An international team led from Oxford University has surveyed global preferences regarding vaccination priorities, distribution, and mandatory vaccinations.
By José R. Zárate
With the arrival of vaccines and the urgent need to curb transmission as quickly as possible, authorities in each country have had to debate and establish priority vaccination groups. It's similar, though not quite as dramatic, to deciding who gets priority in the first lifeboats of a sinking ocean liner.
To observe and compare these decisions across different countries, the Oxford Covid-19 Vaccine Preference and Opinion Survey (Candor) project conducted 15,536 surveys between November 15 and December 21 of last year with adults over 18 years of age in 13 countries: Australia, Brazil, Canada, Chile, China, Colombia, France, India, Italy, Spain, Uganda, the United States, and the United Kingdom . These countries represent approximately half of the world's population and a wide range of social and economic contexts. In each country, between 1,000 and 1,500 people were interviewed and asked to evaluate various issues related to priority vaccination groups, the organization of vaccination strategies, whether or not vaccination should be mandatory, and other related topics.
Far from finding a wide range of opinions, and according to the study preprinted on medRxiv , the researchers, led by Raymond Duch and Philip M. Clarke of Oxford University, observed considerable global agreement in prioritizing healthcare workers, the elderly and those with high-risk illnesses , a broad range of essential workers, and those with lower incomes. These preferences were not dependent on the respondents' education levels, income, or political ideologies. Government allocation of vaccination programs also prevailed, although there was some polarization in a few developed countries regarding whether or not vaccination should be mandatory.
Although doubts and resistance to vaccination have been decreasing, especially given that the pandemic is not abating and that vaccines are safe, there is still 10% of the world's population that does not intend to get vaccinated. This fragile public trust in authorities is partly what has led to a careful consideration of priorities and the establishment of equitable programs ; and this is why some privileged individuals who 'jump the line' cause so much social backlash. The World Health Organization developed a framework of values based on six principles: Well-being, Respect, Global Equity, National Equity, Reciprocity, and Legitimacy . Its Strategic Advisory Group of Experts on Immunization subsequently proposed a roadmap that prioritizes healthcare workers and the elderly.
Essential workers
As in Spain, the UK's strategy is primarily based on healthcare workers and age, starting with the older age groups followed by the clinically vulnerable. In France, a committee of experts recommended prioritizing, after healthcare workers and the elderly, those most in contact with the public, teachers, transport personnel, and hospitality employees. In the United States, some areas have also opted to immunize essential workers such as teachers, police officers, and bus drivers, in addition to those over 65 and those of any age with high-risk medical conditions. Chile was planning a similar strategy (it should be noted that the study was conducted in December, before vaccinations had begun and when there was some uncertainty).
Interestingly, in some countries, people over 65 preferred that essential workers be vaccinated first . Perhaps this was due to altruism, a desire to reduce the likelihood of infection from contact with unvaccinated individuals, or a desire to choose an optimal vaccination program that would help end the pandemic and return life to normal.
There is a global consensus on free vaccination organized and distributed by health authorities . At least two-thirds of the population in each country said that distribution should only be available through government programs. However, some countries, such as Australia and India, have considered the private sale of vaccines, a possibility that has not yet materialized. Support for private distribution ranged from 13% in Canada to 28% in Chile . And, in case of need or delay, approximately half of the sample would be willing to buy the vaccine on the private market: this option ranged from 18% in France to 79% in India and Uganda. Perhaps due to distrust of their governments, low- and middle-income countries were particularly enthusiastic about buying the vaccine on the private market, although they also strongly supported government provision.
According to the authors, if private purchase is permitted, it is essential to develop policies that ensure such a possibility does not jeopardize the ability to acquire the doses needed for government-run vaccination campaigns. “Ideally, private access would complement public provision to maximize the economic and health benefits of vaccination and minimize the potential for corruption. Successful vaccination policies for other diseases have sometimes involved incentive payments, penalties, or restrictions (such as barring unvaccinated children from attending school).”
Similar patterns
A key to the successful rollout of vaccinations is that the public perceives the allocations as fair and equitable. Without clear and reasoned communication, there is a risk of resistance and polarization emerging , as happened and continues to happen in some places with masks. Without state control, the authors also warn of the risk of black markets for vaccines emerging, which would threaten the safety and fairness of the campaigns.
In the survey, each person made eight binary choices about potential vaccine recipients that varied randomly across five attributes: occupation, age, transmission status (risk of contracting and transmitting the virus), income risk, and risk of death from COVID-19. The pattern of values is quite similar: “The global public shows a striking consensus on which population segments should be prioritized for the vaccine.”
In virtually every country, the elderly are given preference. The only exception is China, although the authors caution that the surveyed population in that country was younger than in the others, which may have skewed the results.
Logically, in most low- and middle-income countries (Brazil, Chile, Colombia, India, and Uganda), respondents show preferences, always after healthcare workers and the elderly, for the most socially and economically disadvantaged people , and also for non-essential workers who cannot work remotely; this pattern is similar, although less pronounced, in the United States, Canada, China, Australia, and European countries.
Obligation or not
The same consensus is evident regarding priority for vaccination: essential workers should go first, followed by healthcare workers, the elderly, and those with underlying health conditions , of course. The choices have not been influenced by self-interest, partisanship, vaccine hesitancy, income level, or education level. Instead, they “reflect a broad social consensus on who should be vaccinated.” And they add that “there appears to be much greater heterogeneity in national policies than in public preferences.”
Approximately 24% of the sample strongly opposed mandatory vaccination , while around 38% strongly supported it. In France, for example, there is broad consensus against mandatory vaccination (around 60% opposed). Opinion was highly polarized in the United States and the United Kingdom, and somewhat less so in Australia, Brazil, Chile, and Colombia. In China, India, and Uganda, very few people opposed mandatory vaccination.
One positive message from the study, the authors conclude, is that, “with the exception of mandatory vaccination, the global public generally has consistent preferences regarding vaccination programs , and these remain consistent across political and geographical differences. Considering these preferences is important for the efforts and choices of different governments to gain public acceptance of their COVID-19 vaccination programs.”