With two Covid-19 vaccine candidates expected to be approved for the US market in the coming weeks, a expert group met on Tuesday to indicate which Americans should be vaccinated first. In a 13-to-1 vote, they put healthcare workers, staff and residents of long-term care facilities on the front line.
the Advisory Committee on Immunization Practices (ACIP) – a panel of independent medical and public health experts – has been meeting for months to reflect on who to prioritize during a pandemic when vaccine stocks are still limited.
ACIP is very influential in the United States. He makes recommendations on vaccination policy to the Centers for Disease Control and Prevention, which overwhelmingly accepts the committee’s advice. States are not, however, obliged to follow it. It is up to governors – and individual hospitals and vaccination sites – to make their own vaccine prioritization plans.
But with hospitalizations and deaths from coronaviruses exponentially rising, the meeting was another stark reminder that vaccine rationing will be a painful reality for months to come as stocks remain low.
“There is an average of one Covid death per minute right now,” said Dr Beth Bell of the University of Washington, who chairs the ACIP working groups, at the opening of the meeting. “During the time it will take us to hold this ACIP meeting, 180 people will have died from Covid-19.”
And that’s one of the reasons why, vaccine and public health experts told Vox, ACIP should have intervened sooner. Large health groups, such as World Health Organization (WHO) and National Academies of Science, Engineering and Medicine (NASEM), have published guidance on how countries and other decision-making bodies can define their prioritization plans for Covid-19 vaccines.
“It would have been helpful to have this a week ago,” said Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, as states, which were awaiting advice, must place their first orders of Covid-19 vaccines with the government and share their initial distribution plans by Friday. “States have not been completely ignored here,” Faden added – as ACIP had indicated in previous meetings the direction in which they were likely to go – but Tuesday’s advice could have been more specific, in particularly with regard to how to immunize American health workers.
The advice is not specific enough
The main task of ACIP on Tuesday was to vote for phase 1a deployment for two priority groups: health workers and staff and residents of long-term care facilities, comprising approximately 24 million people.
According to CDC officials, there will only be 5 to 10 million doses of vaccine available per week for these groups once the vaccines are approved, which is expected to happen before the end of the year. The two manufacturers who are expected to have vaccines approved first, Moderna and Pfizer / BioNTech, will have enough doses to vaccinate only about 20 million people at the end of December.
Residents and staff of long-term care facilities are a top priority as they have 40% of Covid-19 deaths in the United States, according to the committee. And it makes sense to put healthcare workers first – they have also been among the groups hardest hit by the virus and we need them healthy and working to make the healthcare system work. .
But the gap between the priority groups and the expected supply is a problem that ACIP should have solved, according to experts.
It is not clear from the guidelines which of the health workers should start, said Jason schwartz, assistant professor of public health at the Yale School of Public Health. “This is important because states may have 20,000 or 100,000 doses and determining where to use them in a priority group is going to be a difficult question.”
ACIP only said that “people in direct contact with patients”, staff working in care and long-term care facilities, and workers without coronavirus infection in the past 90 days should come first.
“Direct patient care is often interpreted as doctors, nurses and clinicians,” said Saad Omer, director of the Yale Institute for Global Health, which is on the WHO’s Covid-19 vaccine prioritization committees and from NASEM. “But you have to go beyond that to say explicitly that it includes cleaning workers, other people who do housework, et cetera.”
These groups are potentially just as exposed to the coronavirus as doctors or nurses in ICUs since they work in the same high-risk spaces.
“There is a huge difference between a dermatologist who performs cosmetic surgery in a private practice and someone who is in a Covid-19 department in a large downtown hospital”, Lawrence Gostin, director of the Institute O’Neill for National and Global Health Law at Georgetown University, added. “It would be extremely helpful if there could be more stratification based on the risk of the health worker.”
In addition, if ACIP had been more specific about health workers who are at high risk, “you leave open a strategy of prioritizing them and then going to other high risk groups rather than [immunizing] all staff in the health system, ”said Faden – who also advises WHO on vaccine prioritization.
The next challenge: how to put seniors first
Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, says most states plan to be able to vaccinate all of their health workers within three weeks of receiving the first shipments of Covid-19 vaccine. If that’s true, “the issues here regarding under-prioritization will be very short-lived and the need for more detailed advice is reduced,” said Schwartz.
ACIP typically establishes recommendations for vaccine policy based on specific vaccines, and they will meet again and potentially change their advice as soon as the Covid-19 vaccines are approved by the Food and Drug Administration. They will also have to vote on the groups to come after phase 1a of the deployment.
If ACIP follow up on what they have telegraphed so far, the committee will prioritize essential workers (such as teachers, food and agriculture workers, police and firefighters) in phase 1b, and adults 65 years of age and over and with conditions high-risk medical conditions in phase 1c.
ACIP would deviate from other international expert groups with this plan, Omer said. the WHO and OURS immunization frameworks prioritized both older people and adults with underlying health problems alongside or immediately after health workers, rather than essential workers.
“The reason everyone prioritizes older people – over people aged 18 to 29 – is that even between 65 and 74 they have a 90 times higher risk of death,” Omer explained. . “My hope is [ACIP] will revisit some of the assumptions that motivated tradeoff considerations between essential workers and older populations. ”