COVID-19 vaccine prioritisation in low and middle-income countries: where should older people fit in?
By Peter Lloyd-Sherlock, UEA, January 19th
At the end of 2020, a Global Platform blog raised concerns about Indonesia’s “interesting” reported decision to explicitly exclude all people aged 60 or more from the first phase of their vaccine roll-out. Since then, messages coming from Indonesian officials have been somewhat confusing, with some indications that there has been a rethink. Hopefully, this is the case, although four days ago the BBC reported that older Indonesians still remain excluded.
Over the past weeks, many low and middle-income countries (LIMICs) have started to publish information about how they will approach vaccine prioritisation. Of course, vaccine nationalism ensures that progress towards reaching significant numbers of people will be excruciatingly slow in most of these countries. Even in high-income countries, vaccination will not represent a magic bullet for saving lives and restoring normality. Roll-out will be gradual and must not deflect attention away from the basics of prevention and control: hands, eyes and space.
The vaccination strategies of many LMICs may say more about aspiration than about what will actually occur over the coming months. As such, they should probably be taken with a large pinch of salt. Nevertheless, they are important inasmuch as they set a template for the longer-run and provide insights into countries’ global health priorities.
The Global Platform network has started to take a closer look at plans for a number of countries and has found some striking contrasts. All countries understandably place some or all health workers in their top priority, but, beyond that, thinking appears to diverge. Some countries follow a similar approach to the UK and other high-income countries. Mexico, for example, includes people aged 80 or more in their top priority, with people aged 70-79 and 60-69 following on from this. Peru begs to differ, treating all people aged 60 or more as a single category and giving them a lower priority than a wide range of groups, including the entire military, private security guards and election workers. In the case of Brazil, individual states appear to be setting their own differing priorities. São Paulo State (which has seen the largest number of reported COVID-19 deaths) appears to have given its indigenous population of all ages in a higher priority than older people.
There may be justifications reasons for some of these idiosyncracies. In Peru, there are particular concerns about controlling infection during forthcoming national elections. Indonesia argues that there are insufficient data on SINOVAC vaccine safety for people at older ages. A recent article on COVID-19 vaccination observed that: “In some settings, the elderly may be prioritized, in others, it may be the population most likely to get infected and responsible for community spread” (Russel & Greenwood, 2020). This argument is deeply concerning, as it appears to imply that both of these approaches have equal ethical validity. It also appears to suggest that “stay-at-home older people” are unlikely to pass the condition on. This view, based on ageist stereotyping rather than evidence, resonates with justifications made by several Indonesian officials. Arguments such as this have little validity and gloss over the obvious issue that giving older people a low priority in any country is likely to substantially increase the pandemic’s death toll.
All of this shows the urgent need for a more systematic approach to prioritising vaccination in different countries, based on three broad criteria.
Openness and clarity about goals
Governments must establish the primary goal of their vaccination programmes. Is it to minimise deaths, ease pressure on hospitals, limit infection or something else? These different goals are not mutually compatible. For example, those people most at risk of dying of COVID-19 may not be the same as those who contribute most to infection. Similarly, evidence is starting to emerge that different types of vaccine may be more suited to some goals (such as reducing infectivity) than to others (easing symptoms).
Realism about local context
Prioritisation only makes sense if it considers the likely rate at which countries obtain access to particular vaccines and their capacity to roll them out. It should also consider epidemiological factors, including the general status of the pandemic and the prevalence of other risk factors. For example, evidence from South Africa indicates a strong association between HIV status and COVID-19 case fatality (Davies, 2020).
Equity and social justice
The prioritisation of different groups for vaccination will have large effects on the overall burden of harms generated by the pandemic in each country. But it will also affect how these harms are distributed across different groups within these societies.
As discussed above, prioritisation should be consistent with the primary goal of a vaccination programme. But this goal-setting must itself be guided by principles of equity and social justice. These include that:
· Prioritisation should be a consensual process, based on informed societal debate.
· Vaccination should conform to wider principles of universal rights to health. In practice, this means vaccines should be free or affordable for all and that access will not be influenced by ability to pay or political leverage (such as lobbying by TNCs to vaccinate staff versus less powerful interests).
· Policy should recognise that some groups have limited logistical capacity to mobilise notionally universal entitlements in reality. For example, how will poor, frail older people or disabled people reach vaccine centres?
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Fiona M Russell & Brian Greenwood (2020) Who should be prioritised for COVID-19 vaccination?, Human Vaccines & Immunotherapeutics, DOI: 10.1080/21645515.2020.1827882
Davies M-A . HIV and risk of COVID-19 death: a population cohort study from the Western Cape Province, South Africa. medRxiv Prepr Serv Heal Sci. 2020;20145185. doi:10.1101/2020.07.02.20145185.