By Peter Lloyd-Sherlock, Adelina Comas-Herrera and Martin McKee

A version of this blog is also available at: https://www.bmj.com/content/372/bmj.n211/rr-1

As COVID-19 vaccines become available, many low and middle-income countries (LMICs) are publishing prioritisation plans. Beyond giving some or all health workers the highest priority, these plans differ markedly. Some follow a similar approach to most high-income countries. Mexico, for example, starts with people aged 80 or more, moving progressively through those aged 70-79 and 60-69 [1]. Peru, in contrast, places everyone aged 60 or more into a single category below several other groups, including the military, private security guards and election workers [2]. Brazil is prioritising its indigenous population of all ages above non-indigenous older people, other than those living in care homes [3]. Unusually, Indonesia initially prioritised younger people over those aged 60 or more in the first phase of roll-out [4].

Governments have sought to justify their priorities in different ways. Peru has concerns about forthcoming national elections. Indonesian officials argue there are insufficient data on safety of China’s Sinovac vaccine in older people [1]. Nevertheless, there is an evident need for systematic guidance for prioritisation.  WHO has published ethical guidance, but we argue that it lacks specificity and should focus on three key considerations [5, 6]. 

Openness and clarity about goals.

WHO guidance states: “The overarching goals of protecting individuals and public health, while recognizing the need to minimize impact on societies and economies, should drive the allocation process of health products across different countries” [6]. Minimising deaths, easing pressure on hospitals, limiting spread of infection, or accelerating a return to normal life are all desirable outcomes, but not always mutually compatible [7]. For example, groups most at risk of dying of COVID-19 may not be those most likely to spread infection or most important for rebooting economies.[1] Rather than strike a messy compromise, governments must establish a primary objective.

On 6 February 2021, the Director General of WHO set out a more focussed, less ambiguous goal, stating: “There is a disturbing narrative in some countries that it’s OK if older people die. It’s not OK… It is important that everywhere older people are prioritised for vaccination. Those most at risk of severe disease and death from COVID-19, including health workers and older people, must come first. And they must come first everywhere.” [9].

Realism about local context.

Prioritisation must reflect the speed of procurement of particular vaccines and national capacity to roll them out to different groups. India’s purported aim of treating all its 250 million people aged 50 and over as a single group avoids difficult choices, but the country would be better served by a more differentiated strategy [10]. LMICs with prevalent HIV and TB should consider evidence of high COVID-19 case fatality among people with these infections [11]. Also, prioritisation will only be meaningful if it is linked to feasible delivery plans addressing access barriers and vaccine acceptance. Even in some high-income countries rollout has already diverged from stated priorities, due to difficulties reaching high priority groups [12].

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. It will also affect how these harms are distributed across different groups within these societies. Any strategy should be consistent with the primary objective of a vaccination programme. And those objectives must themselves be guided by principles of equity and social justice. These are:

Prioritisation should be a consensual process, based on informed societal debate, with the participations of all social sectors.

Vaccination should conform to wider principles of universal rights to health. This means vaccines should be free or affordable for all and that access will not be influenced by ability to pay or political leverage. There is already evidence of lobbying by corporations to prioritise the vaccination of their own staff and of senior political figures jumping the queue [13, 14].

Policy should take into account that some groups have limited logistical capacity to mobilise notionally universal entitlements to access vaccinations. For example, poor, frail older people or disabled people face particular challenges in reaching a vaccination point.

Concluding thoughts.

This short paper establishes some general parameters to support policymaking and national debate. Within each of these, it identifies preliminary sets of considerations. While these can be applied to all countries and settings, it does not follow that the resultant policies will be the same. A one-size-fits-all global template will be neither feasible nor desirable. Inevitably, decisions will be shaped by a complex interplay of political considerations, expediency and heuristic framing. Nevertheless, it is to be hoped that to some degree they will reflect the available scientific evidence.

