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Australian research has proposed a means to develop an ethical framework to support national decision-making about which groups of people need earlier access to vaccinations during pandemics such as influenza and COVID-19.

In pandemic situations where demand for vaccine outstrips supply, three papers in the journal Vaccine outline how:

• a flexible ethical framework to guide priority vaccine allocation was developed for the Australian context
• informed citizens viewed different approaches to vaccine prioritisation in Australia
• ethical thinking in context is essential to decision making.

Cross-disciplinary collaborations by researchers from the Australian Partnership for Preparedness Research on Infectious Disease Emergencies (APPRISE) and colleagues considered a vaccine allocation framework for pandemic influenza, aspects of which are highly relevant to current considerations about COVID-19.

Professor Jodie McVernon, Director of Epidemiology at Peter Doherty Institute for Infection and Immunity, a joint venture of the University of Melbourne and Royal Melbourne Hospital, led the investigation of vaccine allocation for target groups and said maintaining trust, promoting equity and reducing harms were found to be most important in the Australian context.

“Asking citizens their opinion was an important part of our process. In the case of influenza, they backed an indirect strategy that prioritises vaccinating people most likely to spread the disease and gives the best results for society as a whole. But citizens were also not opposed to a direct strategy of saving the most lives by vaccinating those most at risk from the disease.”

Professor McVernon said the framework considered both indirect, direct and dosing strategies and provides a baseline that some countries could use once pandemic-specific details are known about an emerging virus, its health impacts and the properties of available vaccines, including optimal scheduling.

“To date we have evidence that COVID-19 vaccines have direct benefits to reduce disease outcomes, but whether or not they will prevent onward spread of infection to have additional indirect benefits, even on the unimmunised, remains uncertain.

“Many of the people at greatest risk from influenzas are also at risk from COVID-19. The framework found that ‘Level 1’ priority groups to get early access to vaccine were healthcare workers and people who self-identify as First Nations Australians.

“In the context of COVID-19, healthcare workers are both at higher risk of being infected and of transmitting the virus,” she said. “First Nations people have a lower health status and are at higher risk of poor outcomes. We also have ongoing justice obligations because of current inequities and past wrongs.”

The framework allows for ‘Level 2’ priority groups to be defined depending on chosen outcomes and information about specific pathogen and vaccine characteristics. Examples of Level 2 groups include those selected on equity and outcome grounds, those with underlying health risks or those at increased risk of close contact that helps spread disease (such as schools and residential institutions).

APPRISE Research Fellow Dr Jane Williams from Sydney Health Ethics at the University of Sydney said that when considering strategies for prioritising scarce vaccine it’s important to be clear about the main goal of the program and think about how benefits and harms will accrue to different groups in society.

“Different strategies are appropriate for different vaccination goals. The usual considerations about direct and indirect protection from vaccination may be less significant for COVID-19 at this point, at least until we have more information about whether or not the vaccine prevents transmission.

“Context is crucial to decisions about how to allocate vaccine. What is appropriate for one country might be less justifiable for another and existing public health COVID control measures might also shape vaccine strategy.”