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Emerging concerns

  • Some states are experiencing more vaccine supply than demand, whereas in other states demand outpaces supply. National Public Radio, April 12, 2021; New York Times, April 18, 2021.
  • COVID vaccines: Who’s hoarding and who’s helping? Politico, February 12, 2021
  • COVID-19 has had a disproportionate impact on people of color in the United States. The COVID Racial Data Tracker
  • Lobbyists have petitioned state governments for vaccine priority. New York Times, December 20, 2020.
  • Controversy over when to vaccinate incarcerated people. Washington Post, January 2, 2021.
  • Though CDC has recommended priority groups for vaccination, states are free to determine how to allocate their vaccine doses. New York Times, December 23, 2020.

Ethical principles

  • [When a vaccine becomes available, consider] prioritizing groups of people known to be central to spreading infection or “super-spreaders.” WHO Ethics in Pandemic Flu
  • [When a vaccine becomes available, consider] prioritizing persons at increased risk of death if infected. WHO Ethics in Pandemic Flu
  • [When a vaccine becomes available, consider] prioritizing children and young adults based on the fair innings argument. WHO Ethics in Pandemic Flu
  • [When a vaccine becomes available, consider] prioritizing health-care workers and other essential service providers to help sustain the health-care system. WHO Ethics in Pandemic Flu
  • Some theoretical distribution criteria that would generally not be ethically supported are: to each according to purchasing power, to each according to what he or she deserves; first come, first served; race, ethnicity, religious belief, gender, sexual orientation, or IQ. CDC Ethics in Pandemic Flu
  • Governments and the health care sectors should engage stakeholders in determining what criteria should be used to make resource allocation decisions, should ensure that clear rationales for allocation decisions are publicly accessible and should provide a justification for any deviation from the predetermined criteria. University of Toronto

Recommendations and practices

Emerging concerns

  • Communities of color have received a disproportionately smaller share of available vaccines compared to white communities. New York Times, March 5, 2021.
  • 38% of all deaths from COVID-19 in the United States are linked to nursing home facilities. New York Times, December 4, 2020.
  • Approximately 20% of the prison population has tested positive for COVID-19. Columbia University Justice Lab, December 16, 2020.
  • Undocumented immigrants fear COVID-19 vaccination may lead to deportation. USA Today, December 19, 2020.
  • Algorithms designed to determine vaccination priority may fail to prioritize most vulnerable populations. Washington Post, December 23, 2020.

Ethical principles

  • Those responsible for infectious disease outbreak response should ensure that all individuals are treated fairly and equitably regardless of their social status or perceived “worth” to society. WHO Ethics in an Outbreak
  • Particular consideration must be given to individuals who are confined in institutional settings, where they are highly dependent on others and potentially exposed to much higher risks of infection than persons living in the community. WHO Ethics in an Outbreak
  • Ensure that public health policies and plans are sensitive to race, ethnicity, sex, sexual orientation, gender identity, and other unique characteristics of individuals affected by the policies or plans. APHA Code of Ethics, 4.5.11.

Recommendations and practices

Emerging concerns

  • The United States fell far short of its goal to vaccinate 20 million Americans by the end of 2020. New York Times, December 31, 2020.
  • Large quantities of vaccines are set to expire in the United States before they can be distributed to the public. New York Times, December 31, 2020.
  • Narrow vaccination eligibility criteria have led to the expiration of vaccines before they can be used. New York Times, January 8, 2021.
  • Rural areas have yet to receive COVID-19 vaccines. The Texas Tribune, January 8, 2021.

Ethical principles

  • Public health officials have a responsibility to maximize preparedness in order to minimize the need to make allocation decisions later. CDC Ethics in Pandemic Flu
  • The distribution of goods should be guided by criteria specified well in advance of any need to apply them. CDC Ethics in Pandemic Flu
  • Equal opportunity to access resources should be assured to those within agreed upon priority groups. CDC Ethics in Pandemic Flu
  • Ensure that reasonable alternative options are considered and evaluated, and that final public health policies and plans are designed to most effectively accomplish stated goals while minimizing the potential for harm. APHA Code of Ethics, 4.5.9.

Recommendations and practices

  • Bhutan inoculated almost their adult population against COVID-19 in just two weeks. Vice, April 16, 2021.
  • In Florida, hospitals that fail to meet their vaccination goals will have their distribution reallocated to hospitals and facilities that meet their targets. Tampa Bay Times, January 4, 2021.
  • New York has loosened vaccine distribution criteria in an effort to reach more people before the vaccines expire. New York Times, January 10, 2021.

