Who Lives, Who Might Die — CDC Experts Decide Who’s First in Line for the COVID Vaccine
Prioritizing vaccine-recipients is painful triage for advisory panel
by DAVID AXE
Experts advising the U.S. Centers for Disease Control and Prevention have officially recommended who should be next in line for the growing, but still limited, supply of novel-coronavirus vaccine.
The 14-member Advisory Committee on Immunization Practices wants to protect the most vulnerable Americans — those over the age of 75 — while also getting a head-start on protecting the tens of millions of essential workers who keep the economy functioning, as well as younger people who are the most likely to transmit the disease.
The ACIP panel voted 13 to one to approve the guidelines on Sunday evening. The guidance, which is non-mandatory and seems unlikely to greatly please or deeply disappoint anyone, charts a middle path between opposing camps in the epidemiological community.
Some experts want states to prioritize the elderly for vaccination in order to save lives now, regardless of the long-term consequences. At the same time, at least one leading scientist is pushing for authorities to vaccinate essential workers and younger people sooner, potentially hastening the end of the pandemic and saving lives in the long run.
“The meeting of ACIP was explicit in the goal of balancing two goals — preventing sickness and death and preserving what they called ‘societal functioning,’” Jennifer Reich, a University of Colorado sociologist who studies immunization, told Angry Planet. “These seem compatible goals, but when there is inadequate supply of a vaccine or unequal opportunities to receive them, these goals may present conflict.”
In choosing to prioritize both groups despite a shortage of vaccine, ACIP “is splitting the difference,” Lawrence Gostin, a Georgetown University global-health expert, told Angry Planet.
The U.S. Food and Drug Administration granted emergency-use approval to the first U.S. COVID vaccine, a two-dose shot from New York pharma Pfizer, last week. Pfizer quickly shipped around three million doses to all 50 U.S. states.
More shipped this weekend amid widespread confusion over just how many vials were available, and whether the U.S. government had told Pfizer where to send them.
A second two-dose vaccine, from Massachusetts firm Moderna, got the FDA’s nod on Friday. Moderna started trucking and flying out the first of an initial batch of six million doses on Sunday. A third two-shot vaccine, from AstraZeneca in the United Kingdom, could get approval for emergency use in coming weeks.
The quantity of vaccine available to Americans is growing, and could exceed 10 million — enough for five million people — any day now.
But it’s still a drop in the bucket. Experts estimate around 70 percent of Americans — that’s 270 million people — will need natural or vaccine-based immunity in order to end the pandemic.
Recognizing that COVID shots will probably be in short supply for months, the ACIP panel is conducting vaccine triage, gradually creating a list of vaccine-eligible groups, organized by priority.
Ultimately, it’s up to state authorities to decide where doses go and who gets them, but for the most part states have followed the CDC guidance — even when that guidance might be a bad match for a particular state’s population and politics. (Looking at you, Florida.)
Which is to say, the ACIP panel’s advice really matters. It can help decide who gets immunity now, and who must continue risking infection and death.
The panel is sorting the American population into “phases” for vaccination. Those first in line for shots in “phase 1a” include front-line healthcare workers — doctors, nurses and medical staff who come into close contact with COVID patients — plus residents of nursing homes whose age and co-morbidities mean they have the highest chance of dying of COVID.
Phase 1a includes around 24 million people. It would take 48 million doses to vaccine all of them, assuming no spoilage. Manufacturing, shipping and administering all those doses could take months at current rates, even after three companies have the green light from the FDA.
At some point, probably this coming spring, states will be ready to move on to the next group, the so-called “phase 1b.” ACIP recommended this phase include all adults 75 and older — that’s around 19 million people — plus an estimated 30 million essential workers labor in grocery stores, meat-processing plants, transit and prisons.
It’s clear why the panel would prioritize people over the age of 75. “Risk for severe illness with COVID-19 increases with age, with older adults at highest risk,” the CDC explained. “People in their 50s are at higher risk for severe illness than people in their 40s. Similarly, people in their 60s or 70s are, in general, at higher risk for severe illness than people in their 50s. The greatest risk for severe illness from COVID-19 is among those aged 85 or older.”
But essential workers, who tend to be younger, are vulnerable in ways many older Americans aren’t. A 75-year-old retiree might be able to protect themself by staying home and limiting exposure to other people. A 25-year-old bus driver doesn’t have that option. “Essential workers are among the most vulnerable because they have to face the public every day and have no option to work remotely,” Gostin explained.
Workers in the most essential industries are also disproportionately people of color. They have “a strong claim for priority given their greater COVID case-rates, as well as historical health disparities,” Gostin added.
Edwin Michael, an epidemiologist at the Center for Global Health Infectious Disease Research at the University of South Florida, wants workers and young people to move up the ACIP panel’s list, from phase 1b to phase 1a. To make space for these groups, the CDC should bump people in nursing homes down the list, Michael told Angry Planet.
“While older people in nursing homes are at high risk, it might be worth also to consider prioritizing other high-risk groups [such as] people working in other essential high-contact jobs — especially groceries, transport, workers running public utilities, teachers — and racial and ethnic communities, given COVID-19’s outsized impact on these minorities, who often also work in these front-line jobs,” Michael said. “This could be done if safety in care-homes can be ramped up to reduce transmission in such controlled places.”
But Michael’s proposal struck some epidemiologists as reckless. “In this emergency situation we now find ourselves in, preventing deaths right now is a greater priority than the theoretical benefits of vaccinating healthy young adults first for benefits that will take place over a longer time horizon — time when clinicians and vulnerable people will die from COVID-19,” Anthony Alberg, a University of South Carolina epidemiologist, told Angry Planet earlier.
The ACIP panel avoids that risk by recommending the most vulnerable essential workers get vaccinated at the same time as Americans 75 and older. Of course, lumping these two groups together extends the timeline for dosing them. With 49 million people in phase 1b, together requiring 98 million doses of vaccine, it’s not inconceivable that states might still be administering shots to this group in late spring or early summer.
And only after states finish with this group are they likely to begin offering shots to people in other age groups and industries. While the CDC’s experts juggle which vulnerable groups should be first, second and third in line for shots, most of us have little choice but to wait, mask up, socially-distance and hope we don’t catch the virus.
“Deciding who to vaccinate is an ethical challenge,” Jeffrey Klausner, a professor of medicine and public health at UCLA who previously worked at the CDC, told Angry Planet. “Does one vaccinate those with the longest life-expectancy? Greatest value to society? Greatest risk for immediate complications or death?”
There are no easy answers. As long as vaccine is in short supply, the CDC’s experts — and the state authorities who look to them for guidance — will have to continue making hard choices.
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