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How the COVID-19 vaccine is distributed determines how the pandemic will end

National health care systems will make things more organized, but the US is still finding its footing

Sara May Bergstresser

Bioethics, Public Health, and Biochemistry

Columbia University

The news is now full of pictures of the first vaccinations for COVID-19. In the UK, 90-year-old Margaret Keenan was the first to get her “jab," and in the US, the first vaccines have been given to health care workers including New York nurse Sandra Lindsay

In both the UK and the US, the COVID response over the past nine months has been haphazard, with many failed policies, soaring case numbers and deaths, controversy, and widespread social and economic disruption. The vaccine rollout represents a much needed promise of hope for the future, but it is important to remember that a lot more still needs to happen before the pandemic can be controlled. Not even the vaccine stories for Margaret Keenan and Sandra Lindsay are complete, since for full protection they will both need to take the second dose of the Pfizer/BioNTech vaccine after about three weeks.

On the surface, it may look like an organized global rollout process is getting underway, but there are still many uncertainties surrounding vaccine distribution internationally and within each country. How quickly vaccines can become widely available and who receives early priority are determined by national purchasing power, available supply, logistics, national priorities, and variations in health regulations and laws. 

Countries with national health systems such as the UK and Canada have the opportunity to use existing care provision frameworks and facilities to help organize efficient population-wide vaccine initiatives. The US, on the other hand, does not have the same type of health system infrastructure, which means vaccine distribution may vary wildly from state to state. National priorities also dictate the order in which people will be able to receive the vaccine, and national policymakers must decide whether to focus on direct protection for vulnerable individuals or to prioritize those who are most likely to spread the disease to others. 

The CDC has put out recommendations about which groups should get early vaccine priority. These recommendations were based on the Advisory Committee on Immunization Practices (ACIP) Interim Recommendation for Allocating Initial Supplies of COVID-19 Vaccine. The CDC cites its main goals to be: “Decrease death and serious disease as much as possible,” “Preserve functioning of society,” and “Reduce the extra burden COVID-19 is having on people already facing disparities.” Based on this, the two main groups recommended for early vaccination are Healthcare Personnel and residents of nursing homes (“Long Term Care Facilities”). After that, an approximate sense of where others may be in the queue can be calculated here. Nevertheless, recent history has shown that public health recommendations are not always followed in the US, and individual states may choose to allocate differently from ACIP recommendations. 

Finally, as is typical for new pharmaceutical products, safety monitoring must continue after its rollout. This is even more important for COVID vaccines, because they were developed rapidly under atypical circumstances, and problems of public trust remain. ACIP and the CDC also recommend that any adverse events should be reported to the Vaccine Adverse Events Reporting System (VAERS), even if it is not clear that a vaccine caused the event. Vaccine data is difficult to track in the US due to its uneven health practices and regulations, so a new nationwide system is starting up to aid in that effort. 

In the UK, a more comprehensive plan for allocation has been released, with the explicit intent to inform future policy. These recommendations also prioritize older adults and healthcare providers, but they go on to elaborate on many subsequent priority categories based on age and risk due to underlying health conditions. The UK, due to its existing national health infrastructure and decision to purchase sufficient vaccine doses for its population, is starting its rollout efficiently so far. 

In the US, director of the National Institute of Allergy and Infectious Diseases Anthony Fauci, predicts that a return to something close to normal can be achieved by the end of 2021, as long as the vaccination rollout goes well and 75-80% of the population are vaccinated by that time. There are a number of issues that may complicate this optimistic timeline including past health communication missteps, public mistrust, and vaccine hesitancy, states receiving fewer doses than promised, problems with Pfizer vaccine cold storage requirements in rural areas, and confusion over packaging leading to wasted doses. If these limitations cannot be overcome, the process will take longer than hoped. 

There are also tensions between implementing some numerically sound strategies for stopping the spread of disease and the need to increase public trust. For example, some health economists and policy experts argue that people most likely to become “superspreaders” be prioritized over the more vulnerable, but this would mean that young people who are more likely to have asymptomatic or mild cases would be vaccinated before the elderly, those with preexisting health risks, and other vulnerable and underserved populations. It is important to remember that health policy must account for human behavior in addition to the predictions of epidemiological models; for communities at high risk whose members have disproportionately become infected and died, watching healthy college students at spring break parties after getting their vaccines first would likely further diminish trust in the public health system and its recommendations.

One main lesson that should be permanently learned from COVID is that infectious diseases that start anywhere across the globe can fast become global pandemics. It is a priority of ethics and justice that humans should have access to vaccines regardless of whether they live in economically powerful countries. Right now, wealthy countries are buying up most of the available doses, meaning that “nine out of 10 people in 70 low-income countries are unlikely to be vaccinated against COVID-19 next year.” Many people in low-income countries might have to wait until 2023 or 2024 for vaccination. In an attempt to counter this trend towards severe inequality, WHO has a plan to ensure equitable allocation, but it faces many implementation challenges. The arrival of vaccines from additional manufacturers is also promising for fairness in distribution because they have fewer technical limitations. The impending release of the Moderna vaccine is notable because it has less stringent cold chain requirements, and the Oxford–AstraZeneca vaccine is specifically aiming for “global supply, equity, and commitment to low-income and middle-income countries” and should be ready for use in 2021.

Finally, a second important lesson that must be learned is that for public health plans to succeed, it is not sufficient for scientists to work fast. Countries must design and implement sound public health policies, people must follow these policies, and the idea of vaccine as “magic bullet" must be replaced with a more nuanced understanding of the complexities of Covid and its spread. This means that preventative public health practices like social distancing and mask wearing must be continued throughout the vaccine process. Some of these health behaviors might even be here to stay within certain risky contexts, since coronaviruses may continue as seasonal outbreaks like influenzas, and new infections will continue to emerge into the human population.