Now that the first COVID-19 vaccines are being rolled out, Operation Warp Speed, the FDA, and the CDC have recommended that governors proceed first with vaccinating two groups: healthcare workers and residents in nursing homes. But what about after that?
Planning has started in all the states and territories regarding who will get the vaccine third on the priority list, potentially starting before the end of January. The choice can be reduced to two major categories: maintenance of essential services and reduction of hospitalizations and mortality.
Operation Warp Speed, FDA, and CDC have recommended that priority should go to workers who preserve essential services for the COVID-19 response and for the overall functioning of society. Estimated at 87 million, this category includes food and medicine supply chain workers (e.g., truck drivers, grocery store and pharmacy employees), infrastructure workers, teachers, and those working in national security. The essential worker category is logical and important but will have minimal impact on reducing hospitalizations and our high daily death rate. And it will take months to implement.
The alternative candidate for third priority is vulnerable populations where vaccination will have the effect of reducing hospitalizations and deaths. Joel Zivot, MD, recently suggested vaccinating all Medicare (53 million) and Medicaid (70 million) recipients ahead of healthcare workers. Presumably, vaccinating this large group would give vaccine to the most vulnerable and underserved populations and would have a sizable impact on reducing hospitalizations and deaths. We assume that this suggestion would also include indigenous populations, the homeless, and inmates in prisons. Vaccinating these pools of patients would go throughout spring and possibly early summer.
In the same vein, former FDA Commissioner Scott Gottlieb, MD, proposed vaccinating all those 65 and older. That would be 53 million people or approximately half the number of adults with high-risk medical conditions. His plan has the advantage of simplicity. A more nuanced approach would be to vaccinate those elderly who have specific individual risk factors associated with COVID-19 mortality, such as sickle cell anemia, chronic renal disease, lymphoma/leukemia, chronic cardiovascular disease, obesity, and diabetes.
In weighing these two competing priorities, maintaining essential services versus reducing hospitalizations and mortality, we are struck by the urgency of rising hospitalization rates and mortality, now averaging 3,000 deaths per day. Many hospitals are at dangerously high capacity. In contrast, essential services seem to be holding up remarkably well. Reducing hospitalizations and mortality is becoming much more difficult.
We have gone from superspreader events such as the February Biogen conference in Boston to many smaller events in family settings heightened by the commencement of the holiday season. The ongoing spread continues despite testing frequently, creating “bubbles,” avoiding indoor restaurants, and “Zooming” many family and religious events. And the seniors are not the ones at bars and pubs.
For us, the scale should be tipped toward reducing hospitalizations and mortality. But we take a different approach to further this end. We previously suggested giving the vaccine to selected localized hot zones of infection where mortality is high and hospitals are reaching capacity. Vaccine would be administered in rapid sequence to tiers 1a-4 of the National Academies’ prioritization framework.
Within the hot zone there is no moral dilemma regarding which group gets the vaccine — everyone receives it. The only exclusions would be those with history of severe allergic reactions, immunocompromised patients, age <16, pregnant or lactating mothers (as dictated by the Pfizer phase III trial and the FDA evaluation) and those opposed to receiving a vaccine.
For mid-late January 2021 or later, we now suggest a dual approach. Each state should proceed with giving vaccines to either essential workers or to individual high-risk people and, also, give vaccine to one local hot zone where hospital and ICU capacity are high. The vaccine will not be effective for those already in the hospital but may prevent the progression of COVID-19 infection from the early first phase or incubation period from advancing to the more advanced stages that include respiratory infection (pneumonia) or cytokine surge. Blanketing the local community will have the added advantage of potentially breaking the chain of transmission by vaccinating those local spreaders who circle around the most susceptible.
We recognize that the extent to which the current COVID-19 vaccines prevent infection, as opposed to clinical illness, remains uncertain. But it seems probable that they will at least reduce viral loads among individuals who are super-spreaders. If that occurs, then we should see some impact on transmission. Deploying this strategy in hot zones would provide valuable early data on the vaccines’ real-world effectiveness in reining in the pandemic.
We feel that our approach would have a larger effect on reducing morbidity and mortality by focusing on breaking the chain of transmission and thereby reducing the stress on the healthcare system. Giving vaccine to those 65 and older (or other high-risk categories) protects high-risk individuals, but they are mostly not responsible for the virus’s spread.
Our approach includes the small community around the high-risk individuals. In under two months we would know: how the vaccine breaks the chain of transmission; how much test positivity is reduced 7 days after the first dose; how much is hospitalization reduced 7 days after the booster shot; and, what do the positivity and hospitalizations rate look like if only 40% of people take the booster shot at one hot zone compared to the curves in another hot zone where 90% of people take the booster shot.
Understandably, during a pandemic, it is hard to organize and collect useful information. But targeting local hot zones lends itself to just that, viz., the collection of useful data. This would also include comparing vaccines against each other. Our approach allows entry of vaccine 2, 3, and 4 to the market by giving each vaccine its own two or three hot zones.
What about states that do not have clearly identified local hot zones? They should follow the dictum of the great Wayne Gretzky: “Skate to the puck.” By that we mean, target the places that are likely to become hot zones in the near future. Officials should remember that hot zones come and go, and there is inherent delay between targeting an area and then implementing the vaccination program.
The CDC has given the governors the final responsibility for prioritizing vaccine distribution. There still may be time to modify the current prioritization plans and to consider and implement another approach.
Daniel Teres, MD, is a clinical instructor in public health and community medicine at Tufts University School of Medicine in Boston. Martin A. Strosberg, PhD, is emeritus professor of political science, healthcare policy, and bioethics at Union College in Schenectady, New York. Martin A. Strosberg, MPH, PhD, is emeritus professor of healthcare policy, and bioethics at Union College in Schenectady, New York.
Last Updated December 28, 2020