[1] Some commentators have claimed that older people are most at risk of death, but are less at risk of spreading infection, since they have less social or economic interaction with others [8]. There is no evidence to support this claim, which reflects a misguided and stereotyped assumption of old age and marginality.

REFERENCES

1. Government of Mexico. Política nacional rectora de vacunación contra el virus SARS-CoV-2 para la prevención de la COVID-19. https://coronavirus.gob.mx/wp-content/uploads/2021/01/PolVx_COVID_-11Ene2021.pdf [accessed 28.1.21].
2. Government of Peru, Ministry of Health. Quiénes serán vacunados? http://www.minsa.gob.pe/vacuna-covid-19/?op=3 [accessed 28.1.21].
3. Federal Government of Brazil, Ministry of Health, https://www.gov.br/saude/pt-br/assuntos/noticias/entenda-a-ordem-de-vacinacao-contra-a-covid-19-entre-os-grupos-prioritarios [accessed 28.1.21].
4. Lloyd-Sherlock Peter, Muljono Paramita, Ebrahim Shah. Ageism in Indonesia’s national covid-19 vaccination programme BMJ 2021; 372 :n299.
5. WHO (2020) Fair allocation mechanism for COVID-19 vaccines through the COVAX Facility. https://www.who.int/publications/m/item/fair-allocation-mechanism-for-covid-19-vaccines-through-the-covax-facility [accessed 28.1.21].
6. WH0 (2020) WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination. https://www.who.int/news/item/16-09-2020-who-sage-values-framework-for-the-allocation-and-prioritization-of-covid-19-vaccination [accessed 28.1.21].
7. Karin Hardt, Paolo Bonanni, Susan King, Jose Ignacio Santos, Mostafa El-Hodhod, Gregory D. Zimet, Scott Preiss. Vaccine strategies: Optimising outcomes. Vaccine, Volume 34, Issue 52, 2016, Pages 6691-6699. https://doi.org/10.1016/j.vaccine.2016.10.078
8. Fiona M Russell & Brian Greenwood (2020) Who should be prioritised for COVID-19 vaccination?, Human Vaccines & Immunotherapeutics, DOI: 10.1080/21645515.2020.1827882.
9. https://twitter.com/DrTedros/status/1358084910569975810 [accessed 6.2.21].
10. Hindustan Times India Covid-19 vaccination: FAQs on schedule, precautions, side effects https://www.hindustantimes.com/india-news/india-covid-19-vaccination-faqs-on-schedule-precautions-side-effects-101610689958226.html [accessed 28.1.21].
11. 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.
12. Lauter S, Lorenz-Dant K, Comas-Herrera A and Perobelli E (2021) International “living” report: Long-Term Care and COVID-19 vaccination, prioritization and data. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 18th January 2021. Accessed 24/1/2021 https://ltccovid.org/wp-content/uploads/2021/01/COVID-19-vaccine-and-LTC-prioritization-and-data-18-January-update.pdf [accessed 28.1.21].
13. Martinne Geller. Unilever gets vaccine partnership offers as it plots worker safety strategy. Yahoo Finance 13 January 2021. https://uk.finance.yahoo.com/news/unilever-strongly-encourages-workers-covid-172908310.html?guccounter=1&guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAAJi7kye1p_q33P-CplUs7V217nOIrwL6sFfwJPwyUl7jZY2eLRSrgPeO0YMDjxHzXQcxSSwiWFvHLU2wv-oNdmQURwMV6ECdPAvZ3NkngHO1v7LoAr-aRHXUIbcGbCwy5b9bpGL6hH5KCKdPn7t58mkBaJCRif-bbXjX7x9Oldng
14. https://elcomercio.pe/politica/gobierno/martin-vizcarra-pilar-mazzetti-alguien-como-el-presidente-de-la-republica-debe-abstenerse-de-participar-en-un-ensayo-clinico-vacuna-sinopharm-nndc-noticia/