US plan to expand access to Covid-19 vaccine likely creates new debacles

AHealth officials across the country are fighting to get Covid-19 vaccination programs up and running, outgoing Health and Human Services Secretary Alex Azar threw a new wrench into the work on Tuesday, asking states to ” immediately expand priority access to tens of millions more. .

But it will be several months before there are enough vaccines available to meet this type of demand. The move virtually guarantees that the current narrative around vaccine rollout – it’s too slow – will change, but not in a positive direction: Biden’s incoming administration will likely face a wave of complaints about long queues, unsuccessful efforts to find vaccine supplies, and an inequitable distribution system as he tries to deliver on his promise to see 100 million doses of vaccine delivered in the first 100 days of the new president’s term.

Azar’s new instructions put 152 million people – about half of the country’s adult population – at the top of the vaccination line. But Operation Warp Speed, the U.S. effort to speed up vaccine development and distribution, currently estimates it will take until the end of March before it has 200 million doses to distribute. While these doses can be manufactured and shipped seamlessly, that’s only enough for 100 million people, given that currently licensed vaccines each require two doses.

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Azar reported on Tuesday that 38 million doses of the vaccine have been made available to states so far.

The new prioritization system pushes all people 65 years and older, as well as people 16 years and older with a high-risk health condition, to the front of the immunization line, where they join the agents. health care providers, residents and nursing home staff. (The Centers for Disease Control and Prevention’s list of health problems that put people at high risk for serious Covid infection is here.)

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If states follow Azar’s instructions, a 24-year-old smoker who works from home would have the same vaccine priority status as a frail 85-year-old – and ahead of non-smoking teachers, municipal bus drivers, the meat packing plant. employees and other essential front-line workers that the CDC previously recommended should be vaccinated during phase 1b.

States, lacking sufficient federal funding and facing limited supplies, have struggled to complete immunization of people in phase 1a, which includes health workers as well as residents and staff of long-term care facilities – a population of around 24 million people. Federal officials believe efforts will become easier as supply becomes available, but to this day only 9.3 million people received their first dose of vaccine, according to the CDC.

The initial prioritization schedule was established by the Advisory Committee on Immunization Practices, an expert group that made recommendations to the CDC. ACIP planned to include essential front-line workers and adults 75 years and older in the second phase of vaccine deployment. There are about 49 million people in these two groups, a more manageable number in times of vaccine shortages.

By changing the prioritization schedule, Azar brought to the fore the people he wanted to see there in the first place. When ACIP recommended health workers and nursing home residents for phase 1a, it insisted that the first group be replaced by people 65 and over, STAT reported in November. But CDC director Robert Redfield had already approved the recommendation.

ACIP’s plan also had its critics, with some experts questioning how feasible it would be to require pharmacists or people working in an immunization clinic to determine who qualifies as an essential front-line worker.

“Who’s supposed to be the keeper of this?” I mean, you can’t go to Rite Aid and Walgreens and ask the pharmacist to be the gatekeeper, which is basically what you have to do, ”said Peter Hotez, co-director of the Texas Children’s Center for Vaccine Development. in an interview.

Hotez, who published an opinion piece in The Washington Post on Monday, calling for changes in the vaccination rollout, said the steps outlined by ACIP were too complex and were slowing down the program. “So my point is to throw them out at this point.”

Beth Bell, a professor of global health at the University of Washington who chaired a task force that developed the ACIP recommendations, expressed dismay at Azar’s instructions to states.

“We all want the most effective and efficient immunization program. But I’m very concerned that this approach… isn’t the best way to get us there, ”Bell said.

The outgoing HHS secretary blamed states for the slow deployment, saying some adhere so closely to prioritization schedules that they were not using their assigned doses. “The severe micromanagement of some states of this process has prevented vaccines from reaching more of the vulnerable population more quickly,” Azar said.

He also warned states that those who do not use up their doses quickly will see their supplies dwindle in the future. So far vaccine allocation has been strictly population based; From two weeks onwards, states that use up their doses quickly will receive a larger allowance.

But in two weeks, Azar won’t be the secretary of HHS, which means it’s unclear if the plan will hold up.

If states follow Azar’s instructions, efforts to protect essential front-line workers – people who cannot work from home and whose work puts them at greater risk of contracting Covid – will fall further back in time. the prioritization system.

“By opening things up… there would be efficiency gains, but there would be significant losses in terms of equity, racial justice and the ability to… prevent morbidity and mortality in a high risk group. Said Kristen Ehresmann, director of infectious disease epidemiology, prevention and control for the Minnesota Department of Health.

“You gain something and you lose some things,” she said. “And I think a lot of the things you lose are really important things.”

Saad Omer, director of the Institute of Global Health at Yale University, supported the focus on adults over 65. But Omer, who was on a National Academy of Medicine panel that recommended priority groups for vaccines and who worked on a priority schedule for the World Health Organization, said changing advice to this stadium will have a cost. State and local public health authorities will have to destroy some plans and write others.

“There has been a boost at the state level,” said Omer, who noted that these decisions should have been made months ago. “And all the community partners are completely confused.”

Azar also announced on Tuesday that Operation Warp Speed ​​would no longer hold back half of vaccine supplies, a move it took to ensure that when people need their booster doses, there is. has enough to give them a second matching vaccine within the allotted time. required – 21 days for the vaccine developed by Pfizer and BioNTech, and 28 days for the one developed by Moderna. Biden’s incoming administration had previously said it planned to cancel the policy.

Tom Frieden, former CDC director, was among those who criticized the initial decision to withhold the second dose. “You have to flood the area with the available vaccine, anticipating that the manufacturers won’t fail,” said Frieden, who is now president and CEO of the global health initiative Resolve to Save Lives.


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Jun Quentin

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