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Figure.  Public Preferences for Coronavirus Disease 2019 Vaccine Allocation
Public Preferences for Coronavirus Disease 2019 Vaccine Allocation

Data are from the State Health Access Data Assistance Center coronavirus disease 2019 survey, fielded April 23 to 27, 2020.

Table.  Public High-Priority Ratings for Coronavirus Disease 2019 Vaccine Allocation by Subpopulation
Public High-Priority Ratings for Coronavirus Disease 2019 Vaccine Allocation by Subpopulation
1.
Kinlaw  K, Barrett  DH, Levine  RJ.  Ethical guidelines in pandemic influenza: recommendations of the ethics subcommittee of the advisory committee of the director, Centers for Disease Control and Prevention.   Disaster Med Public Health Prep. 2009;3(suppl 2):S185-S192. doi:10.1097/DMP.0b013e3181ac194fPubMedGoogle ScholarCrossref
2.
Mello  MM, Silverman  RD, Omer  SB.  Ensuring uptake of vaccines against SARS-COV-2.   N Engl J Med. 2020. doi:10.1056/NEJMp2020926PubMedGoogle Scholar
3.
Toner  E, Barnill  A, Krubiner  C,  et al.  Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States. Johns Hopkins Center for Health Security; 2020.
4.
National Academies of Sciences, Engineering, and Medicine.  Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine. National Academies Press; 2020. doi:10.17226/25914
5.
Vawter  DE, Garrett  JE, Gervais  KG,  et al; Minnesota Center for Health Care Ethics, University of Minnesota Center for Bioethics. For the good of us all: ethically rationing health resources in Minnesota in a severe influenza pandemic. Accessed August 28, 2020. https://www.health.state.mn.us/communities/ep/surge/crisis/ethics.pdf
6.
Schmidt  H.  Vaccine rationing and the urgency of social justice in the COVID-19 response.   Hastings Cent Rep. 2020;50(3):46-49. doi:10.1002/hast.1113PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Social inequities have been magnified. This is the time to reverse it
    Dana Ludwig, MD | Stanford University
    This study of preferences for vaccine allocation was excellent and worthwhile in elevating the visibility of discussion of this important topic. But around the edges of it's conclusions, I suggest there is a possible insidious insertion of biases that could promote inequities further.

    Several weeks ago, a JAMA Viewpoint recommended that prison inmates be recruited for vaccine trials, as inmates might benefit from access to the studies because they are at high risk for death from COVID-19;  regulatory guidelines view inmates as a group vulnerable for exploitation by clinical investigations. At the time, I objected to this
    view, and recommended that if the authors were especially concerned about inmates, they should give inmates first priority to receive vaccines AFTER the studies are complete.

    In this research, in the results of the survey, I see no mention of the priority that should be given to prison inmates. This is consistent with my observation that the scientific community biases the outcome of studies in favor of their interests by the way they formulate the questions, and not by violating their study design. If you don't ask about inmates, you won't get an answer.

    But addressing that inequity is not as simple as adding a question. One of the shortcomings of democracy is that the majority vote for policies that support their interests, without regard to the negative impact on the minorities.

    I believe there is a simple solution to this problem of inequities. The Gates Foundation has a guiding principal in their work: "All lives have equal value". In light of this principle, the policy guiding allocation of vaccines could be based on two variables only:

    * the chance of death of the individual who does not receive the vaccine
    * the chance of the individual, if infected, passing the virus on to other individuals.

    If these criteria are applied based on available data, priorities would be something like this (just a guess):

    1) Healthcare providers in nursing homes, that represent 35%-50% of cases in many counties (SFN providers are a greater risk of transmission to multiple SNF residents)
    2) nursing home residents
    3) Inmates and staff of prisons
    4) Agriculture workers (noting the oversized impact on the California Central Valley).
    5) Native Americans in high risk communities
    6) Healthcare providers and patients in acute care hospitals. Priority to the most at-risk staff such as CNAs, LVNs, RNs, and then physicians
    7) Other essential workers (risk-stratified) such as first police, paramedics, etc, and then retail workers and trades. Possible preference to workers with high numbers of individuals living in the worker's home, to address the inequities in mortality of low income workers in high density housing with extended families.