Emerging concerns

  • Less than 2% of the global COVID-19 vaccine supply has been administered in Africa. Relief Web, April 8, 2021.
  • High-income countries have purchased enough COVID-19 vaccine to vaccinate their populations many times over while other nations have failed to secure adequate supplies. National Public Radio, December 3, 2020.
  • With far fewer doses sent to African countries than are being shipped to the United States and Europe, vaccine distribution campaigns across Africa are not likely to begin until April 2021. Washington Post, December 17, 2020.
  • Economic recovery from the pandemic has been limited in countries unable to vaccinate their population. New York Times, December 25, 2020.
  • COVAX, the WHO backed global initiative to provide vaccines to low- and middle- income countries, is facing budgetary shortages. Associated Press, December 15, 2020.

Ethical principles

  • Countries that have the resources to provide foreign assistance should support global epidemic preparedness and response efforts, including research and development on diagnostics, therapeutics, and vaccines for pathogens with epidemic potential. WHO Ethics in an Outbreak
  • Broad international cooperation in the development and dissemination of vaccines and treatments is in the interests of all countries as such cooperation offers the best chance of minimizing the global impact of an influenza pandemic. WHO Ethics in Pandemic Flu
  • According to the principle of reciprocity, each country should do what it can to contribute to this effort, with the understanding that it can expect the same from the rest of the international community. WHO Ethics in Pandemic Flu
  • Countries should participate in the development and implementation of frameworks and mechanisms that aim to ensure fair and equitable sharing of benefits, in support of public health, among all countries, taking into particular consideration the specific needs of developing countries. WHO Ethics in Pandemic Flu
  • The United States recognizes its membership in the global community, and the pandemic planning process acknowledges the importance of working with and learning from preparedness efforts globally. CDC Ethics in Pandemic Flu
  • First, the ethical principle of solidarity suggests that countries should respond collectively when natural threats to health are identified. Second, countries have obligations to help one another under inter- national laws, including human rights laws; many of these obligations are affirmed and elaborated upon in IHR (2005) (12). Finally, an influenza pandemic is inherently a global crisis; lack of response to a pandemic threat in one country puts all other countries at increased risk.  WHO Ethics in Pandemic Flu

Recommendations and practices

  • All countries should receive doses in proportion to their population size in order to immunize the highest-priority groups. World Health Organization
  • AstraZeneca pledged to provide their COVID-19 vaccine on a not-for-profit basis to low- and middle-income countries. Nature, November 30, 2020.

Emerging concerns

  • At least 75% of a nation’s population must be inoculated against COVID-19 in order to achieve herd or community immunity. New York Times, December 24, 2020.
  • 71% of the U.S. population are willing to receive a COVID-19 vaccine. Kaiser Family Foundation, December 15, 2020.
  • Vaccine hesitancy is greatest among people who live in the rural South, are white, and are conservative. National Public Radio, April 15, 2021; New York Times, April 14, 2021.
  • Viral surges are being fueled among people who have been ineligible to receive the COVID-19 vaccine. National Public Radio, April 13, 2021.
  • Allergic reactions to COVID-19 vaccines have occurred, although it is rare. New York Times, January 6, 2020.

Ethical principles

  • Given numerous historical examples of abuse of individuals, particularly those who are considered vulnerable, in the name of the public good (e.g. involuntary sterilization of the mentally retarded, the U.S. Public Health Service Syphilis Study at Tuskegee, the internment of Japanese-Americans during World War II), public health officials must adequately acknowledge and respond to strong currents of suspicion and distrust of the healthcare system. CDC Ethics in Pandemic Flu
  • Individual liberty should be restricted with great care and only when alternative approaches to realizing the goal of weathering the pandemic are not likely to be effective. CDC Ethics in Pandemic Flu

Recommendations and practices

  • Some United States colleges are requiring students to receive COVID-19 vaccines to return to campus in the fall semester. National Public Radio, April 11, 2021.
  • Mandate vaccination with care. Nature, July 22, 2019.
  • Equal Employment Opportunity Commission states that employees may be barred from the workplace if they refuse to take the COVID-19 vaccine. New York Times, December 18, 2020.
  • It is morally acceptable to receive COVID-19 vaccines that have used cell lines from aborted fetuses in their research and production process. The Vatican Congregation for the Doctrine of the Faith

Emerging concerns

  • Proposals to reduce the number of doses, extend the length of time between doses, changing the dose, or mixing and matching vaccines in order to immunize more people against COVID-19 have not been scientifically evaluated in clinical trials. FDA, January 4, 2021.
  • Receiving just the first dose of the Moderna or Pfizer vaccine may confer partial immunity to COVID-19. Canadian Broadcasting Corporation, December 24, 2020.

