Age-based vaccine rollout not consistent

New strategy not yet followed all across state

Arizona’s abrupt switch to an agebased COVID-19 vaccine rollout this week means some people 55 and older can get vaccinated, but that change is not consistent statewide.

The new model is a hybrid. While the state is now emphasizing agebased vaccination, counties have the job of prioritizing the vaccination of front-line essential workers and vulnerable communities as they see fit.

It’s a simpler process, with the switch influenced by the decision that an age-based approach more quickly reaches the most people at higher risk.

An age-based approach also eliminates figuring out how people would have to document their underlying health conditions to qualify.

The change in Arizona’s rollout came about after a unanimous recommendation by the Arizona Vaccine and Antiviral Prioritization Advisory Committee, which includes state, local, and tribal experts and health care partners.

Some confusion is expected as counties adjust their plans, several officials said.

The state’s change already has drawn criticism, too. Advocates for people with disabilities say the agebased system is a step back for their

community, putting younger people with high-risk conditions such as cerebral palsy and Down syndrome further down in the queue for a vaccine.

Two state-operated vaccine sites this week opened up 50,000 appointments to the 55 and older age group. They were filled within two hours. More appointment opportunities are expected, but not all counties are able to move to the 55 and older group right away as they continue to work through older groups.

Demand for the vaccine is expected to continue outpacing supply for the foreseeable future.

Maricopa County, which is home to nearly two-thirds of the state’s population, is continuing to vaccinate under the old way, by phase and priority, spokesman Ron Coleman wrote in an email. Those in Maricopa County who are 55 and older can get vaccinated at state-run PODs (points of dispensing sites) and pharmacies, which follow state criteria, but not yet at county-run locations.

Cochise County in southern Arizona decided Wednesday to move forward with vaccinating people 55 and older, even though just 41.8% of its population of people over 65 had received at least one dose of vaccine as of Feb. 28.

The state’s new vaccine plan says jurisdictions should move into the next age group down once either 55% of the current targeted age group is vaccinated, or once officials feel that there is no longer demand for vaccine.

Cochise County’s vaccination partners “have observed a reduced demand for appointments and agreed it is the right time to welcome the next age group phase,” according to a Wednesday afternoon county news release.

“Our community partners expressed they are ready to expand to the next age category as they report receiving fewer and fewer appointments from the 65 and older age group, and in turn are experiencing a higher demand for appointments from people who are 55 and older,” said Alicia Thompson, director of Cochise County Health & Social Services.

Officials in Yuma County say they want to vaccinate more people in the 65 and older group before they start vaccinating people 55 and older.

State data shows 36.3% of the over-65 population in Yuma County had received at least one dose of vaccine as of Feb. 28. Just 8% of individuals 65 and older in Yuma have been fully vaccinated with two doses of vaccine, that same state data showed. Yuma County has been Arizona’s hardest-hit county in terms of its rate of COVID-19 cases relative to population throughout the pandemic.

Similarly, Pima County has 48% of its 65 and older population with at least one dose of vaccine and wants to get to the 55% level before opening up vaccines to those 55 older and to the broader group of front-line essential workers, Dr. Theresa Cullen, Pima County Health Department director, said in an email.

As of Feb. 28, counties’ vaccination rates for the 65 and older age group varied widely. In Mohave County, just 19.4% of the over 65 population has received at least one dose of vaccine, the state’s data shows, while in Coconino County it’s 71.3%, which is the highest rate in the state.

Coconino County has done an efficient job in providing technical assistance to people over age 65 who need help signing up and has had success with outreach to that population too, health and human services director Kim Musselman said.

Coconino County vaccination sites opened Wednesday to people 55 and older. County officials will continue with their rollout plan vaccinating front-line essential workers, Musselman said.

Coconino County began vaccinating all front-line essential workers two weeks ago, among them restaurant workers, grocery store employees and utility workers. They are also vaccinating adults with high-risk medical conditions living in shelters or other congregate living settings, which follows the previous state recommendation.

County officials are doing their best not to confuse the public, Musselman said, so it made sense to not make any changes to the front-line worker vaccine plan.

Several county health officials contacted by The Arizona Republic this week said they generally like the new hybrid rollout plan because it provides more clarity about how to proceed with vaccinations moving forward and also follows the data that shows people with underlying health conditions are more likely to be 55 or older.

