San Diego Union-Tribune (Sunday)
THERE’S BROAD AGREEMENT ON WHO WILL GET VACCINE FIRST; WHO’S NEXT?
Health care workers, nursing homes on top of list; it’s tricky after that
One of the greatest scientific feats of the past century may be a week away: The rollout of a vaccine against a virus that scientists didn’t even know existed a year ago.
Vaccines developed by Pfizer, Moderna and others appear to be far more effective than anyone expected, which will make them an invaluable tool in turning the tide of a pandemic now spiraling out of control.
But what’s the best way to use that tool? There’s broad consensus over who should get the vaccine first: health care workers and those living in skilled nursing and assisted living facilities. Those workers are the only thing keeping hospitals afloat, and nursing homes have been the worst-hit by the virus.
From there, it gets messy. Part of the issue is that researchers aren’t sure whether to prioritize those most likely to spread the coronavirus or those most likely to die of COVID-19. Those are two distinct rollout strategies.
Policymakers are also grappling with how to ensure a vaccine gets to low-income communities and people of color, who have been hit especially hard by the pandemic due to inequities that have deep historical roots.
San Diego County shared its vaccine allocation plan Wednes
day, which aligns with recommendations from the state and Centers for Disease Control and Prevention. But because each state will ultimately decide how to prioritize vaccine doses, there will likely be a patchwork of policies within the U.S. and between nations. And that may only add to public confusion and frustration while doses are in short supply.
“Everyone wants answers. I think when the vaccines come out, there’s going to be a lot of stress and anger and anxiety,” said Dr. Susan Little, who is helping plan UC San Diego Health’s vaccine rollout.
“I’ll say it for the tenth time: Transparency and clear messaging is the best we can hope for, because I think the more mixed messages that come out, the more frustrated people are going to be.”
Dearth of doses
There wouldn’t be any handwringing over how to dole out doses if there were enough vaccine for everyone. But that won’t be true any time soon.
Californians will get 327,000 doses of Pfizer’s first vaccine shipment, likely around mid-december, with 28,000 of those headed to San Diego. Each person needs two shots, so that’s enough for nearly 164,000 Californians and 14,000 San Diegans — in a state with 40 million residents and a county with 3.3 million.
The CDC and California Public Health Department have made clear that those first doses should go to health care workers, paramedics and residents of long-term care facilities such as skilling nursing and assisted living facilities.
There hasn’t been much argument around vaccinating health care workers at a time when the pandemic is poised to go from bad to worse. The CDC estimates that the nation’s COVID-19 death toll could reach 329,000 by the day after Christmas. One study found that front-line health care workers in the U.S. and U.K. had about 12 times the risk of getting COVID-19 as the general population.
“Everyone seems to agree that we need to protect our health care system,” said Dr. Davey Smith, a UCSD infectious disease expert. “That helps us all stay alive.”
And there’s a clear case for vaccinating residents of long-term care facilities, who’ve accounted for 40 percent of COVID-19 deaths in the U.S. The order of who’s up next depends on whether you’re looking to protect those most likely to become seriously ill or die from COVID-19 or trying to stop the coronavirus’ spread.
“They may involve vaccinating different groups of people,” said Little of the two approaches. “And in this case, they probably do.”
There’s no consensus on the right answer. The CDC’S Advisory Committee on Immunization Practices, which issues guidelines on whom to vaccinate when, has signaled that it may recommend vaccinating essential workers sooner than older adults and those with pre-existing conditions, in part to slow the virus’ spread in workplace settings.
Proponents of that approach say it’s the unchecked spread of the virus that is prolonging the pandemic — and that ultimately leads to more hospitalizations and deaths.
That makes sense, Smith says, but he sees two issues. One is that because those most likely to spread the coronavirus tend to be young and healthy, they might be less likely to take a vaccine if one were offered to them. The other problem? “We have no idea if they’re preventing transmission,” says Smith of the
COVID-19 vaccines developed by Pfizer, Moderna, Astrazeneca and others.
Confused? That’s understandable. Clinical trials are tracking how well these vaccines prevent COVID-19 illness. And by that measure, Moderna and Pfizer’s vaccines are about 95 percent effective, with Astrazeneca’s vaccine 70 percent effective on average.
But nearly half of those infected with the coronavirus never develop symptoms, according to the CDC, yet can still infect others (which is why holiday travel is so risky).
