Abstract
With current COVID-19 vaccine demand outweighing supply and the emergency authorization/rollout of three novel vaccines in the United States, discussions continue regarding fair prioritization among various groups for this scarce resource. The US federal government’s recommended vaccination schedule, meant to assist states with vaccine allocation, demonstrates fair ethical considerations; however, difficulties remain comparing various groups to determine fair vaccine access and distribution. Although strides have been taken to analyze risks versus benefits of early vaccination across certain high-risk populations, prioritizing vulnerable populations versus essential workers remains challenging for multiple reasons. Similarly, as COVID-19 vaccine allocation and distribution continues in the US and in other countries, topics that require continued consideration include sub-prioritization among currently prioritized groups, prioritization among vulnerable groups disproportionately affected by the COVID-19 pandemic, like ethnic minorities, and holistic comparisons between groups who might receive various and disparate benefits from vaccination. Although all current COVID-19 vaccines are emergency authorization use only and a vaccine mandate would be considered only once these vaccines are licensed by the US Food and Drug Administration, future vaccination policies require time and deliberation. Similarly, given current vaccine hesitancy, mandatory vaccination of certain groups, like healthcare personnel, may need to be considered when these vaccines are licensed, especially if voluntary vaccination proves insufficient. Continued discussions regarding risks versus benefits of mandatory COVID-19 vaccination and the unique role of healthcare personnel in providing a safe healthcare environment could lead to better deliberation regarding potential policies. This commentary aims to address both questions of fair prioritization and sub-prioritization of various groups, as well as ethical considerations for mandatory COVID-19 vaccination among healthcare personnel.
Introduction
With the recent rollout of three novel coronavirus 19 (COVID-19) vaccines in the United States, questions surrounding fair prioritization of various groups have come to the forefront. The Advisory Committee on Immunization Practices (ACIP) created recommendations for fair allocation using four ethical principles: minimizing harm and maximizing benefit, promotion of justice, mitigating health inequities and promoting transparencyCitation1. Using these principles, the ACIP made a series of vaccination schedule recommendations. However, further sub-prioritization of these groups and prioritization of other vulnerable groups remains controversial. Inclusion of essential workers is additionally challenging. Though early, discussions also continue regarding potential vaccine-mandate policies among healthcare personnel. This commentary aims to discuss a) fair prioritization and sub-prioritization of various groups in future phases of COVID-19 vaccination and b) ethical considerations for mandatory vaccination among healthcare personnel.
Fair prioritization of COVID-19 vaccines
The ACIP recommendations included healthcare personnel and long-term care facility (LTCF) residents in phase 1a as both groups would most likely receive the greatest overall benefit from initial vaccination. Healthcare personnel have high risk of exposure, infection and spread of COVID-19 among themselves and their patients while LTCF residents display high morbidity and mortality ratesCitation1, and are high risk due to numerous other factors (community spread, age, etc.). Vaccination of healthcare personnel potentially mitigates further indirect harms like spread within hospitals. The ACIP’s recommended vaccination schedule includes non-healthcare frontline essential workers and persons aged ≥75 years in phase 1b and persons aged 65–74 years and/or those aged 16–64 years with high-risk medical conditions in phase 1cCitation2. These recommendations demonstrate fair prioritization based on those four guiding ethical principlesCitation2. However, distribution at the state level may require further sub-prioritization. Among hospitals, this could include prioritization of personnel who would gain greatest initial benefit from the vaccine or have greater COVID-19 exposure risk. Similarly, institutions may consider early vaccination opportunities for personnel who are essential to hospital function and prevention of spread within facilities (i.e. environmental services personnel).
Fair prioritization of other vulnerable groups remains unclear. Previous proposals supported prioritization of ethnic minorities as the pandemic has disproportionately impacted morbidity and mortality rates, and socioeconomic suffering within these groupsCitation3. The US has prioritized the elderly as a vulnerable population but discussions on race and socioeconomic status remain minimal and could lead to a biased result if not appropriately addressed. While recent CDC recommendations include considerations of ethnic minorities within phase 1bCitation4, this is within the parameters of essential worker vaccination. Comparing various groups based on age, ethnicity, comorbidities, etc. is complicated because the degree and type of benefit varies widely among disparate groups. Risks of morbidity/mortality versus exposure and spread versus risks associated with socioeconomic status (and racial/ethnic disparities therein) are all distinctly different types of potential harms. Acknowledging the diversity of benefits and reductions in COVID-19-associated risks from early vaccination and comparing them across disparate groups is challenging but vital. While individual group analyses have been runCitation1,Citation2 and initial inter-group assessments are promisingCitation4, a complete comparison across all groups would aid in ensuring fair prioritization among those most severely affected by COVID-19 and those who might gain the greatest use from the vaccine.