However, Arizona advocates for people with disabilities say the age-based approach leaves out vulnerable young people with conditions such as Down syndrome who would be at high risk for complications were they to contract SARS-CoV-2, the new coronavirus that causes COVID-19.

State health director Dr. Cara Christ said Wednesday that vulnerable populations are on the whole better served under the new plan because the agebased approach more quickly reaches more people at higher risk. She expects the state will begin vaccinating people in the 45 and older age group in April.

“At the end of April, beginning of May, 35 and above, and then we’ll open it up to everybody four to five weeks after that,” she said. “So we anticipate being through all the ages that are eligible for vaccine by the start of summer.”

Arizona now does not prioritize any medical conditions under the new plan. Rather, individuals will get vaccinated in their age group. Front-line essential workers still can be prioritized at county levels, while the state sites will base eligibility solely on age.

Arizona at the state level had been vaccinating people only in what it called phases 1A and priority 1B, which includes health care workers, first responders, long-term care facility staff, long-term care residents, people ages 75 and older, K-12 school staff and child care workers, law enforcement/protective services and people 65 and older.

The next groups in line were non-priority 1B, which included a large group of essential front-line workers, among them food and restaurant workers and those who work for critical utilities like electric and water services.

State officials say their hybrid plan still prioritizes essential front-line workers, just at the county level.

A drop-down menu on the Arizona Department of Health Services’ website includes a range of jobs considered front-line essential, varying from a golf course employee to agricultural workers, airline staff and Uber and Lyft drivers.

In Cochise County, Thompson said the hope is to give the one-dose Janssen vaccine made by Johnson & Johnson to essential workers at four different distribution sites in the county — in Douglas, Sierra Vista, Benson and the Willcox area.

The Willcox area site will be primarily for the agricultural workers who are employed at more than 1,000 farms, Thompson said.

“The Janssen vaccine is 76% effective in reducing the chance of getting the virus. Both Moderna and Pfizer are about 94% effective in reducing your chance of getting the virus. Johnson & Johnson is almost 100% effective in reducing death from COVID-19,” Thompson said. “So it makes sense, offering the Johnson & Johnson vaccine to younger, healthier essential workers.”

Christ on Wednesday encouraged the same. She said counties can use the Janssen vaccine how they see fit when it starts arriving early next week, but she recommended it go to front-line essential workers “because they are younger, they’re healthier, (and) we want to make sure that we’re protecting them as they have day-to-day interactions with the public, and so one dose would be able to get us there faster with those populations.”

Cochise County expects to get 1,200 doses of the Johnson & Johnson vaccine for next week. Right now, Thompson expects the front-line essential workers in Cochise County to be vaccinated on a first-come, first-served basis through the state’s registration system, but more details need to be worked out, she said.

“To begin with, we will set it up pretty much the way we’ve been doing it. We open a POD, it’s designated for a certain category and people schedule the appointment to go there,” Thompson said.

As the county gets more vaccine, especially the Johnson & Johnson vaccine, county officials expect to bring a vaccine POD directly to some of the larger farms and vaccinate the workers on a designated day, Thompson said.

Also included in the state’s previous 1B non-priority group were adults with high-risk conditions living in congregate settings, such as group homes, jails or prisons.

After the non-priority 1B population, the state’s plan had been to move into 1C, a group that included any adult with a high-risk underlying health condition, such as diabetes, obesity or chronic obstructive pulmonary disease.

Those adults now will need to wait for their age group to get a vaccine, though state officials emphasize that most of those at highest risk are 55 or older.

About 90% of known COVID-19 deaths in Arizona have been among those aged 55 and over, with 75% of all the deaths in the 65 and over age group, state data show. About 65% of COVID-19 hospitalizations have been among those aged 55 and over. Those aged 55 and over make up only 25% of cases, however, illustrating the greater chance of adverse outcomes in older individuals.

Generally, it makes sense to vaccinate those at highest risk of severe outcomes first, and, generally, that does correlate by age. But not always, so sorting by age may leave out vulnerable people. For example, a 35-year-old with diabetes may be at higher risk for serious illness than a healthy 60-year-old.

