Medical workers — and not just doctors and nurses — at high risk for catching and spreading COVID-19. Police officers. Seniors who live in crowded houses. Morticians.
These are some of the groups a scientific advisory committee thinks should have first crack at a coronavirus vaccine. Everyone assumes there won’t be enough vaccine for all who want it when it first becomes available, so the government will need to ration doses.
On Tuesday, a committee of the National Academies of Sciences, Engineering and Medicine released a draft allocation framework that suggested how to do that rationing. It proposed delivering the shots in four phases.
Medical workers with direct exposure to the virus would get shots in the first phase. This includes people providing direct patient care in hospitals, nursing homes and private homes, along with transport and environmental services workers. People who live in group settings like nursing homes or in overcrowded situations would also be in the first phase, as would first responders, including ambulance service workers, police, and firefighters. People at especially high risk for serious illness because of chronic health conditions like cancer, chronic obstructive pulmonary disease, diabetes and obesity would also get priority, but the group did not specify exactly how. There likely won’t be enough vaccine at first for all Americans with such medical problems, so the government may need to reserve the shots for people who have two or more serious health conditions. Morticians and funeral home workers could get shots in the first phase.
The mission of the academies, which are composed of top scientists, is to provide independent, objective advice to guide policy.
The National Academy of Medicine, at the behest of the National Institutes of Health (NIH) and U.S. Centers for Disease Control and Prevention (CDC), created the expert panel to study allocation in July. The 18-member committee is heavy on epidemiologists, but also includes a health economist, a geriatrician, bioethicists, and foundation leaders. Traditionally, the CDC’s Advisory Committee on Immunization Practices (ACIP) recommends who should get vaccines, and it has been discussing since April how to allocate a new coronavirus shot. Its recommendations may come later this month, said Jose Romero, ACIP chairman and professor of pediatrics and pediatric infectious diseases at the University of Arkansas for Medical Sciences.
At the academy panel’s first meeting in July, Victor Dzau, the academy’s president, said he expected final recommendations from that group by late September to early October.
NIH Director Francis Collins, said at that meeting that this issue could benefit from extra “deep thinkers.”
“This is going to be controversial,” he said. “Not everybody is going to like the answer.”
Eddy Bresnitz, a former deputy commissioner of the New Jersey Department of Health who is now advising the department on coronavirus response, said he thinks the advisory groups will both be valuable. “I think that these are going to be in some ways synergistic or complementary,” he said.
In the report, the committee said its framework is mean to “guide” ACIP.
Asked who will make the final decision on allocation, Romero said, “I don’t know, to tell you the truth.” His recommendations will go to the CDC.
In deciding who gets a vaccine first, experts and government officials need to weigh its likely effect on spread of disease, on preventing serious illness and death, and how well it works in different groups. If it’s markedly more effective in younger people, for example, it might be better to target them even if the elderly are most likely to die from the disease. Because COVID-19 has disproportionately affected Blacks and Latinos, members of both committees have discussed how to make sure people of color have early access.
The committee said that “mitigation of health inequities” is one of its goals. It said it was taking into account work environments, living arrangements and social determinants of health that may increase risk of certain chronic health problems and place an outsize burden of sickness and death on people of color. The committee said that those in charge of distributing the vaccine should make sure that it is delivered in a timely manner to areas of “high social vulnerability.”
Politics vs. science
The vaccine discussions come at a time when many Americans are worried about the role politics is playing in the nation’s response to the new virus. A new survey from STAT, a health news site, and Harris Poll found that 78% of Americans think the approval process for a new COVID-19 vaccine is being driven more by politics than science. About one-third of the adults surveyed were in no rush to get a new vaccine, but 67% said they would like to get one as soon as it’s available.
In its second phase, the academy committee included more people with underlying health problems, the remaining older adults, teachers and school staff, along with people who live and work in prisons, as well as residents of homeless shelters and of group homes for people with physical or mental disabilities or who are in recovery. Many such people who live in group settings have health problems and are unable to socially distance. Some essential workers who cannot avoid exposure to the virus could get shots in this phase. This could include transportation and food and drug store workers. The committee specified that these workers should be offered vaccine regardless of their immigration status.
The third phase includes more essential workers, including those who work in hotels, restaurants, hair salons and exercise facilities. Children (if they’ve been included in clinical trials) and young adults would also get shots because of their role in spreading disease.
The last phase is for the healthy people who are left. If there’s still a vaccine shortage, the committee suggested using a lottery. The committee said the United States should make the vaccine available to everyone within 12 to 18 months.
Along with figuring out who gets the doses, public health officials will be faced with distribution challenges. Two of the vaccines farthest along in development, made by Moderna and Pfizer, require two doses given three to four weeks apart. Both must be stored at extremely low temperatures.
Romero said the need for cold storage could make it harder to distribute the vaccine in rural areas.
AstraZeneca announced the Phase 3 trial of its COVID-19 vaccine this week.
Health workers first
ACIP has been in general agreement that some health care workers and those with underlying health problems should be first in line. Modeling discussed at its last meeting found that vaccinating nursing home staff was more effective at reducing viral spread and death than vaccinating residents. In general, younger people mount a stronger immune response after vaccination than the aged. In addition, many nursing home outbreaks start with staff, who may have been exposed to the coronavirus at home and who often work in more than one facility.
Bresnitz, who attended the recent ACIP meeting, said one committee member suggested acceptance of the vaccine by health-care workers might make other people more confident about getting it.
At the ACIP meeting, Kathleen Dooling, a CDC doctor, asked the committee to assume that there may be a total of 3 million doses of the two vaccines available in October, 10 to 20 million in November and 35 to 45 million in December. Romero said these are hypothetical numbers. He said it is unlikely that any vaccine will be available before November. “Not only do we not know how much vaccine will be available, but we don’t know which vaccine will be available,” he said.
Regardless, supply will fall short. Dooling had these estimates for people at high priority: 17 to 20 million health-care workers with either direct or indirect exposure to the virus, 60 to 80 million essential workers, more than 100 million American adults with health conditions that put them at high risk and 63 million people aged 65 and older. Some of those groups overlap.
Bresnitz pointed out that a Department of Homeland Security document lists seven single-spaced pages of categories of essential workers.