Who should receive priority for inoculation as the vaccines become available? Currently, the CDC proposes that health care and residents of long term care facilities should be the first to get the vaccines. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations.html This is a reasonable first step. As more shots become available who should be next in line? The CDC lists the priorities as minimizing death and serious disease, preserving the economy and “reducing the extra burden COVID-19 is having on people already facing disparities”.
The number of health care workers in Virginia is estimated at 367,000 while long term care facility residents are estimated at 19,600. https://www.kff.org/coronavirus-covid-19/issue-brief/estimates-of-the-initial-priority-population-for-covid-19-vaccination-by-state/ Virginia expects about 370,000 vaccine doses in December, which should about cover the first priority individuals.
Let us address the CDC’s first goal, reducing death and serious disease. Clearly, the most effective approach is to administer the vaccine on the basis of oldest first, perhaps with some adjustment for preexisting conditions. Virginians over 60 were estimated by the Census Bureau at 19.8% of the population in 2020, or about 1.4 million people. Virginians over 70 number about 650,000. https://acl.gov/sites/default/files/programs/2016-11/Virginia%20Epi%20Profile%20Final.pdf. Therefore, depending on how quickly the vaccines ship, we should be able to give the vaccine to most of the Virginians at the highest risk this winter
Arguments have been made that after health care workers and long term care residents get the shots, “essential workers” should have the highest priority. There are several problems with this argument. First, if we are interested in reducing death and serious disease, concentrating on the older population (some of whom are also “essential workers”) is clearly the most effective. Of the 4,650 Virginians who have died from Covid-19 as of December 20, 2020, 4186 were over 60, about 90%. https://www.vdh.virginia.gov/coronavirus/coronavirus/covid-19-in-virginia-demographics/ This population also accounted for more than 56% of hospitalizations. Vaccinating this population would be a major step to reducing the impact of covid by reducing deaths and hospitalizations.
On the other hand, vaccinating “essential” workers would do little to reduce death and hospitalizations, since younger people have so much less probability of contracting a serious case of covid. One estimate of the number of Virginia “essential workers” estimated the number at 760,000. https://www.thecommonwealthinstitute.org/2020/04/22/profile-of-essential-workers-in-virginia-during-covid-19-women-people-of-color-and-immigrants-are-important-contributors-in-front-line-virginia-industries/ About half of the “essential” are in health care, so only about 400,000 doses would be needed for the remaining workers. Those doses, if used for the over 70 population should reduce deaths in Virginia by nearly 85%, a far greater impact than using those doses on those much less at risk.
Another problem is defining who is essential. The above estimate included grocery, pharmacy, trucking and cleaning workers. These definitely essential workers have been heroically working throughout the pandemic. Certainly some have died. Others have been very sick. However, comparatively speaking, to the extent that these workers are younger and have fewer co-morbidities, they have also been impacted much less by the disease. Moreover, as soon as a decision is made to give “essential” workers the vaccine, other groups will insist on being included. Already, teacher unions have claimed they should have priority, even though in many cases their presence in classes with students was not heretofore thought essential. Owners and workers at small businesses that have been closed no doubt feel that their livelihoods are essential. My point is not to say that Jane is more important than John, only that sorting out “essential” will engender much ill will and is much more problematic than simply giving vaccines to younger and younger cohorts as they become available.
Vaccinating those most threatened by the virus would also allow the economy to fully reopen, since most workers are at little risk. Those who are could isolate themselves or not until they are eligible for the vaccine.
Finally we come to the “reducing the extra burden Covid-19 is having on people already facing disparities.” It is not clear who would qualify under this. If this refers to the poor, steps should be taken to provide free shots for those otherwise eligible. Would those unemployed because of covid get the shot before someone working? Deciding to deny a shot to someone at much greater risk so we can give one to someone facing a “disparity” certainly seems unethical.
The fairest and simplest way to distribute the vaccine after giving it to health care workers and nursing home residents should be by descending age cohort, with some adjustment for other co-morbidities. It is clear, fair and would allow us to more quickly put this disaster behind us.