COVID-19 (COrona VIrus Disease-2019) Тема - 6

Example 1. Health workers at high to very high risk of becoming infected and transmitting SARS- CoV-2 in the Community Transmission epidemiologic setting

For the Community Transmission epidemiologic setting, health workers at high to very high risk of becoming infected and transmitting SARS-CoV-2 are included in Stage Ia. There are three reasons, linked to the Values Framework, supporting this prioritization. First, protecting these workers protects the availability of a critical essential service in the COVID-19 pandemic response. Also, the indirect health effects of the pandemic beyond COVID-19 are likely to be much worse if such services are compromised or overwhelmed. Second, evidence suggests that health workers are at high risk of acquiring infection and possibly of morbidity and mortality (10, 11). There is also a risk of onward transmission to people who are also at high risk of serious COVID-19 outcomes. Third, prioritization of these workers is also supported by the principle of reciprocity; they play critical roles in the COVID-19 response, working under intense and challenging conditions, putting not only themselves but also potentially their households at higher risk for the sake of others.
There are also pragmatic reasons for prioritizing health workers at high to very high risk of infection. Health workers already interact directly with health systems, which should facilitate effective deployment of a vaccine programme, particularly including if two or more doses need to be administered. Launching a vaccine programme with a relatively accessible target population will allow more time for the development of delivery mechanisms to other priority groups.
In a second step (Stage Ib), older adults defined by age-based risk specific to country or region are included.

Example 2. Sociodemographic groups at significantly higher risk of severe disease or death

For the Community Transmission epidemiologic setting, sociodemographic groups at significantly higher risk of severe disease or death are included in Stage II. The reasons for this prioritization are grounded in the principles of equal respect and equity.
In keeping with the overall public health strategy that places an initial focus on direct reduction of mortality and morbidity, groups with comorbidities or health states that put them at significantly higher risk of severe disease or death are prioritized to Stage II. However, there are other groups in the population who may be at just as high a risk of these severe outcomes but who are not captured in a prioritization solely by comorbidities. These groups disproportionately include those who are systematically disadvantaged with respect to social standing and economic and political power. In many contexts, disadvantaged groups are more likely to experience a higher burden of infection and consequent COVID-19 because of crowded work or living conditions over which they have no effective control (12–15), as well as a higher prevalence of background states of poor health that increase their risk of severe COVID-19 (16). They may also have less access to appropriate health care necessary for the diagnosis of high-risk conditions such as heart failure or chronic kidney disease (17). Some individuals in these groups would likely qualify for prioritization if their comorbidities were known or ascertainable, but because of inequitable access to health care their conditions often will be undiagnosed and untreated.

Which disadvantaged sociodemographic groups are at significantly higher risk of severe disease or death will vary from country to country. In many contexts, the evidence of elevated risk for COVID-19 severe disease and death will be lacking or less clear than for the risk factors like age or comorbidities. Policy-makers may have to decide which disadvantaged groups are likely to be sufficiently burdened by COVID-19 to include in Stage II. While broader efforts must be made to reach out and identify risks among disadvantaged groups, these decisions may have to be based on reasonable assumptions about differential impact inferred from other relevant contexts, including past public health emergencies (18). Table 1 provides examples of groups that, depending on the country context, may fall under this prioritization category.

Example 3. Social/employment groups at elevated risk of acquiring and transmitting infection because they are unable to effectively physically distance

For the Community Transmission epidemiologic setting, social/employment groups at elevated risk of acquiring and transmitting infection because they are unable to effectively physically distance are included in Stage III. There is considerable overlap in the groups that should be considered in this category and the Stage II sociodemographic groups category just discussed. The relevant difference is that for some disadvantaged groups there may not be good reasons to conclude that they are at significantly elevated risk of severe disease and death (and thus that they do not qualify under Stage II). However, these groups may nevertheless still be at increased risk (if not significantly increased risk) of severe COVID-19 due to the reasons related to inequity discussed above. Groups that have no choice but to work without physical distancing or access to personal protective equipment, or no choice but to live in high-density homes in high-density neighbourhoods fall into this category (19, 20). They are disadvantaged relative to other groups in the population who benefit more easily and more significantly from non-pharmaceutical interventions, both in terms of their own risk and in terms of onward transmission to loved ones and co-workers. Incarcerated people also fall into this category, although the rationale is somewhat different. Even if the restriction of their liberty is justified, that does not justify leaving unaddressed the elevated risk associated with being incarcerated.
In an ideal world, policy-makers could clearly distinguish, based on evidence regarding level of risk, which disadvantaged groups fall under Stage II criteria and which under Stage III criteria. In the real world, these decisions may have to be made with only limited relevant data. Adherence to the principles of equal respect and equity will require a careful assessment to ensure that all relevant sociodemographic groups are given equal consideration for both Stages.