with hospitals' prioritization decisions. At some centers, older faculty, who may not have had much patient contact, were vaccinated ahead of residents, who are on the front lines but often younger. Let me be clear: I do not doubt it is possible for academic medical centers to make huge errors. I am sure that folks with the power to make decisions to benefit themselves might do so. But the more I looked into this specific complaint, that wasn't necessarily the case.
It was entirely possible that vaccinating older healthcare workers, even those with less patient contact, was preferable to vaccinating younger workers on the front lines. This is simply because the risk of bad COVID-19 outcomes grows massively with age and, simultaneously, the danger of being on the front lines has diminished. By January 2021, the risk of healthcare workers contracting SARS-CoV-2 in the hospital was drastically lower than early on in the pandemic, in part due to appropriate countermeasures deployed during the pandemic, such as ventilation and PPE. In other words, what looked like an injustice (residents come last) might actually save more lives.
But one can take this logic further: why not simply vaccinate people based on age, irrespective of occupation, a strategy closer to what the U.K. adopted? And what if we gave more people a first dose and delayed the second dose, rather than giving two doses to fewer people? Finally, if we want to prioritize frontline workers, what if we gave vaccines first to people truly working the highest-risk jobs? That isn't resident physicians, it turns out, but . To some degree, all of these ideas might have saved more lives than what we chose to do in the U.S.
Who Is Next In Line: Kids or Global Citizens?
In the next couple months, the U.S. will have vaccinated every adult who wants one. What comes after this? Pfizer has released results from a randomized trial powered for . At the same time, millions of elderly individuals in Africa, Asia, and South America remain unvaccinated.
The risk of dying from COVID-19 is incredibly low in children and adolescents. In 2020, the chance that a kid ages 5 to 14 would die of COVID-19 was . To put that in perspective, in a normal year, the risk a child commits suicide in this same age group is 10 times higher. In contrast, the risk of death if an 80-year-old becomes infected is as high as 20%. For outcomes besides death, one study showed that visits to the ICU from severe cases of COVID-19 or multi-inflammatory syndrome in children (MIS-C) occurs in .
After all U.S. adults who wish to be vaccinated are vaccinated, COVID-19 hospitalizations will plummet, deaths will plummet too. Cases are more unpredictable, but it is likely they too will plummet. What should our policy be next? Should the U.S. commence vaccinating adolescents in this country? Or instead, should these limited doses be given to older individuals in other nations?
I must admit that I view it as deeply problematic to vaccinate adolescents and kids who are at astonishingly low risk of bad outcomes in wealthy nations before we vaccinate older individuals around the world. Many more people will die as a result of this nationalist choice.
While I am sympathetic to the idea that all nations have some duty to protect their own citizens first, vaccinating all adults will largely accomplish that goal. The clinical trials of vaccinating children are far too small, and the risk of death is far too infrequent to prove that vaccines save lives in kids. What is certain is that deploying these vaccines to older individuals in nations that will still struggle with SARS-CoV-2 is certain to save many more lives.
Moreover, there is even an argument of self-interest here. No nation on earth will truly be safe from re-emergence of coronavirus until all nations pursue vaccination. Widespread pandemic spread in Asia or Africa in the winter will threaten the U.S., even if we demand negative tests prior to entry or implement some "immunity passport" system -- a proposition that concerns me for other reasons.
No matter what the motivation, if indeed we vaccinate U.S. children ahead of older adults in other nations, who are at far higher risk of bad outcomes from SARS-CoV-2, I suspect we may have to explain our choice to future generations.
Prioritizing Vaccination of Hotspots
Another question that has emerged is whether the U.S. should divert vaccine supply to hotspots, such as certain counties in Michigan. COVID-19 cases are climbing there, while they are at record lows in other locations, such as California.
The answer is clear to me: yes, we should move doses to where they mean more. This strategy can avert infections and quell the pandemic, and adults in other cities that are not experiencing spread will not suffer from a short delay in getting their dose.
On Twitter, I saw one observer comment that vaccines should be diverted to hotspots only if they agree to mask mandates or to close certain types of businesses or schools. I am troubled by the idea that we would hold vaccines hostage, while we enforce our ideas about COVID-19 policy. I worry that this type of thinking -- which I believe is contrary to public health principles -- has not served us well this pandemic.
An Opportunity to Save More Lives
We are nearing a situation where our actions will be scrutinized by future generations. Will the U.S. embark on a campaign to vaccinate our children who face staggeringly low risks of bad outcomes from SARS-CoV-2 or will we commit our efforts to saving tens of millions of older individuals who, by sheer chance, have been born in nations that lack the resources of ours? I believe that the right answer in all vaccination questions is to do what saves the most lives. A clear opportunity has presented itself; let's make the smart choice.
, is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of .