Complicating fair prioritization, mistrust of the healthcare system and COVID-19 vaccines is prevalent among some minorities, decreasing the likelihood of uptakeCitation5. Even among healthcare workers, race appears to play a role in hesitancy and unequal early access to vaccinesCitation6. Future studies could broadly explore the role of race in vaccine access, prioritization and hesitancy, including examination of techniques (i.e. motivational interviewingCitation5) for enhancing trust.
Addition of essential workers to fair prioritization discussions remains challenging. First, although guidelines are now more specificCitation4 the category of “essential worker” is still far too broad with few inter-industry comparisons to understand benefits across various occupations. Second, comparing vulnerable populations to essential workers is a problem of incomparable harms and benefits. Essential workers may be at greater risk of occupational exposure or their necessity to society justifies prioritization while vulnerable populations may be at higher morbidity and mortality risk. Although vulnerable populations may be individually saved, vaccinating essential workers may decrease transmission. Current analyses demonstrate that early vaccination of essential workers decreases morbidity/mortality and transmissionCitation4; however, this may be due to essential workers who are also considered a vulnerable population. Further stratification among essential workers and discussion of essential workers separate from vulnerable populations may be necessary as the groups require different considerations. A systematic approach to comparing disparate harms would be helpful in future rationing crises.
Vaccine mandate
Mandatory vaccination is historically controversialCitation7. Legally, healthcare systems can impose vaccine requirements of licensed vaccines on their workforce, with medical or religious exemptionsCitation8. With demonstrated effectiveness of mandatory influenza vaccinationCitation7, many healthcare systems require this annual vaccine among employees with direct patient contact. While vaccine-mandate discussions may seem premature and current COVID vaccines have only been granted emergency use authorization (i.e. vaccination is voluntary only), policy development requires time and deliberation. If voluntary vaccination proves insufficient, existing policies will be helpful.
Traditional ethical justification of mandatory vaccination requires a large-scale reduction of harms such that the greater good of mandatory vaccination outweighs individuals’ autonomous choice to not vaccinateCitation9. Harm reductions may include decreased COVID-19 infections, spread and death among personnel, patients, family members and communities. Justification of mandatory vaccination among healthcare personnel in particular extends to the ethical responsibility to make healthcare environments safeCitation7. Vaccines are often considered within the scope of actions healthcare personnel take in order to protect the welfare of their patients. Healthcare environments are held to a higher moral standard of safety, justifying licensed vaccine-mandate policies.
Conversely, mandatory vaccination requires consideration of vaccination risks and autonomy. Risks include reportedly higher rates of side effects in populations under age 55Citation10. Because the complete range of side effects of this novel vaccine are unknown, comprehensive risk assessments are difficult. Healthcare personnel also have autonomy of choice regarding treatment preferences, including vaccination. However, necessary and reasonable public health interventions are allowed to override personal autonomy. Making voluntary vaccination more desirable may preserve autonomy while ensuring sufficient vaccination. Alternatively, once vaccines are licensed, healthcare systems could partially mandate vaccines for personnel with higher exposure risk or those who work with vulnerable populations. Healthcare personnel appear to display significant COVID-19 vaccine hesitancy and future research is needed to analyze this phenomenon and understand how to enhance uptake among these groups.
Conclusion
Complete comparison of disparate vulnerable groups and stratification among essential workers is difficult and necessary to ensure fair prioritization. Ethical analysis of a vaccine mandate among healthcare personnel is broad, including harm reductions, the importance of safe healthcare environments and risks associated with a novel vaccine. Ultimately, difficult decisions lie ahead to prevent transmission and spread of this deadly pathogen.
Transparency
Declaration of funding
This study was not funded.
Declaration of financial/other relationships
A.D. has disclosed that he is a consultant at Merck and has received research funding from The Clorox Company. No other potential conflict of interest was reported by the authors. CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.
Acknowledgements
No assistance in preparation of this article is to be declared.
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