From last April to December, José Romero met weekly with other vaccine and infectious disease experts to discuss how the nation should dole out early doses of lifesaving COVID-19 vaccines in the most effective and fair way.
He and other members of the Advisory Committee on Immunization Practices (ACIP), which advises federal health officials, knew there wouldn’t be enough vaccine for everyone who wanted it. So they spent untold hours devising a phased vaccination system that would slowly increase eligibility for shots as manufacturing ramped up.
In December, days after the Pfizer-BioNTech vaccine received emergency approval, ACIP recommended that the first doses go to 24 million frontline health workers and people who lived and worked in long-term care facilities. Once those groups were vaccinated, doses could go to 19 million people age 75 and up and to 30 million more essential workers. The guidelines were meant to prioritize the people most likely to die of COVID-19 and those who faced frequent exposure at work.
Then things got crazy.
There was even less vaccine than the U.S. Centers for Disease Control and Prevention had expected and pressure was increasing to vaccinate people fast. States, counties, and cities started tweaking the rules. By the end of December, Florida and Texas had pushed essential workers like teachers and grocery workers aside, making everyone 65 and up and younger people with certain chronic health conditions eligible instead.
Then the federal government turned the flood of demand into a torrent. During the last full week of the Trump administration, Alex Azar, then secretary of the Department of Health and Human Services, and former CDC Director Robert Redfield announced that shots everywhere in the United States should now go to people 65 and up — an additional 28 million — and younger people with chronic health problems that raised COVID-19 risk — an additional 81 million. (There’s some overlap between the groups.) They claimed bigger shipments of doses to states would come from a stockpile that later proved nonexistent.
“I was floored,” said Romero, who was ACIP’s chair. “I was really scratching my head as to why was there this opening of the floodgates. … We had been told all along there was not enough vaccine. …
“Why would you do that? The American public then expects this, and we … can’t deliver.”
Romero, a pediatric infectious diseases physician at University of Arkansas for Medical Sciences and Arkansas secretary of health, now wonders if even setting the floor at age 75 made too many people eligible.
He and other members of ACIP, along with members of a panel formed by the National Academy of Sciences at the behest of the CDC and National Institutes of Health to provide guidance on vaccination priorities, have watched with dismay as federal, state, and local governments assembled a hodgepodge of rules and systems. It soon became clear, they said, that the Trump administration had ignored their advice to pump money and effort into distributing vaccines and communicating to the public about them.
Daniel Polsky, a health-policy expert at Johns Hopkins University who served on the National Academy panel, said his group, which worked from July to October, could get little information from the federal government about how vaccines would be distributed. He was “dumbfounded” to discover once vaccines were approved that “they weren’t hiding information from us. There was no information to share.”
The result is that states were left with much of the planning and responsibility for vaccine delivery, but got little federal support. Meanwhile, millions of people frightened of a mutating virus were told they were eligible for shots and should get them. People who might have been willing to wait under the earlier rules wanted shots now. They overwhelmed phone lines and online reservation systems. They resented friends who found a way to work the system. They saw the rules were different across state and even county lines and resented that, too. Confusion and anger abounded.
Baruch Fischhoff, a psychologist on the National Academy panel who studies risk assessment at Carnegie Mellon University, likened the swarm for vaccines to the toilet-paper panic last spring.
“This was an officially generated shortage,” he said. Surveys in the fall showed most people accepted “risk-based priorities,” he said. He thinks most would have been more willing to wait their turn if priorities had been clear and consistent.
The crush has worked against the disadvantaged people of color — a group disproportionately harmed by the virus — that both committees wanted desperately to protect.
“It has been pretty awful,” said Sarah Long, a pediatric infectious diseases doctor at the Drexel University College of Medicine who joined ACIP in December.
Releasing too much demand caused “predictable chaos,” she said. “All of a sudden, it was this chaotic free-for-all with the usual suspects winning.”
The system would have worked better, she said, if states “had followed the rules — the first rules.”
‘Varying rules erode trust’
Both Pennsylvania and New Jersey now largely follow the new CDC guidance and allow vaccines for people 65 and up, along with those who have any of 12 health conditions, including cancer, kidney disease, and type 2 diabetes. But Philadelphia has hewed more closely to the original ACIP guidelines, vaccinating those 75 and up and those having a shorter list of health problems while continuing to give shots to essential workers. There still aren’t nearly enough doses even for that smaller group.
William Schaffner, a Vanderbilt University Medical Center infectious diseases specialist who represents the National Foundation for Infectious Diseases on ACIP as a liaison, said the committee always expected variation, particularly when it came to essential workers. Agriculture workers, for example, are more important in some places than others. Experts had learned in the past that “if you were too rigid, then vaccine would go unused.”
But the committee did not anticipate this much variation. Nor did it expect that so many of the health workers in the top priority group would be wary of the new vaccine. Health systems had to do more educating and coaxing than expected, and that slowed the process down early on.
He thinks ACIP should have moved more quickly. By the time it made its final recommendations, many states had already devised their own plans. Romero counters that allocation plans had to be tailored to specific vaccines and were passed within days of FDA approval.
The variability in rules just increases wariness. Polsky, who formerly worked for the University of Pennsylvania and still lives in Lower Merion, said it doesn’t seem fair to a 66-year-old in Philadelphia that he can’t get vaccinated when people his age who live a few blocks away across City Avenue can. “Anything that kind of erodes the foundation of trust is going to have an impact on vaccination rates,” he said.
So far, white people, the racial group most likely to want the vaccines, have been the dominant group receiving them. Black people, who surveys show are much more likely to be skeptical about the shots, have been vaccinated at lower rates. Fischhoff said such numbers are misleading. Even if many Black people don’t want the shots, more than enough do to use their share of the current supply if they have adequate access.
Ana Diez Roux, dean of Drexel’s Dornsife School of Public Health and a National Academy committee member, said it is just and equitable to make extra efforts to protect underserved groups who have been most harmed by the virus. Plus, she said, if large pockets of unvaccinated people remain, the pandemic will continue.
No one expects that public health officials can put the genie back in the bottle when it comes to eligible groups. What is needed now, the experts said, is clear messaging about priorities from the federal government, money, and other help to make vaccination more efficient at the local level, better communication to hesitant groups from people they trust, and much more transparency about how many shots are available, who’s getting them, and how many others are waiting.
“Without having basic information and communication, you just open the door to chaos,” Fischhoff said.
In Maryland, where Polsky works, about two million people are now eligible for vaccines that require two doses. The state gets about 10,000 doses a day.
“Do the math,” he said. “It’s really bad.”
Polsky said public health officials need to realign expectations with reality. “At some point, God willing, everyone who needs it will get it. It just takes time,” he said.
“It’s not that everyone’s going to get an appointment tomorrow. Everyone needs to understand that.”
On a more hopeful note, he said it will likely be easier to get a vaccination appointment in March, as production continues to grow and a third vaccine from Johnson & Johnson is expected to receive emergency authorization.
Romero thinks it will be easier by “early summer.”