When a coronavirus vaccine is available, who should receive it first?
A preliminary plan designed by the Centers for Disease Control and Prevention this spring prioritizes healthcare workers, then people with underlying medical conditions and seniors. The CDC has not yet decided whether the next in line should be black and Latino, groups disproportionately affected by the coronavirus.
But suppose healthcare workers and people with underlying medical conditions use the first few doses of the vaccine available. Should some be kept in reserve for black and Latino people? What about bus drivers and train drivers? Perhaps teachers or schoolchildren should obtain it so that they can return to the classroom with ease.
If a shortage occurs, most of the nation will not have an opportunity to receive initial batches of a vaccine under the CDC plan. And as the United States fights an increasing number of coronavirus cases, an increased demand for drugs and perhaps ventilators is expected. They will also need a fair distribution system.
One solution that is beginning to attract the attention of public health experts is the so-called weighted lottery, which gives everyone the opportunity to access, although some get a better chance than others.
Doctors and ethicists classify patients and decide which groups should be given preference and to what extent. First responders, for example, may be heavier than, for example, very ill patients who are unlikely to recover.
The goal is to avoid random or uneven distribution of a treatment or vaccine when there is not enough for everyone. Such a system has already been used in assignments for remdesivir, the first drug to be shown effective against coronavirus.
“This is all very new,” said Dr. Douglas White, an ethic and vice president of the critical medicine department at the University of Pittsburgh, who started using a weighted lottery last month to distribute remdesivir.
The patients have accepted the results, even when they lost in the lottery and were denied the medication, he added.
“I suppose it is because we are very transparent about the reason and the ethical framework that applies to everyone who enters the hospital, be it the president of the hospital or someone who is homeless,” he said.
To assign the medication, Pittsburgh doctors decided that the lottery would give preference to healthcare workers and emergency medical workers. Doctors also weighed the odds of favoring people from economically disadvantaged areas, who tend to be mostly black and Hispanic.
People with other illnesses and limited lives, such as end-stage cancer patients, had the odds weighted against them, giving them a lower chance of winning in the lottery. The system did not consider age, race, ethnicity, quality of life, ability to pay, or whether a patient has a disability.
The lottery started in early June, Dr. White said: “We had 64 patients. We had to make the remdesivir supply last for at least two weeks. We only had enough to treat one in four patients. “
They had a brief respite from the lottery when the cases started to drop and the remdesivir supplies seemed adequate. But on Sunday, with the increase in cases and the decrease in numbers for only half of the patients who could receive help, the hospital system was forced to return to the lottery.
A weighted lottery will be used in South Carolina if the growing number of patients causes a shortage, said Dr. Dee Ford, an infectious disease specialist at South Carolina Medical University and a member of an advisory group for the state department of health. . So far, she said, the state supply of remdesivir remains adequate.
Dr. White and his colleagues were considering a weighted lottery before the remdesivir shortage began. And other ethicists as well, like Dr. Robert Truog of Harvard Medical School, who had learned about the system when he feared lack of ventilation in March.
She consulted with Dr. White, who had developed a system that awarded severely ill coronavirus patients points based on their estimated probability of survival. After Dr. Truog and colleagues published a document on fan distribution, Dr. Truog said, “We got a call from an economist at MIT.”
The economist, Parag Pathak, told Dr. Truog that he and other economists had spent years thinking about how to allocate resources, and that they had successfully developed and used weighted lotteries.
For example, Dr. Pathak told her that such systems are used to allocate places in over-subscribed charter schools, giving preference to children in certain neighborhoods. Dr. Truog was intrigued, but it turned out that there were enough fans, so a lottery was not necessary.
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Frequent questions
Updated July 23, 2020
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What will school be like in September?
- Many schools are unlikely to return to normal hours this fall, requiring the routine of online learning, impromptu child care, and delayed work days to continue. California’s two largest public school districts, Los Angeles and San Diego, said July 13 that instruction will be remote only in the fall, citing concerns that rising coronavirus infections in their areas pose too serious a risk to students and teachers. Together, the two districts enroll about 825,000 students. They are the largest in the country so far to abandon plans for a partial physical return to classrooms when they reopen in August. For other districts, the solution will not be an all-or-nothing approach. Many systems, including the country’s largest New York City, are devising hybrid plans that involve spending a few days in classrooms and other days online. There is no national policy on this yet, so check with your municipal school system regularly to see what’s going on in your community.
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Is the coronavirus in the air?
- Coronavirus can remain in the air for hours in tiny droplets in stagnant air, infecting people as they inhale, growing scientific evidence suggests. This risk is highest in crowded interior spaces with poor ventilation, and may help explain overcast events reported in meat packing plants, churches, and restaurants. It is unclear how often the virus is transmitted through these small droplets or sprays, compared to the larger droplets that are expelled when a sick person coughs or sneezes, or is transmitted through contact with contaminated surfaces, Linsey said. Marr, Virginia Tech aerosol expert. Aerosols are released even when a symptom-free person exhales, speaks or sings, according to Dr. Marr and more than 200 other experts, who have summarized the evidence in an open letter to the World Organization. Of the health.
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What are the symptoms of coronavirus?
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What is the best material for a mask?
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Does Covid-19 transmit asymptomatic?
- So far, the evidence seems to show that it does. A widely cited article published in April suggests that people are most infectious approximately two days before the onset of coronavirus symptoms, and estimated that 44 percent of new infections were the result of transmission from people who still had no symptoms. Recently, a senior expert at the World Health Organization stated that transmission of the coronavirus by people without symptoms was “very rare,” but later withdrew that claim.
But remdesivir was another story, Dr. White and Dr. Truog realized: scarcity was not only possible; they were happening
“When the shortage of remdesivir started, we felt that a lottery system would be a much better allocation method than a point system,” he explained. His group and Dr. Truog developed a weighted lottery to remdesivir, and Pittsburgh hospitals began using it.
They also noted another advantage: weighted lotteries can allow researchers to rigorously discover which subgroups of patients perform best with a new drug or vaccine.
That’s because the assignment within a group is random. Distribution is, in effect, a randomized, controlled clinical trial. The only difference between, for example, people over 60 who received the drug and those who did not, is tossing a coin in the lottery.
For that reason, the results may reveal how well a drug or vaccine works for subgroups of people.
That type of analysis has been done to study variations in student performance in different schools, answering questions like: Did students with higher test scores get the same results with or without a charter school? Did the school benefit those who were not doing well in your neighborhood schools?
A large federal clinical trial showed that remdesivir slightly improved inpatient recovery times. However, that study was not designed to show whether some groups, such as younger people or those who were earlier in the course of their infection, benefited more than others.
These outcome data are buried in electronic patient health records. If patients participated in a weighted lottery, it would be much easier to see who benefited and who did not with remdesivir.
Similar questions can be addressed if a vaccine were distributed with such a lottery. But obtaining those data would be more complicated, because the distribution of the vaccine can involve tens of millions of people.
Still, in principle, lottery data about a vaccine can be as useful as data from randomized clinical trials, Dr. Pathak said.
“We would like people to think ahead about how vaccines are assigned,” he said. “There is no way we can vaccinate everyone, so we have to think about what is fair and what is fair.”
