What it will take to equitably distribute a COVID-19 vaccine

Highlights

• •The national vaccine allocation strategy should prioritize healthcare workers across settings.
• •It should prioritize access for high-risk populations.
• •It should avoid using age as a criterion.

In oral and written testimony delivered earlier this summer to the National Academies of Science, Engineering, and Medicine (NASEM), the American Geriatrics Society (AGS) stressed the importance of a key priority in stemming the tide of COVID-19: prioritizing health professionals and older adults in the distribution of a future COVID-19 vaccine.^{1 , 2} Delivered in response to an NASEM draft framework for the equitable distribution of coronavirus immunizations — which has since been finalized to include several important points raised by the AGS — our comments stressed the importance of ensuring age is never used to exclude someone categorically from care, including prevention for a disease as deadly as COVID-19.^{3 , 4}

Developed by an inter-professional group of experts, the distribution strategy includes a summary of lessons learned from past allocation frameworks for mass vaccination campaigns, as well as from recent guidance during the COVID-19 pandemic for the allocation of medical resources and supplies.^{3 , 4}

Drawing from these lessons, the committee defined the foundational principles, primary goal, and criteria for determining an equitable allocation framework. The criteria include:

• •Risk of acquiring infection^{3 , 4}
• •Risk of severe morbidity and mortality^{3 , 4}
• •Risk of negative societal impact^{3 , 4}
• •Risk of transmitting disease to others^{3 , 4}

We appreciate that older adults, people with chronic conditions, and others at high risk of dying from COVID-19 are prioritized in the framework. However, the AGS is concerned that portions of the underlying analysis that informed these recommendations lean on stereotypes that potentially devalue older adults.⁵

“We refer specifically to the idea that age in and of itself is a potential criterion for making allocation decisions,” noted Timothy W. Farrell, MD, AGSF, vice chair of the AGS Ethics Committee, in oral testimony before the NASEM committee responsible for the framework.^{1 (para. 11)} “Our current reality is that, due to advances in our understanding of diseases and how to treat them, people are living healthy lives even when they have heart disease or other chronic conditions. Resting these recommendations on an analysis that does not reflect the complexity of how we age runs the risk that older people will be discriminated against because of their age when this framework is implemented,” he concluded.^{1 (para. 11)}

And we as a Society agree.

In further written comments submitted to the committee by the AGS, our geriatrics experts strongly recommended that our national vaccine allocation strategy:

• •Prioritize the health workforce, broadly defined to cover workers across care settings, including in long-term care, assisted living, and other congregate living facilities, and in home and community-based settings²
• •Prioritize access for high-risk populations, including older adults, those living in congregate settings, people with chronic health conditions, and communities of color²
• •Avoid using age as a criterion, given the diversity of the older adult population²

Importantly, NASEM distanced the guidelines from the previous focus on life-years saved and instead focused on avoidance of death, citing concerns about ageism that had been raised in the AGS testimony.^{3 , 4 , 6} However, NASEM did not exclude the possibility of reverting to the life-years saved argument in situations when younger adults have disproportionately high mortality from a pandemic.^{3 , 4} We commend NASEM for de-emphasizing the life-years saved approach in its final COVID-19 vaccine allocation framework, but we also urge NASEM and other groups to avoid reverting to the life-years saved argument in the future, given its inherent ageism.^{5 , 6}

We are more confident than ever that a COVID-19 vaccine is possible and on the horizon, but we should not — and, ultimately, cannot — let ageism overshadow progress that benefits us all as we age.