    Dana Ludwig, M.D.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Public Health
    September 29, 2020

    US Adults’ Preferences for Public Allocation of a Vaccine for Coronavirus Disease 2019

    Author Affiliations
    • 1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
    • 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
    • 3State Health Access Data Assistance Center, Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
    • 4Health Policy and Management and Director, State Health Access Data Assistance Center, University of Minnesota, School of Public Health Minneapolis
    JAMA Netw Open. 2020;3(9):e2023020. doi:10.1001/jamanetworkopen.2020.23020
    Introduction

    A vaccine against severe acute respiratory syndrome coronavirus disease 2 (SARS-CoV-2) will be essential for mitigating the pandemic. However, given global need, demand is expected to exceed supply. When vaccines were limited during the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention developed recommended priority populations based on ethical criteria.1 Experts have begun to identify which groups ought to receive priority for a SARS-CoV-2 vaccine, including elderly people, front-line health care workers, and people with existing medical conditions that put them at high risk of severe illness and death.2-4

    Public engagement can contribute to resource allocation decisions. Incorporating public preferences could advance the perceived legitimacy of vaccine allocation guidelines.4 This survey study’s objective is to describe the public’s preferences for allocating a SARS-CoV-2 vaccine.

    Methods

    The study was determined exempt by the University of Minnesota Institutional Review Board and a waiver of informed consent was granted because data were deidentified and questions posed minimal risk to participants. Data were collected through a module included on the AmeriSpeak Omnibus Survey, fielded by NORC using telephone and internet modes from April 23 to 27, 2020. Respondents were members of AmeriSpeak, a probability-based panel designed to be representative of the US household population. The panel recruitment rate is 34.0%.

    The key measure, adapted from H1N1 public engagement activities in Minnesota,5 described the potential for SARS-CoV-2 vaccine scarcity and that health authorities may have to set guidelines. The survey question asked: “It is anticipated that in the next 12-18 months, a vaccine for coronavirus will be available. However, at least at first, there may not be enough to go around. Public health authorities must set guidelines about who gets the vaccine first. Please indicate the level of priority that should be given for each of the listed groups.” Respondents indicated which of 8 groups (based on age, health risk, and employment type) should receive high, medium, or low priority.

    Descriptive statistics using NORC-provided survey weights generated nationally-representative estimates. Respondents’ preferences were compared using χ2 tests by age, race/ethnicity, and self-rated health status, since coronavirus disease 2019 mortality varies by these factors. Race/ethnicity was self-reported and classified as non-Hispanic White, non-Hispanic Black, non-Hispanic other or multiracial (includes non-Hispanic other; non-Hispanic multiracial; and non-Hispanic Asian), and Hispanic. P values were 2-sided, and statistical significance was set at .05.

    Results

    The survey participation rate was 14.4%, with a final sample of 1007 adults. Among these, 524 (51.4%) were women, 113 (18.1%) were aged 18 to 29 years, 375 (30.7%) were aged 60 years or older, 645 (62.6%) were White, and 170 (20.3%) reported fair or poor health (Table).

    The Figure demonstrates respondents’ high willingness to allocate vaccine preferentially to front-line medical workers (937 respondents [91.6%] rated them high priority), high-risk children (807 respondents [81.0%] rated them high priority), and high-risk older adults (799 respondents [80.6%] rated them high priority). Respondents also reported priority for middle-aged people with higher risk (745 respondents [75.2%] rated them high priority) and for essential (nonmedical) workers (743 respondents [72.0%] rated them high priority). Fewer respondents reported high priority for pregnant people (627 respondents [64.0%] rated them high priority). While respondents ranked people with moderate mortality risk the lowest, they were more likely to give higher priority to children (348 respondents [39.2%] rated them high priority) than adults (242 respondents [29.0%] rated them high priority). A total of 142 respondents (17.7%) ranked all 8 groups as high priority.