Ethical principles

  • Because the scientific basis for efficacy of particular interventions continues to be studied and models projecting the course of a pandemic are being investigated, sound scientific evidence for proposed interventions may not currently exist. The current knowledge basis should serve as a foundation for ethical guidelines and a commitment to ongoing scientific and ethical evaluation of interventions should be made. CDC Ethics in Pandemic Flu
  • Enhancing the available range of prophylaxis and treatment options should decrease the need to focus on scarcity of resources and allocation during a pandemic. CDC Ethics in Pandemic Flu

Recommendations and practices

  • Great Britain has delayed the distribution of the second doses of the Pfizer and AstraZeneca vaccinations up to 12 weeks to attempt to vaccinate more people with the first dose. New York Times, January 3, 2021.
  • If a second dose of a vaccine is not available, a vaccine produced by a different manufacturer may be substituted in Great Britain. New York Times, January 1, 2021.
  • At this time, suggesting changes to the FDA-authorized dosing or schedules of these vaccines is premature and not rooted solidly in the available evidence. Without data supporting such changes in vaccine administration, we run a significant risk of placing public health at risk, undermining the historic vaccination efforts to protect the population from COVID-19. FDA

Emerging concerns

  • Vaccine misinformation and conspiracy theories are spreading rapidly. Washington Post, February 22, 2021; Washington Post, February 11, 2021.
  • INTERPOL warns of counterfeit COVID-19 vaccines and of vaccine misinformation spread through media. INTERPOL
  • A pharmacist rendered more than 500 doses of the vaccine useless because of anti-vaccination conspiracy beliefs. New York Times, January 4, 2021.
  • Social media companies largely unable to prevent spread of COVID-19 vaccine misinformation on their platforms. Washington Post, December 18, 2020.

Ethical principles

  • When decisions must be made in the face of uncertain information, the uncertainties should be explicitly acknowledged and conveyed to the public. WHO Ethics in an Outbreak
  • Governments, nongovernmental organizations, and academic institutions should make efforts to support media training in relevant scientific concepts and techniques for communicating risk information without raising unnecessary alarm. WHO Ethics in an Outbreak

Recommendations and practices

  • Trusted community stakeholders should participate in efforts to amplify meaningful and relevant vaccine-affirming messages to crowd out misinformation about the COVID-19 vaccine. Johns Hopkins Center for Health Security, July 9, 2020.
  • CDC has produced a social media toolkit to talk about COVID-19 vaccinations.
  • Black doctors are sharing accurate information about COVID-19 vaccines on social media. National Public Radio, January 1, 2021.

Emerging concerns

  • Usability, privacy, and equity must be considered in the context of vaccine passports. Washington Post, April 7, 2021.
  • Federal vaccine monitoring program is limited to English speakers. The Verge, December 17, 2020.
  • Florida and Texas have barred the use of vaccine passports. Washington Post, April 6, 2021.

Ethical principles

  • Countries should develop core capacities for public health surveillance and response that comply with the international legal obligations in the framework of the International Health Regulations (IHR) 2005. WHO Ethics in Pandemic Flu
  • Systematic observation and data collection are essential components of emergency response measures, both to guide the management of the current outbreak and help prevent and respond to outbreaks in the future. Even if these activities are not characterized as research for regulatory purposes, an ethical analysis should be undertaken to ensure that personal information is protected from physical, legal, psychological, and other harm. WHO Ethics in an Outbreak
  • Collecting surveillance information on a mandatory basis is ethically appropriate on the grounds of public interest if an accountable governmental authority has determined that universal participation is necessary to achieve compelling public health objectives. WHO Ethics in an Outbreak
  • Regardless of whether individuals are given the choice to opt out of surveillance activities, the process of surveillance should be conducted on a transparent basis. WHO Ethics in an Outbreak

Recommendations and practices

  • World Health Organization’s Smart Vaccination Certificate Working Group is focused on establishing standards for a common architecture for a digital smart vaccination certificate.
  • The Vaccination Credential Initiative is a voluntary coalition of public and private organizations committed to empowering individuals with access to a trustworthy and verifiable copy of their vaccination records in digital or paper form using open, interoperable standards.
  • The ACLU has published a list of criteria to abide by in the creation of vaccine passports to ensure equity and protection of privacy. ACLU, March 31, 2021.
  • The Biden administration will not oversee the creation and implementation of vaccine passports. The Hill, April 6, 2021.
  • New York state has piloted the voluntary and free Excelsior Pass, a vaccine passport developed in collaboration with IBM that relies on blockchain technology to securely verify vaccine status without the transfer of private information. National Public Radio, April 12, 2021.
  • Denmark plans to implement COVID-19 vaccine passports in anticipation of international travel requirements. The Local DK, January 8, 2021.