Who should get the vaccine first?

Washington's coronavirus vaccine line started without much, if any, dispute. Health care workers and long-term care facilities' residents and staff were not only prioritized here but everywhere else in the country. It made sense: We needed nurses and doctors healthy so they could treat those with the most severe cases of the disease, and those afflicted with the most awful bouts were disproportionately people who lived in nursing homes.

But as the vaccine rollout has played out, questions about the order of our vaccine line have become far more fraught. Should a pair of 67-year-old, couch-bound retirees get their shots before a 31-year-old bus driver exposed to dozens of passengers every day? Should they get them before a group of fraternity brothers who, in gathering recklessly, could be spreading the virus? And, perhaps most nagging of all, should teachers receive injections before other essential workers to speed the return of in-person learning?

President Joe Biden answered that last question for states earlier this month, ordering them to give every educator at least one shot by the end of March. Unlike Oregon, Washington had not prioritized teachers before Biden's missive. Now, pre-K through 12th grade school teachers and staff, as well as child care workers, are eligible to sign up for shots statewide. Ruth Faden, the founder of the Johns Hopkins Berman Institute of Bioethics, told me a few weeks before Biden's announcement that there are "good moral arguments" for vaccinating teachers. "One of the principles that should be a central ethical principle in the context of how we think about this pandemic is our commitment to the well-being of children," Faden said.

Specifically, she added, children are dependent on others to get what they need, including an education. "Childhood is a very developmentally sensitive period of life. So if your interests are poorly served, if you lose out at critical points in your growing up years as a child and adolescent, it can set you back for the rest of your life."

Faden was also clear, however, that vaccinating teachers doesn't often do much to reduce death or severe illness, which she mentioned as the pandemic's top ethical priority. Accomplishing that goal equitably should be part of any state's plan, she says. "We have to make sure that as we focus on reducing severe disease and death, that we pay a special attention to the communities that have experienced the greatest burden of severe disease and death, which are low-income communities, Native peoples, and communities of color."

Looking at Washington's vaccine order before the Biden reshuffling, which bumped up the 65-and-over crowd and elders in multigenerational households, Faden gave our state high marks. "Governor [Jay] Inslee has what I think is absolutely the right public health strategy backed up by the right ethical value." Of course, she noted, taking additional measures to reach vulnerable communities is vital. The Washington State Department of Health's rollout has, by its own admission, fallen short on its goal to achieve equitable vaccination rates.

 

Faden's field—bioethics—examines whether something is the right thing to do. But there's another part of the rollout equation, one that doesn't always align with our do-good sensibility: What's the optimal way to distribute vaccines to stop the spread of the virus and, specifically, death?

Laura Matrajt, a mathematical modeler in the Vaccine and Infectious Disease Division at Fred Hutchinson Cancer Research Center, took up the question well before the NIH-Moderna and Pfizer-BioNTech vaccines were approved. Which means the study she lead-authored for Science Advances couldn't know that the efficacy of those shots would be around 95 percent, that transmission of the virus would remain low (relatively speaking) in Washington, and that our vaccine rollout would lack supplies and speed. Given those factors and what her research has found, Matrajt says the state has handled its rollout correctly, prioritizing older people who are generally at the greatest risk of dying from Covid-19.

But some of the paper's other conclusions prompt a fascinating what-if. If we'd had more vaccine supply—a lot more—and the same vaccines available, the optimal way to curb deaths would have been to inject high transmission groups first. That means children (if they'd been studied during vaccine trials) and young adults would have followed health care workers in the vaccine line. Beer bong bros before grannys.

It's a moot point now. As anyone who's tried to sign themselves or loved ones up for vaccine appointment knows, we have devastatingly little supply at the moment, though that is gradually changing. The findings might be more relevant whenever our next round of vaccinations begins.

Some other research Matrajt worked on is more immediately relevant. Still in its pre-print stage (meaning it has not been peer-reviewed), the study found something fairly intuitive but critical: That if one dose of a two-dose vaccine has a high enough efficacy, we should give out a single shot of it in an environment of low transmission. If it doesn't protect us particularly well, we should stick to doling out two per person.

The one-shot alternative rollout is alluring, if only because it would effectively double our vaccine supply. Unfortunately, we don't know for sure how effective the Pfizer or Moderna vaccines are after just one dose. But the arrival of the one-shot Johnson and Johnson vaccine will certainly prompt more questions about which groups should receive which types of vaccines. Matrajt would like to study the intricacies of those allocations. She has one other wish, too, one assumption that's baked into so many coronavirus studies: "I hope people understand that it is really important to keep social distancing as much as possible while vaccination is happening."

In other words, no matter how you feel about our vaccine line, you should definitely keep voicing your opinions at a distance.