Those 55 and older account for about 60% of all Arizonans with medical conditions, Christ said, and those 45 and older account for about 70-80% of Arizonans with medical conditions.

“So it made sense to quickly move through those age categories because we are going to be able to hit a lot of high-risk individuals a lot sooner,” she said.

Some other states have adjusted their plans to base distribution on age, but most states are still vaccinating based on earlier phased plans similar to the one Arizona just scrapped.

The CDC still recommends the type of priority plan Arizona is deviating from, with a phase 1C that prioritizes people ages 16-64 with underlying medical conditions and other essential workers.

Connecticut moved to a fully age-based system. Eligible are individuals ages 55 and older, plus the previously prioritized health care providers, medical first responders, long-term care facility and congregate setting residents and staff and educators and child care providers. Those ages 45-54 will be added March 22, followed by ages 35-44 starting April 12 and ages 16-34 starting May 3. No groups are based on chronic illness or employment.

Other states have taken more hybrid approaches to balance ages with chronic illnesses.

Rhode Island has an age-based rollout but with “accelerated distribution to people in the most vulnerable geographies and with specific health conditions,” according to that state.

Those ages 60-64 will be eligible in mid-March alongside those ages 16-64 with certain underlying health conditions like diabetes, lung, heart or kidney disease or weakened immune systems. Then come the remaining age groups.

In Maryland, after the ongoing phase of adults 65 and over and certain priority groups, the next big group are adults ages 16-64 at increased risk of severe illness from comorbidities, as well as essential workers. Then comes the general population of health adults ages 16-64.

Arizona’s age-based plan may be an advantage to some people with underlying health conditions, but it hurts a lot of younger state residents with physical and intellectual disabilities, said Jon Meyers, executive director of The Arc of Arizona, which advocates for the rights of people disabilities.

“For the vast numbers of the people we represent, it actually could put them farther behind the curve,” Meyers said. “If you have Down syndrome, it doesn’t matter what age you are. You are 10 times more likely to die if you come down with COVID.”

Individuals with disabilities who lived in group homes were included in the early phase of the vaccine rollout, but they represent just about 10% of the overall population in Arizona with disabilities, Meyers said.

“They are just as vulnerable as those who live in group homes,” Meyers said. “They are at every age on the spectrum and they are equally vulnerable regardless of their age.”

Maricopa County officials, at a Tuesday news briefing, appeared supportive of the state’s shift in strategy but will continue with their own county-based priority plans. Spokesperson Fields Moseley said the decision “gives us a little more clarity of what vaccination distribution is going to be like going forward.”

Marcy Flanagan, Maricopa County public health director, said the Arizona Department of Health Services presented the VAPAC committee, of which she is a member, with “very informative” data in favor of switching to a hybrid age-based approach, specifically data on the high percentage of those with chronic medical conditions that are in higher age brackets.

“It was easy to know that by going by age, we’re able to really capture those at highest risk for hospitalization and death, and that’s why that decision was made,” she said. “But remember, it’s also a hybrid strategy. We’re also working with our employers of front-line essential workers to get vaccine out to those individuals as quickly as possible.”

Flanagan said counties are continuing to target front-line essential workers at the county level, while the state uses an age-based priority system — hence the “hybrid approach.”

The county is working to apply national guidelines for front-line workers to its “large community of frontline essential workers to determine phasing and timelines,” Coleman said.

Maricopa County hopes to release details on its plan to vaccinate front-line essential workers next week, he said.

“Maricopa County is working with ADHS’s decision to adopt a hybrid model for vaccine administration and to use the CDC’s Advisory Committee on Immunization Practices guidance for immunizing front-line essential workers,” Coleman wrote. “This decision provides some much-needed direction to our residents and our public health team.”

One county-level effort is to continue vaccinating at long-term care facilities that did not enroll in the federal program. The plan is to complete all first and second doses at long-term care facilities by the end of April, Flanagan said.

Maricopa County also is using its doses to coordinate vaccine distribution for front-line essential workers, and it plans to use some Johnson & Johnson single-dose vaccines for that effort. The county will continue to target hard-to-reach populations.

County officials expect that demand for the vaccine will continue to outpace supply for at least one or two more months, Coleman said.