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Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States

Report cover for Interim Framework for COVID-19 Vaccine Allocation and Distribution in the United States
Eric Toner, Anne Barnill, Carleigh Krubiner, Justin Bernstein, Lois Privor-Dumm, Mathew Watson, Elena Martin, Christina Potter, Divya Hosangadi, Nancy Connell, Crystal Watson, Monica Schoch-Spana, Tener Goodwin Veenema, Diane Meyer, E. Lee Daugherty Biddison, Alan Regenberg, Tom Inglesby, Anita Cicero
Date posted:
August 19, 2020
Publication type:
The Johns Hopkins Center for Health Security
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The COVID-19 pandemic will continue for the foreseeable future, but widespread vaccination could hasten its end. At least 165 candidate vaccines for the SARS CoV-2 virus are in development around the world and there is hope that one or more of these candidates will soon be shown to be sufficiently safe and effective to achieve emergency use authorization in the United States. When a vaccine has been authorized for use, it will initially be in limited supply. During this period of scarcity, a plan is needed for how to allocate and distribute the limited supply—which groups should be prioritized to receive the vaccine first and which groups can wait until later. This difficult and potentially contentious topic is being actively discussed in the United States by the Advisory Committee on Immunization Practices (ACIP) of the US Centers for Disease Control and Prevention (CDC) and the National Academy of Medicine (NAM), as well as globally at the World Health Organization (WHO) and elsewhere. The purpose of this report is to offer an additional ethics framework for use in making decisions about allocation of SARS-CoV-2 vaccine during this initial period of scarcity in the United States and make related suggestions about vaccine distribution. Our approach takes into account considerations of medical risk, public health, ethics and equity, economic impact, and logistics. We note where our approach aligns or differs from the 2018 CDC guidance for vaccine allocation in a severe influenza pandemic, which is the most recent pandemic vaccine guidance from the US government. 

This report is the product of deliberations of a multi-disciplinary team of public health experts at Johns Hopkins University including members from the Center for Health Security, the Berman Institute for Bioethics, The Armstrong Institute for Patient Safety and Quality, the International Vaccine Access Center, the Center for Vaccine Research, in the Johns Hopkins Schools of Public Health, Medicine, and Nursing. The deliberations were informed by a review of available literature and open source government documents. We were not privy to any proprietary or unpublished information that may be available to other groups considering these issues that could alter judgments about prioritization, and acknowledge the evolving state of the evidence about pathogenesis and vaccine response. Therefore, our suggested priority groups should be viewed only as plausible examples of candidates for top tier prioritization when applying the framework, and not as definitive recommendations.

The intended audience for this report includes policy makers and technical experts in the US federal government currently working on vaccine allocation plans, those at the state and local levels who will be implementing allocation plans, community leaders, activists and the general public interested in influencing vaccine allocation decisions. The principal product of this report is an ethical framework to guide discussion and inform decisions about vaccine allocation. This framework places emphasis on promoting the common good, by promoting public health and also by enabling social and economic activity. It also emphasizes the importance of treating individuals fairly and promoting social equity, for example by addressing racial and ethnic disparities in COVID mortality, and by recognizing the contributions of essential workers who have been overlooked in previous allocation schemes.  The framework also includes a third ethical value not often well-articulated in ethics discussions of vaccine allocation and whose importance we wish to elevate—the promotion of legitimacy, trust and a sense of community ownership over vaccine policy, while respecting the diversity of values and beliefs in our pluralist society. We consider the ethical principles that should guide COVID-19 vaccine allocation and identify more specific policy goals and objectives that follow from these ethical principles.  



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