Pandemics: Beyond “women and children first”

Feydzhet Shabanov/ stock.adobe.com

I am originally from the South (OK, Texas, but still…), and I grew up knowing that people with integrity put the safety of women and children first. For example, when a woman boards a full bus, a man likely gets up and offers his seat. If it’s raining, my husband drops me off at the restaurant door and then goes to park the car.

This practice applies not just in uncomfortable situations but unsafe circumstances as well. If the lawn mower is on its last legs and the blade may to break into smithereens and come flying out in all directions, then mom is certainly not allowed to mow the lawn. Dad cuts the grass until the mower is repaired or a new one purchased.

Now, let’s escalate these hypothetical situations further. If a shooter enters a room, some men will instinctively push any women and children behind them. But what if the man enters the room not with a gun but coughing, sniffling, and clearly suffering from a severe respiratory illness? There may be no bullets but, in 2020, this man is likely perceived as a clear and present threat to others.

The topic is currently being discussed around supper tables across the globe. What if a vaccine for SARS-CoV-2, the virus that causes coronavirus-19 disease (COVID-19)—a proverbial bullet-proof vest—becomes available? Who gets to be at the front of the line?

The idea of women and children first is believed to have been coined in 1852 when the British troop shipHMS Birkenhead sank off the coast of South Africa. Of the more than 634 men, women, and children on board, only 193 survived the disaster, including all of the women and children.¹ This logic doesn’t really translate well to pandemics, emerging pathogens, and vaccine protocols, does it? The question remains: Who gets the vaccine first when it becomes available, and who gets it if the supply is limited? And who decides who is at the front of the line?

Unfortunately—or fortunately depending on your perspective—only 50% of Americans intend to get vaccinated for SARS-CoV-2 once a vaccine is available.² Public misperception surrounding the need for and safety of vaccination is a real problem globally. In 2019, well before COVID-19 came along, the World Health Organization (WHO) listed vaccine hesitancy as 1 of the top 10 major global health threats.³ With a COVID-19 vaccine being developed and brought to market at “warp speed,” the unknowns about adverse effects and overall longevity of efficacy are likely to be a huge stumbling block to vaccine administration to the masses. So, the line may not be as long as some think, yet the public is still concerned with who gets to go first.

In 1964, the Advisory Committee on Immunization Practices (ACIP) was chartered to provide expert advice and recommendations for vaccine use in the civilian American population to the secretary of US Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC).⁴ Today, the ACIP remains a globally respected gold standard for guidance on childhood immunization schedules, efficacy monitoring (think rabies titers) and, of course, pandemic priority populations for vaccination.

The secretary of HHS appoints 15 voting members of the ACIP following an application process. According to the CDC, 14 of the members have expertise in vaccinology, immunology, pediatrics, internal medicine, nursing, family medicine, virology, public health, infectious diseases, and/or preventive medicine. One member is a consumer representative who provides perspectives on the social and community aspects of vaccination.⁴ All 15 serve as volunteers and are joined by 8 ex-officio committee members representing federal agencies with immunization program responsibilities as well as 30 more nonvoting members who act as liaisons from external organizations with immunization expertise, such as the American Medical Association and the American Academy of Pediatrics.

According to ACIP, when developing recommendations, the members use an explicit evidence-based method based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.⁵ In April 2020, amid the expanding pandemic, the ACIP formed a 41-member COVID-19 working group charged with preparing for the introduction of safe and effective COVID-19 vaccines, reducing disease transmission and associated morbidity and mortality, helping to minimize disruptions to society and the economy, including health care capacity, and ensuring equity in vaccine allocation and distribution.^6,7

However, a second group has been appointed by the National Academy of Medicine at the direction of top US health officials to develop a framework to determine priority for vaccination.⁸ While the appointment of 2 prestigious expert panels to assess vaccination priorities could prove problematic, it is good to remember that both entities serve only to make recommendations and to advise the HHS secretary. The task of true decision and execution, once a vaccine is available, rests with the Secretary alone.

Despite potential confusion over disparate recommendations, the ACIP working group recently made public early prioritization populations for SARS-CoV-2 vaccination. As reported, “…the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.”⁷ This ranking of priority populations is much more sophisticated than women and children. It is based largely on likelihood of exposure, severity of illness, and the transmissibility characteristics of the virus itself.