    Respondents’ age was associated with differences in their likelihood of assigning high priority to children (age 18-29 years: 87 respondents [72.7%]; age 30-29 years: 400 respondents [79.3%]; age ≥60 years: 320 respondents [88.6%]; P = .006), people older than 65 (age 18-29 years: 80 respondents [70.9%]; age 30-29 years: 413 respondents [82.0%]; age ≥60 years: 306 respondents [84.0%]; P = .03), essential workers (age 18-29 years: 77 respondents [62.4%]; age 30-29 years: 362 respondents [69.6%]; age ≥60 years: 304 respondents [81.8%]; P = .003), and pregnant people (age 18-29 years: 66 respondents [58.2%]; age 30-29 years: 306 respondents [61.4%]; age ≥60 years: 255 respondents [71.9%]; P = .04) (Table). Respondents’ race and ethnicity was associated with differences in high priority rating for the 2 moderate risk groups, children (White: 186 respondents [33.6%]; Black: 77 respondents [50.1%]; Other: 23 respondents [36.1%]; Hispanic: 62 respondents [54.2); P = .001) and adults (White: 115 respondents [21.9%]; Black: 65 respondents [44.1%]; Other: 15 respondents [26.2%]; Hispanic: 47 respondents [46.4%]; P < .001). Respondents’ self-reported health status was associated with differences in high priority rating for nonmedical essential workers (fair or poor: 133 respondents [81.2%]; good: 254 respondents [65.5%]; very good or excellent: 355 respondents [73.4%]; P = .007) and pregnant people (fair or poor: 112 respondents [72.2%]; good: 217 respondents [59.2%]; very good or excellent: 297 respondents [64.2%]; P = .05).

    Discussion

    This survey study found that respondents’ preferences were consistent with experts’ emergent recommendations for priority populations for vaccination, suggesting the public would support guidelines that offer vaccine priority to groups defined by age, risk of dying, and employment type.2-4 More than 90% of respondents identified medical workers as high priority. They also rated people at highest risk of dying as higher priority than people with lower risk.

    The study has limitations. The prioritization question did not impose limits on the number of groups respondents could select as high priority. Also, groups assessed did not account explicitly for race/ethnicity or socioeconomic need, but a fuller framework for ethical decision-making should incorporate social justice considerations.3,6

    Future work on setting priorities for vaccine allocation should use deliberative modes of public engagement to assess public priorities under scarcity and evaluate effective communication. Since the public’s hesitancy toward vaccines is a concern,2 consistent and evidence-based communication on the importance of vaccination and the priority groups for receipt of a scarce vaccine is critically needed.

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    Article Information

    Accepted for Publication: August 26, 2020.

    Published: September 29, 2020. doi:10.1001/jamanetworkopen.2020.23020

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Gollust SE et al. JAMA Network Open.

    Corresponding Author: Sarah E. Gollust, PhD, Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455 (sgollust@umn.edu).

    Author Contributions: Mr Hest had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Gollust, Saloner, Blewett.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Gollust.

    Critical revision of the manuscript for important intellectual content: Saloner, Hest, Blewett.

    Statistical analysis: Hest, Blewett.

    Obtained funding: Blewett.

    Administrative, technical, or material support: Saloner.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: The data set used in this study was developed with support from the State Health Access Data Assistance Center at the University of Minnesota School of Public Health.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    Kinlaw  K, Barrett  DH, Levine  RJ.  Ethical guidelines in pandemic influenza: recommendations of the ethics subcommittee of the advisory committee of the director, Centers for Disease Control and Prevention.   Disaster Med Public Health Prep. 2009;3(suppl 2):S185-S192. doi:10.1097/DMP.0b013e3181ac194fPubMedGoogle ScholarCrossref
    2.
    Mello  MM, Silverman  RD, Omer  SB.  Ensuring uptake of vaccines against SARS-COV-2.   N Engl J Med. 2020. doi:10.1056/NEJMp2020926PubMedGoogle Scholar
    3.
    Toner  E, Barnill  A, Krubiner  C,  et al.  Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States. Johns Hopkins Center for Health Security; 2020.
    4.
    National Academies of Sciences, Engineering, and Medicine.  Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine. National Academies Press; 2020. doi:10.17226/25914
    5.
    Vawter  DE, Garrett  JE, Gervais  KG,  et al; Minnesota Center for Health Care Ethics, University of Minnesota Center for Bioethics. For the good of us all: ethically rationing health resources in Minnesota in a severe influenza pandemic. Accessed August 28, 2020. https://www.health.state.mn.us/communities/ep/surge/crisis/ethics.pdf
    6.
    Schmidt  H.  Vaccine rationing and the urgency of social justice in the COVID-19 response.   Hastings Cent Rep. 2020;50(3):46-49. doi:10.1002/hast.1113PubMedGoogle ScholarCrossref
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