Frontline health workers, those at risk of severe illness and death should get Covid-19 vaccine first: Report

Frontline health workers, those at risk of severe illness and death should get Covid-19 vaccine first: Report
(Getty Images)

The Covid-19 pandemic will continue for the foreseeable future but widespread vaccination could hasten its end, say experts. However, when a vaccine is authorized for use, it will initially be in limited supply. A research team now suggests that frontline health workers providing care for Covid-19 patients, pandemic vaccine manufacturing and supply chain personnel, and those at greatest risk of severe illness and death and their caregivers should be the first in line to the coronavirus vaccine when it is ready.

The multidisciplinary team of public health experts at Johns Hopkins University have recommended priority groups for vaccine allocation, divided into two tiers. These are offered as “candidate groups to whom those creating an allocation scheme should give serious consideration.” The broad candidate groups that should be given serious consideration for tier 1 vaccination include those most essential in sustaining the ongoing Covid-19 response, those most essential to maintaining core societal functions, and those at greatest risk of severe illness and death, and their caregivers.

“The primary reason for including these candidate groups within tier 1 is that their prioritization would likely avert the greatest overall harm. More precisely, including these groups in tier 1 advances the ethical value of 'promoting the common good', and the more specific goals of preventing Covid-19-related illness and death, protecting the health system, and protecting essential services,” the authors explained. “Inclusion of the first two groups is clear — they help address the pandemic and keep basic services available. Additionally, while there are limited doses of vaccine, direct protection against Covid-19 of those most vulnerable to severe disease, and those who have the highest contact with them as care providers, would likely to be the most efficient way to minimize overall morbidity and mortality from coronavirus.” 

The team includes members from the Johns Hopkins Bloomberg School of Public Health Center for Health Security, the Johns Hopkins School of Medicine Armstrong Institute for Patient Safety and Quality, and the Johns Hopkins Berman Institute of Bioethics. According to the authors, other groups who deliberate about vaccine allocation might well reach different conclusions as to the criteria for inclusion in the different tiers or the groups within each tier. “However, any group that proposes priority groups for vaccine allocation must be able to defend their recommendations in terms of explicitly acknowledged values and principles,” the report emphasizes. 


Besides frontline medical workers, frontline emergency medical services personnel, Covid-19 diagnostic and immunization teams, and public health workers carrying out critical, frontline interventions in the community are part of the group the experts have designated as essential in sustaining the ongoing Covid-19 response. Those at greatest risk of severe illness and death include adults aged 65 years and older and those living with them or otherwise providing care to them, frontline long-term care providers, and healthcare workers providing direct care to patients with high-risk conditions. It also covers other individuals and groups at elevated risk of serious Covid-19 disease, including people with health conditions that put them at significantly increased risk of serious disease, potentially including those who are pregnant or are members of social groups experiencing disproportionately high fatality rates. 


Those at greatest risk of severe illness and death include adults aged 65 years and older and those living with them or otherwise providing care to them, say experts. (Getty Images)

Those identified as most essential to maintaining core societal functions in tier 1 are frontline public transportation workers, food supply workers, and teachers and school workers, from pre-kindergarten through 12th grade. 

The researchers, however, caution that there will likely not be enough vaccine supply for all members of tier 1 candidate groups to be offered vaccines concurrently. They stress that prioritization decisions will likely have to be made within tiers. “In this case, how might we think about prioritizing within these groups? Decision-makers prioritizing within tier 1 groups should consider whether certain subgroups have greater needs, provide greater benefit, or have multiple strong claims to limited doses,” they suggest.

For the second tier, the report suggests those involved in broader health provision beyond the Covid-19 response, those who face greater barriers to accessing care if they become seriously ill, those contributing to the maintenance of other essential services not listed in tier 1, and those whose living or working conditions give them the elevated risk of infection, even if they have a lesser or unknown risk of severe illness and death. “Tier 2 expands upon the tier 1 categories to address those who are required to sustain the health system beyond more direct Covid-19 care and those who provide the next level of essential services for a functioning society. Tier 2 also includes those who are at higher risk of bad outcomes because they face barriers to accessing care,” says the study.

Health workers and staff with direct patient contact (non-Covid-19 specific) and pharmacy staff belong to the group the authors consider essential to broader health provision, while those living in remote locations with substandard infrastructure and healthcare access (Native American reservations, isolated rural communities) have been described as a group with least access to healthcare.

Frontline workers involved in maintaining operation of electricity, water, sanitation, information, financial, fuel infrastructure (who cannot work remotely), warehouse, delivery workers (including postal workers), deployed military (including National Guard) involved in operations, police and fire personnel with frequent public contact, and transportation Security Administration and border security personnel with direct public contact belong to the group that the report says are needed to maintain other essential services in the US.

The experts argue that it may take many months before most US residents have access to vaccination when it is ready, and bottlenecks at various stages of the vaccine manufacturing process (for example supply of vials or syringes, fill and finish process) could cause further delays in vaccine availability.


The researchers caution that it may take many months before most US residents have access to vaccination when it is ready. (Getty Images)

The researchers say it is important to emphasize that they are not providing a set of definitive recommendations about who should be prioritized for vaccination. “Rather, based on our ethics framework, we have identified candidate groups that should be given serious consideration as priority groups. We believe that this initial framework could serve as a conceptual resource to inform the design and execution of a timely national dialogue — one achieved through multiple forms of community engagement appropriate to a physical distancing environment. This is a task the federal government should undertake or commission as soon as possible,” write authors. They warn, “The state of knowledge when vaccine product first becomes available cannot now be reliably predicted, and the Covid-19 vaccination will be a long-term endeavor. The virus is likely to become endemic and require ongoing vaccinations and revaccinations into the foreseeable future.”

There must be overall national guidance on vaccine allocation and distribution supported and promoted by the federal government, recommends the team. The researchers argue that while every state has a different context, travel and commerce affect all states and people, and the virus easily crosses both state and international borders. Additionally, with a limited supply, only a national strategy can ensure that the vaccine gets to the priority groups, they write. The study, however, says because every state is different, actions must be local but driven by national principles. Accordingly, states should be planning how they will reach targeted groups, especially those that may be hard to reach. 

The report cautions that what is done early in a vaccination campaign will have implications for every aspect of one’s personal and public life. “We risk reducing confidence in government, as well as our public health and healthcare systems if the allocation, distribution, and administration of the vaccine are not handled appropriately and clearly communicated. If, on the other hand, an allocation strategy is ethical, nationally consistent, fair, and informed by key constituency groups, then vaccination campaign is more likely to go smoothly and be accepted by the public, which would result in many lives saved and faster economic recovery,” the research team explains.


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 Frontline Health Workers Those Risk Severe Illness Death Get Covid-19 Vaccine First