Public Health

Who gets coronavirus vaccine first? Ethics, equity drive plan

Len Strazewski , Contributing News Writer

As COVID-19 vaccine candidates push through the phase 3 trials needed for Food and Drug Administration approval, experts are working on a program aimed at achieving equitable and prioritized distribution of the first 100 million doses.

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But developing this strategy takes more than just understanding the science of immunization, according to William H. Foege, MD, MPH, emeritus distinguished professor of international health at Emory University and former director of the Centers for Disease Control and Prevention (CDC).

“The discussion on how to do that started out with ethics and equity,” he told JAMA Editor-in-Chief Howard Bauchner, MD, on a recent episode of the “Conversations with Dr. Bauchner” podcast.

Dr. Foege co-chaired the National Academies of Sciences, Engineering and Medicine committee that last week released the final report that advises a four-phase plan for allocation of a COVID-19 vaccine when one shown to safe and effective becomes available.

The study recommends the U.S. Department of Health and Human Services and other authorities use existing distribution systems and launch a COVID-19 vaccine promotion campaign and a risk-information program to support allocation that would ensure that the most vulnerable populations receive the vaccine during the time when demand exceeds supply.

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AMA President Susan R. Bailey, MD, lauded the committee’s work, saying the principles outlined “are grounded in science and align with the fundamental values of medicine and ethical responsibilities of physicians set out in the AMA Code of Medical Ethics, with AMA policies relating to public health, and with the overarching goals of AMA’s Center for Health Equity.”

Dr. Bailey noted that the AMA is looking forward to the final vaccine allocation recommendations, which will be determined by the CDC’s Advisory Committee on Immunization Practices. Get an update from CDC physicians on COVID-19 vaccine development and distribution in this AMA-hosted webinar aimed at doctors.



The inequitable impact of COVID-19 is well-established, Dr. Foege said in his interview with Dr. Bauchner, but that phenomenon is not driven by race but, rather, by racism.

Higher rates of severe disease and death among Black, Latinx and Native American communities relates to underlying conditions such as heart failure, kidney failure and a body mass index over 40, as well as social factors that exacerbate risks of exposure, regardless of race or ethnicity, he explained.

“What if you look at the social vulnerabilities? What does it mean to live in a crowded house with three generations living in a house, inability to work from home and every day taking a risk of facing a virus, having problems with transportation, having schoolchildren coming in and out?” Dr. Foege said.

“Let’s take a look at the risk factors and make those the decision points for getting the vaccine, rather than race,” he said, describing the committee’s work. “The virus simply doesn’t understand race and color. It does understand vulnerabilities.”

The two-stage first phase for vaccine allocation would initially include first responders and front-line health care workers who risk exposure to bodily fluids and aerosol virus and have frequent exposure to infected patients. Phase 1a would cover about 5% of the population. Phase 2a would vaccinate another 10% of the population and include patient groups with co-morbidities such as cancer and heart disease who are at risk for severe disease. This National Academy of Medicine graphic illustrates the four phases.

Phases two and three would cover people working in schools, transportation, homeless shelters, nursing homes, long-term care facilities and more. Phase four would include everyone not vaccinated in previous phases.

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Dr. Foege said that the four-phase allocation framework anticipates that initially there will not be much vaccine available, and it focuses on health care workers and other employees working in hospitals because of their risk for exposure.

By the time the first phase is complete, much more vaccine should be available, he said. “So, we should move through phase two and three relatively fast. The problem, I think, is not likely to be the limitation of vaccine but the hesitancy of people wanting to get the vaccine,” he said.

Polls indicate that many people are hesitant about COVID-19 vaccination now, he noted, “but when they see that the vaccine is working [in the first two phases], they may change their minds.”

Physicians will play a key role in answering patients’ questions about SARS-CoV-2 vaccination. Two AMA-hosted webinars arm doctors with some information they need to do so. They are available for viewing at your convenience: