When a coronavirus vaccine becomes available, who should get it first?
A preliminary plan developed by the Centers for Disease Control and Prevention this spring prioritizes health workers, then people with underlying health conditions and the elderly. The CDC has yet to decide whether the next in line should be blacks and Latinos, groups disproportionately affected by the coronavirus.
But suppose health workers and people with underlying health conditions use the first doses of the vaccine available. Should some be kept in reserve for blacks and Latinos? What about bus drivers and train drivers? Maybe the teachers or school children should get it so they can go back to class with peace of mind.
In the event of a shortage, most countries will have no chance of getting the initial batches of a vaccine as part of the CDC’s plan. And as the United States battles a growing number of coronavirus cases, an increasing demand for drugs and perhaps ventilators is expected. They too will need a fair distribution system.
One solution that is starting to grab the attention of public health experts is a so-called weighted lottery, which gives everyone a chance to access it, although some have better luck than others.
Doctors and ethicists classify patients, deciding which groups should be privileged and to what extent. First responders, for example, may be weighed more heavily than, for example, very ill patients who are unlikely to recover.
The aim is to avoid random or inequitable distribution of a treatment or vaccine when there is not enough for everyone. Such a system has already been used in allowances of remdesivir, the first drug shown to be effective against the coronavirus.
“This is all very new,” said Dr Douglas White, ethicist and vice-chair of the Department of Critical Medicine at the University of Pittsburgh, which began using a weighted lottery last month to distribute remdesivir.
Patients accepted the results, even when they lost in the lottery and ended up being denied the drug, he added.
“I guess it’s because we’re very transparent about the rationale and ethical framework that applies to anyone who comes to the hospital, whether it’s the president of the hospital or a homeless person,” did he declare.
To allocate the drug, doctors in Pittsburg decided that the lottery would give preference to healthcare workers and emergency medical workers. Doctors also weighted the odds of favoring people from economically disadvantaged areas, who tend to be predominantly black and Hispanic.
People with other illnesses and with a limited lifespan, such as patients with terminal cancer, had the odds against them, which made them less likely to win the lottery. The system did not take into account age, race, ethnicity, quality of life, ability to pay or whether a patient had a disability.
The lottery started in early June, said Dr White: “We had 64 patients. We had to extend the supply of remdesivir for at least two weeks. We only had enough to treat one in four patients. “
They had a brief respite from the lottery when the tills began to drop and supplies of remdesivir appeared adequate. But on Sunday, as cases rose again and remdesivir was sufficient for only about half of the patients who could be helped by taking it, the hospital system was forced to return to a lottery.
A weighted lottery will be used in South Carolina if the growing number of patients causes a shortage, said Dr Dee Ford, an infectious disease specialist at the University of Medicine of South Carolina and a member of a department of advisory group state health. So far, she said, the state’s supply of remdesivir remains sufficient.
Dr White and his colleagues were considering a weighted lottery before the shortage of remdesivir began. And so were other ethicists, like Dr. Robert Truog of Harvard Medical School, who learned of the system’s existence amid fears of a ventilator shortage in March.
He consulted Dr White, who had developed a system that awarded points to critically ill coronavirus patients based on their estimated likelihood of survival. After Dr Truog and his colleagues published an article on ventilator distribution, Dr Truog said: “We got a call from an economist at MIT”
Economist Parag Pathak told Dr Truog that he and other economists have spent years thinking about how to allocate resources and have successfully developed and used weighted lotteries.
For example, Dr Pathak told him, such systems are used to allocate places in oversubscribed charter schools, giving preference to children in certain neighborhoods. Dr Truog was intrigued, but it turned out that there were enough fans, so a lottery was not necessary.
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Frequently Asked Questions
Updated July 23, 2020
What will school look like in September?
- Many schools are unlikely to return to normal schedules this fall, requiring continued online learning, makeshift child care and reduced work days. California’s two largest public school districts – Los Angeles and San Diego – said on July 13 that distance education would only be remote in the fall, citing concerns that the surge in coronavirus infections in their regions pose too serious a risk to students and teachers. Together, the two districts are home to some 825,000 students. They are the largest in the country to date to abandon their plans for a physical return, even partial, to classrooms when they reopen in August. For the other neighborhoods, the solution will not be an all-or-nothing approach. Many systems, including the country’s largest, New York, are devising hybrid plans that involve spending a few days in class and other days online. There is no national policy on this yet, so check back regularly with your municipal school system to see what is happening in your community.
Is the coronavirus airborne?
- The coronavirus can stay aloft for hours in tiny droplets in stagnant air, infecting people when they inhale, mounting scientific evidence has shown. This risk is highest in congested indoor spaces with poor ventilation, and may help explain the super-spread events reported in meat packing plants, churches, and restaurants. It is not known how often the virus is spread via these tiny droplets, or aerosols, compared to the larger droplets that are expelled when a sick person coughs or sneezes, or transmitted through contact with contaminated surfaces, said Linsey Marr. , an aerosol expert at Virginia Tech. Aerosols are released even when a symptomless person exhales, speaks or sings, according to Dr Marr and more than 200 other experts, who presented the evidence in an open letter to the World Health Organization.
What are the symptoms of the coronavirus?
What is the best material for a mask?
Does asymptomatic transmission of Covid-19 occur?
- So far the evidence seems to show it. A widely cited article published in April suggests that people are more contagious about two days before symptoms of the coronavirus appear and estimated that 44% of new infections were the result of transmission from people who were not yet exhibiting symptoms. Recently, a senior expert from the World Health Organization said that transmission of the coronavirus from people who did not have symptoms was “very rare”, but she later reconsidered that statement.
But remdesivir was another story, Dr White and Dr Truog realized: Shortages weren’t just possible; they were performing.
“When the remdesivir shortages started, we felt that a lottery system would be a much better method of allocation than a points system,” he explained. His group and Dr. Truog developed a weighted lottery for remdesivir, and hospitals in Pittsburgh began using it.
They also noted another benefit: Weighted lotteries can allow researchers to discover, in a rigorous fashion, which subgroups of patients do best with a new drug or vaccine.
This is because the distribution within a group is random. The distribution is, in effect, a randomized controlled clinical trial. The only difference between, say, people over the age of 60 who got the drug and those who didn’t, is the coin toss in the lottery.
For this reason, the results may reveal the effectiveness of a drug or vaccine for subgroups of people.
This type of analysis was carried out to study variations in student performance in different schools, answering questions such as: did students with higher scores do as well with or without a charter school? Did the school benefit those who were not doing well in the schools in their neighborhood?
A large federal clinical trial showed that remdesivir slightly improved recovery times for hospital patients. This study, however, was not designed to show whether certain groups – like young people, or those who were earlier in their infection – benefited more than others.
This outcome data is buried in electronic patient health records. If patients took part in a weighted lottery, it would be much easier to see who benefited and who did not benefit from remdesivir.
Similar questions can be addressed if a vaccine were to be distributed with such a lottery. But obtaining this data would be more complicated, since the distribution of vaccines can involve tens of millions of people.
Yet, in principle, lottery data on a vaccine can be as useful as data from randomized clinical trials, Dr Pathak said.
“We would like people to think ahead of time about how vaccines are allocated,” he said. “We can’t immunize everyone, so we have to think about what’s right and what’s right.”