March 8, 2021

Against CDC guidelines, some states are vaccinating primarily by age. Is that ethical?

Daily Briefing

    CDC guidelines recommend states prioritize vaccinating frontline workers and those with high-risk medical conditions, as well as the elderly. But some states have instead opted to vaccinate by primarily age group to streamline the process—a move that has some health experts concerned.

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    Some states start vaccinating primarily by age group

    While most states and Washington, D.C., are prioritizing vaccinations for people with chronic conditions, some states have opted to establish a primarily age-based system. For instance, on March 1, Connecticut began the process of vaccinating by age group, starting with everyone age 55 and older. The state plans to vaccinate younger adults later in the spring. Officials said the only exception will be teachers and childcare providers, who will also be prioritized for vaccines.

    Similarly, since March 3, Maine has allowed everyone age 60 and over to register for a vaccine. And as of March 8, Vermont will allow those 55 and older with certain high-risk conditions to register for vaccination, before allowing individuals 16 and older with certain health conditions to register the following week.

    Rhode Island has also started shifting toward a primarily age-based vaccination system, saying it will likely shift to vaccinating those age 40 to 65 in mid-March and those in the 16-39 age group by June. Currently, however, the state is still prioritizing those with underlying medical conditions between the ages of 16 and 64.

    Why the move is concerning some health experts

    There are two main objections to a vaccination system based primarily on age. First, it overlooks the risks facing those in underserved communities, as well as racial and ethnic minorities.

    As Greg Gonsalves, a professor of epidemiology at Yale University, argued, an age-based rollout doesn't guarantee equitable distribution of vaccines. "If you have access to resources, you're computer literate, and you have some savvy in working your way through the system to sign up for vaccines—you're going to be first in line no matter what age class you're in," he said.

    Moreover, he pointed out that an age-based approach also ignores racial disparities in Covid-19 risk. "The risk of death for somebody who is African-American and between 55 and 65 may be higher than somebody who's over 65, for instance," Gonsalves said.

    Ana Núñez, an internist and vice-dean for diversity, equity, and inclusion at the University of Minnesota School of Medicine, said age doesn't always reflect a person's overall risk for Covid-19. She explained that other factors, such as housing stability and employment, could have a significant effect on an otherwise healthy person's risk of Covid-19.

    Núñez said white people often outnumber racial and ethnic minorities in a number of states, meaning shifting to an age-based system discriminates against those racial and ethnic groups that are more at-risk

    The second argument against an age-based vaccine rollout is that it disadvantages younger people with disabilities and certain medical conditions, NPR reports. In fact, Disability Rights Connecticut, a nonprofit organization, has filed a complaint over Connecticut's new policy with the U.S. Office for Civil Rights, saying the state should prioritize younger, high-risk people.

    But state officials, and some health experts, have defended the age-based system, arguing the process will be quicker and fairer. "Making sure we get everyone in there, regardless of what industry they're in, regardless of what medical condition they may have, regardless of whether they're employed or unemployed, or whether they have good access to health care or not—is going to help us get the most equitable outcome the most quickly," Josh Geballe, COO of Connecticut Gov. Ned Lamont's (D) administration, said.

    Separately, Amesh Adalja, an infectious diseases expert at the Johns Hopkins Center for Health Security, said that while "there is no obvious right or wrong way to do it," there's "a clear argument to make it as simple and seamless as possible."

    Richard Zimmerman, a professor at the University of Pittsburgh who works at its Center for Vaccine Research, argued that an age-based system is more verifiable. It could cut down on people jumping ahead in line by lying about having a medical condition, since—unlike health conditions—vaccine providers can easily verify a person's age.

    But still other experts think the issue is a short-term problem either way, KHN reports, given that vaccine dose availability is expected to increase rapidly in the coming months. And at that point, according to Sonja Rasmussen, a professor in the pediatrics and epidemiology department at the University of Florida, vaccine hesitancy could be the primary issue.

    "I have a concern we will soon get to a point where we have more vaccine than people who want to get it," she said (Leon, NPR, 3/3; Galewitz/Rodriguez, Kaiser Health News, 3/1).

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