It is prudent to remember that a vaccine is not yet available. Just as researchers are working at “warp speed” to develop a safe, effective vaccine, the virus itself continues to spread through community transmission with many recovering from the disease with immunity. It remains to be seen when the vaccine will be available and how many people in priority populations remain without naturally developed antibodies.

Sound familiar?

If all this sounds a little familiar, it should. The ACIP also determined priority vaccination populations during the (H1N1) 2009 pandemic. The CDC has extensive information available to the public related to pandemic influenza response and vaccine allocation. The CDC doesn’t play favorites with emerging pathogens, but influenza surely receives a large amount of respect and attention from public health officials, especially when compared with emerging coronaviruses. Mutagenicity, morbidity and mortality rates, transmissibility, and other factors combine to demand more attention for influenza than coronavirus. However, we can rest assured that once a SARS-CoV-2 vaccine is available, 50% of Americans will line up,² according to population groups determined by unelected, appointed experts, for a dose of protection from COVID-19 while only about 38% of the population will get a seasonal flu shot that may provide cross-protective immunity to novel influenzas.⁹ How encouraging! Estimates indicate that for community immunity to SARS-CoV-2 to be reached, about 70% of the population must be immune, whether through vaccination or natural disease recovery.^2,10 With approximately 5.5 million cases at the time of writing,¹¹ the United States is about 324 million cases short of the 70% immunity target. Until the majority of us truly trust in science and data, keep calm and mask on.

Jenifer Chatfield, DVM, DACZM, DACVPM, is board certified in zoological medicine and preventive medicine. She has been a practice owner, worked in zoos, and completed international fieldwork. Her peer-reviewed publications include pharmacokinetics, wild animal behavior, infectious disease, and assisted reproduction in endangered species. Chatfield loves French bulldogs, Himalayan cats, the dirtiest of vodka martinis, and basking in the sun on any Caribbean beach. Find more about her exploits and adventures at drjenthevet.com.

References

1. Johnson B. “Women and children first!” Historic UK. Accessed October 18, 2020. https://www.historic-uk.com/CultureUK/Women-Children-First/​

2. Cornwall W. Just 50% of Americans plan to get a COVID-10 vaccine. Here’s how to win over the rest. American Association for the Advancement of Science.June 30, 2020. Accessed September 11, 2020. https://www.sciencemag.org/news/2020/06/just-50-americans-plan-get-covid-19-vaccine-here-s-how-win-over-rest​

3. Ten threats to global health in 2019. World Health Organization. Accessed September 11, 2020. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019​

4. Smith JC, Hinman AR, Pickering LK. History and evolution of the advisory committee on immunization practices—United States, 1964-2014. MMWR Morb Mortal Wkly Rep. 2014;63(42):955-958.

5. About GRADE. Centers for Disease Control and Prevention. October 23, 2018. Accessed September 11, 2020. https://www.cdc.gov/vaccines/acip/recs/grade/about-grade.html​

6. Coronavirus remains front and center at June ACIP meeting. The American Academy of Family Physicians. July 1, 2020.Accessed September 11, 2020. https://www.aafp.org/news/health-of-the-public/20200701acipjunemtg.html​

7. Splete H. ACIP plans priority groups in advance of COVID-19 vaccine. MD Edge Hematology and Oncology. June 29, 2020. Accessed October 18, 2020. https://www.mdedge.com/hematology-oncology/article/224632/coronavirus-updates/acip-plans-priority-groups-advance-covid-19​

8. Branswell H. Confusion spreads over system to determine priority access to Covid-19 vaccines. STAT. July 22, 2020. Accessed September 11, 2020.https://www.statnews.com/2020/07/22/confusion-spreads-over-system-to-determine-priority-access-to-covid-19-vaccines/​

9. Estimates of influenza vaccination coverage among adults—United States, 2017–18 flu season. Centers for Disease Control and Prevention. November 5, 2018. Accessed September 11, 2020. https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm​

10. Herd immunity and COVID-19 (coronavirus): what you need to know.Mayo Clinic. June 6, 2020. Accessed September 11, 2020. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808​

11. United States COVID-19 cases and deaths by state. Centers for Disease Control and Prevention. October 18, 2020. Accessed September 11, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html​