As Alberta moves through Phase 1 of COVID-19 vaccinations, the chief medical officer of health has said an “ethical framework” will be used to determine who qualifies for Phase 2, which will include certain priority groups.
Vaccinations against the novel coronavirus started in December and have offered a glimmer of hope for Albertans during the pandemic. The priority, so far, has been to immunize the elderly in continuing care and staff working in intensive care units.
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But that hasn’t stopped the speculation or the lobbying for certain groups to be included in Phase 2 of inoculations, which is expected to take place between April and September.
Experts say it will be important to look at a variety of factors, including equity, fairness and circumstances as decisions about who will get the shot are made in the largest mass vaccination program in modern history.
On Dec. 28, Hinshaw said many Albertans can benefit from the vaccine but it is currently a scarce resource so different elements have to be taken into account to ensure the vaccine is being allocated in an ethical way.
The province is expected to release guidelines for Phase 2 in the coming weeks.
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Dr. Shannon MacDonald is an assistant professor in the Faculty of Nursing at the University of Alberta. She is also working with the National Advisory Committee on Immunization (NACI) doing public consultations over its vaccine guidelines.
Guidelines released by the NACI in November show that Phase 2 of vaccinations should include health-care workers not included in the initial rollout, residents and staff of other congregate settings, such as living quarters for migrant workers, correctional facilities and homeless shelters, as well as essential workers.
MacDonald explained why people living in congregate settings should receive priority.
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MacDonald said another important priority group may be people with chronic illnesses that put them at high risk of severe illness of death, particularly those who are essential workers and do not have the option to stay home.
She acknowledges that decisions around essential workers will be “tricky.”
“It’s driven both by science, when we have science availability, but it’s also driven by values,” she said.
“For instance, somebody might argue grocery store workers should be first because they’re the ones that are providing us our food. Other people would argue firefighters and police should really be first. Other people might argue teachers should be first so that we can keep our kids in school.
“It’s a balance between ‘use the science we have’ and we augment that with what we value as a society.”
MacDonald said when a decision is purely driven by scientific evidence, it is easier to defend than a decision being driven by values.
“It is more subjective and there needs to be some agreement on what are the values that a society like ours places on those decisions and on people,” she said.
Colin Furness, an infection control epidemiologist at the University of Toronto, said the goal behind vaccinations can determine where vaccinations move to next.
“Do you want to get the economy going? If so, look at factory workers and other kinds of essential workers, and teachers actually to keep schools open.
“If you want to control transmission then maybe you need to actually do servers and other people who have a lot of contact with the public,” he said.
The definition of an essential worker, someone who cannot do their work from home, can be broad; Furness said they can range from personal support workers to transit drivers to factory workers.
“It’s going to be actually hard. You could probably line up dozens or hundreds of job descriptions and a bunch of experts and they wouldn’t necessarily agree about what pile to put people into,” he said.
Furness also said different workers can become essential in different season or different times of year.
“People who drive snow plows aren’t so important in the summer but come winter, obviously they become extremely important. We don’t need to worry as much about teachers in the summer but during the school year, obviously that changes. So you really also want to be thinking and be flexible and adaptable when the vaccine shows up – who is essential right now?”
Blake Murdoch, a research associate with the Health Law Institute at the University of Alberta, said that when it comes to prioritizing essential workers, you have to look at minimizing societal disruption.
“You can make, I think, a strong argument some groups of traditionally underpaid, underappreciated people like grocery store workers might be deserving of getting the vaccine before some other groups,” he said.
Devidas Menon, a professor of health policy at the University of Alberta School of Public Health, said there will be ethical components in deciding who is considered a priority group.
“The other thing is equity. It’s not enough to look at just sickness, of ability to gain health, but the disadvantaged populations – the deaths and infections worldwide that happen in the lower socioeconomic class and people of colour in many places.”
Menon said fairness must also be considered, such as in the case of inmates.
“Some segments of society want to punish prisoners because they’ve done horrible things. On the other hand, they’re confined and they don’t have the luxury of being able – much like the homeless – to isolate themselves.
“So do we not owe them? Is that not a fairness principle?” he said.
Priority setting exercises have been done before, Menon said, such as whether jurisdictions should pay for expensive drugs to treat a small number of patients.
He said these types of decisions are very challenging to make and it is critical for the decision-making process to be transparent.
“They won’t be easy but at least if it’s clear what was done and if it’s defensible – because there’s some general agreement – there will never be unanimity,” Menon said.
“People don’t always agree with decisions that organizations and government make but if they had an idea of procedural justice along the way the decision was made and how it was reached, people are more willing to accept that.”
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