Researchers have no data on how well these vaccines prevent asymptomatic infection; that would have required testing tens of thousands of participants routinely. Another option would have been to compare whether those who live with vaccinated volunteers were less likely to get COVID-19 than those living with participants who got the placebo.
“That little lack of data raises a nagging question,” Smith said.
Britain has decided to sidestep that question altogether. On Wednesday, the nation became the first to authorize Pfizer’s vaccine and is largely basing its plan on age: the one factor that most consistently predicts a person’s risk of dying of COVID-19.
That strategy may avoid an issue that could trigger chaos and confusion in the United States: determining which of the nation’s 85 million “essential” workers should get the vaccine first.
In California, that umbrella term currently includes everyone from grocery store employees to cemetery workers to weather forecasters, according to a document issued by the state in April.
Each state ultimately gets to decide how to allocate its vaccine doses, regardless of federal guidelines. And while states will almost certainly prioritize those who can’t work from home and are at higher risk of being exposed to the coronavirus, that may still leave enough wiggle room for interpretation.
Case in point: At one CDC advisory committee meeting, a member of the
Fraternal Order of Realbearded Santas made the case that Santa Claus impersonators should qualify as essential workers, noting that we all need holiday cheer now more than ever this year.
A shot to set things right
Vaccinating to curtail the coronavirus’ spread or to reduce Covid-related deaths may be two different strategies, but their goal is the same: minimizing the pandemic’s devastating effect on society as a whole.
But that’s not the only possible goal, says San Diego State University bioethicist Joseph Stramondo.
“Another way to think about it is what we owe folks,” Stramondo said. “What they have coming due, basically.”
There’s some overlap between both ways of thinking. For instance, vaccinating health care workers makes practical sense because of their role in caring for COVID-19 patients, but there’s also an ethical argument for vaccinating those who’ve worked tirelessly to help the rest of us over the past year.
You can extend that thinking, Stramondo says, to other roles, such as grocery store workers and bus drivers — especially since these jobs are disproportionately filled by people of color. In San Diego, Hispanics and Latinos make up a third of the county but nearly 60 percent of coronavirus cases, and minority communities have suffered from higher COVID-19 death rates than White residents.
Ensuring that vulnerable populations don’t get left behind was one goal behind guidelines the National Academies of Science, Math and Engineering released in October, which the CDC is using to develop its own vaccination recommendations. Among the proposed groups in the second major phase of vaccination are people living in jails, prisons and detention centers, as well as those in homeless shelters.
Social distancing is nearly impossible in these indoor settings, making them a potential petri dish for new outbreaks. Active infections among inmates and staff in San Diego County jails have jumped from 95 to 161 over the past two weeks.
But the prospect of these groups getting a vaccine sooner than others has already ignited fierce debate.
In mid-october, Colorado’s public health department released a draft plan to vaccinate those in congregate housing in phase “2a”— including college students in dorms, those in homeless shelters and the incarcerated. Older adults and those with underlying medical conditions would follow in phase 2b, according to the document.
The proposal drew scathing criticism from George H. Brauchler, Republican district attorney for Colorado’s 18th Judicial District.
“Gov. (Jared) Polis and his Colorado Department of Public Health and Environment have declared that they intend to prioritize the health of incarcerated murderers, rapists, and child molesters over the lives of law-abiding Coloradans 65 years and older and immunocompromised adults,” wrote Brauchler in a column for the Denver Post.
Polis has since pivoted to say the state never planned to vaccinate those in prison before free adults and will issue revised guidelines soon.
But treating vaccination as if it’s a reward for the most deserving doesn’t sit well with Stramondo.
“There’s a difference between politics and ethics,” Stramondo said. “It may not be the most popular thing to do, but it is the right thing to do. I’m not a big fan of saying, ‘Oh, those are the bad folks that need to be punished twice over, both with incarceration and with this horrific disease.”
These debates will likely escalate as long as vaccine doses remain limited. Dr. Wilma Wooten, San Diego County’s public health officer, recently stated that a COVID-19 vaccine won’t be widely available to anyone who wants one until the spring.
Until then, public health experts stress that the best way to protect yourself against the coronavirus is still through social distancing, wearing a mask and washing your hands.
“We want to think that we are past the greatest part of this challenge with vaccines on the horizon. We are at the beginning,” said Christopher Howard, CEO of Sharp Healthcare, at the county’s Wednesday COVID briefing.
“Nobody wants to hear that, but it is the truth. And we’re going to need your help, the public’s help in the coming weeks, coming months, as we all work together to survive this — and we are talking about survival.”