Balancing speed and equity in the rollout of COVID-19 vaccines

By Maxwell J. Smith

COVID-19 vaccines are in limited supply, and so it’s crucial that their harm-reducing powers are deployed strategically. This likely requires two things: (1) prioritizing vaccines to those at greatest risk of mortality, hospitalization, transmission, and/or infection; and (2) administering vaccinations as rapidly as possible. Yet, it is sometimes not possible to optimally pursue these two aims simultaneously. For instance, sending vaccinators into long-term care homes is likely an optimal strategy for vaccinating those at greatest risk of severe outcomes from COVID-19, but it is hardly the fastest way to vaccinate as many people as possible. Conversely, setting up mass vaccination clinics and inviting all comers is a great way to rapidly vaccinate as many people as possible, but it will inevitably miss key populations who are among the most vulnerable to COVID-19. A key ethical question is how to strike the right balance between these aims and approaches. The debate is often characterized as a tension between speed and equity: if we want to be equitable, we must sacrifice speed, and if we want to be speedy, we must sacrifice equity, or so the debate is commonly presented.

As a bioethicist and member of Ontario’s COVID-19 Vaccine Distribution Task Force, I’ve encountered perhaps every proposal for where this line ought to be drawn. And while I ultimately believe there are ways to meaningfully pursue equity in a manner that need not jeopardize speed, it’s important to appreciate three other persuasive reasons not necessarily grounded in equity that also support the sort of precise, targeted approaches to vaccine prioritization that might otherwise be rejected due to concerns about speed.

First, consider the province of Ontario, Canada, home to nearly 15 million people. In terms of geography, Ontario is the size of France and Spain combined with high-density urban centres along the Canada/US border and remote and isolated communities over 1,000km to the north. Due to logistical challenges associated with the sheer size of the province and remoteness of some communities (some only accessible by airplane), it can be time- and resource-intensive to achieve a high rate of vaccination coverage among the many communities spanning this vast geography. Consequently, if the province hopes to achieve a high rate of vaccination coverage both provincially and within its diverse communities, it must start vaccinating harder-to-reach communities as early as possible. The sooner vaccinations start in hard-to-reach communities, the better chance there is that the rate of vaccination coverage among these communities won’t have fallen hopelessly behind the rest of the province once vaccines have become readily available to all. Importantly, prioritizing remote communities means that vaccinations ought to at least begin in those communities earlier, not that other populations cannot be vaccinated until vaccinations in remote communities have been completed.

The same argument applies to other populations who may require more targeted and intensive strategies for vaccination, such as persons with disabilities living in supportive housing, individuals receiving chronic home care who have difficulty leaving their homes, or even populations who may benefit from engagement and trust building to enhance vaccine confidence. Vaccination strategies targeting these populations likely won’t catapult a jurisdiction up the ranks of vaccination trackers. Yet, leaving such populations behind in the name of speed might mean taking longer to reach target rates of population vaccination coverage. In a sense, speed (of meeting target rates of population vaccination coverage) may be sacrificed by not prioritizing such populations.

Second, targeting vaccines to populations at greater risk of morbidity, hospitalization, transmission, and/or infection is likely the most efficient and rapid way to achieve public health objectives as compared to indiscriminate or less discerning distributive schemes, even when doing so requires a degree of precision that slows rollout. As the example of vaccinating older adults in long-term care homes illustrates, vaccinating the ‘right’ populations, even if it may be slower, can rapidly pay dividends in terms of the achievement of public health objectives, like preventing deaths. Again, speed of a different kind (of achieving public health objectives) may be sacrificed by not prioritizing such populations.

Finally, prioritization has an expressive function. By virtue of being prioritized (either early on in a vaccination program or at all), a distinct message is sent to prioritized populations that it is especially important that they get vaccinated, and get vaccinated early. Failure to prioritize populations facing increased risks may suggest to them that they are at no greater risk than others, which may lead them to think it is less imperative to be vaccinated. This could threaten vaccination uptake among populations who are at risk, and, in turn, undermine the achievement of public health objectives.

There are a number of compelling reasons grounded in equity to be suspicious of vaccination strategies that privilege speed of administration above all else. And these remain the most persuasive reasons not to give up on vaccination strategies targeting harder-to-reach and at-risk populations. But even if not persuaded by arguments grounded in equity, the achievement of target rates of population vaccination coverage, the achievement of public health objectives, and the expressive function of prioritization provide additional reasons to adopt vaccination strategies that might otherwise be rejected due to concerns about speed.


Paper title: Why we should not ‘just use age’ for COVID-19 vaccine prioritization

Author: Maxwell J. Smith

Affiliations: Faculty of Health Sciences, Western University

Competing interests: None declared

Social media accounts of post author(s): @maxwellsmith

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