California health officials are loosening guidelines on who can be vaccinated against coronavirus now – potentially speeding up the pace of vaccinations and, at the same time, opening the door to ethical and logistical questions about how to do this in a fair and orderly manner.
The change came as public health experts and others debated how to get more “injections” in California and across the country, as vaccinations continued to fall short of expectations this week and an increase in cases and deaths threatened to overwhelm hospitals.
On Friday, President-elect Joe Biden’s transition team said he would release almost all available vaccine doses after taking office on January 20, ending the current federal strategy of withholding half the doses to ensure that people can have the second injection later. The announcement of the plan designed to “ensure that Americans who need it most get paid as quickly as possible” came after a group of governors, including Gavin Newsom of California, pleaded with federal authorities to release more vaccines.
Still, it was unclear how distributing more doses to the states would help solve the problem, as they have failed to place many of the doses they have received so far in people’s arms.
California administered just over 652,000 doses of the vaccine, about 32% of the approximately 2.1 million doses it received.
The California Department of Public Health released recommendations on Thursday allowing local health departments and health providers to vaccinate all health professionals in the first group, known as Phase 1a, rather than vaccinating in order of workers’ exposure risk . The recommendation also allows local health departments and providers to start vaccinating residents in the subsequent group, Phase 1b – a much larger group of essential workers and the elderly – as long as they have already made vaccines available to everyone in Phase 1a they wish. This could help to alleviate the problem of doses that are not used if some health professionals refuse vaccination.
Newsom said on Friday that the new guidelines will give healthcare professionals more “common sense” criteria for, for example, offering extra doses to an elderly person if someone decides not to take them or if enough people do not show up to be vaccinated.
“We will see faster administration,” said Newsom. “You will see this.”
Santa Clara County officials said on Friday they would start implementing the recommendations.
“It was only in the last 48 hours that we received confirmation (from the state) that we can offer vaccination to everyone in Phase 1a,” said Public Health Officer of Santa Clara, Dr. Sara Cody, during a press conference. “Before that, we changed level by level, which makes it more complex. So, I think now we can go faster, and this is great for everyone ”.
Phase 1a includes three levels of health professionals, classified by their risk of exposure to COVID-19. The first level includes people working in acute care hospitals and nursing homes, the second level includes people working in emergency care and primary care clinics, and the third level includes dentists and pharmacists.
“We’re trying to get through 1st as quickly as possible,” said Cody. “Once we are confident that people qualified for Phase 1a have access to their appointment and have made it, we will be able to transition to Phase 1b.
The state that allows Phase 1b to start may be getting ahead of where Bay Area counties and health providers are currently, as most are still vaccinating Phase 1a and do not anticipate starting Phase 1b until the end January or early February. But it gives local health authorities flexibility to move on to the next group after offering the vaccine to all health professionals who want it.
“We cannot allow the perfect to be the enemy of the good,” said Dr. Art Reingold, a professor at the UC Berkeley School of Public Health and co-chair of the state committee that analyzes the safety and efficacy of coronavirus vaccines. “The question of, ‘When is it okay when you haven’t finished one phase to start offering vaccines to people in other phases?’ it’s complicated. But it is important that we do this, as long as we are not left without a vaccine for the high priority groups in the previous phases. “
The state has not defined who will be in Phase 1b, but will likely include 15 million essential workers and elderly residents. The first level of the phase is likely to be 8.5 million teachers and caregivers of children, food and agriculture workers, emergency service workers and people aged 75 and over. The second level will be 6.5 million transport workers and critical infrastructure, and people aged 65 to 74, in addition to incarcerated and homeless residents. It is unclear whether the two levels will be vaccinated simultaneously or whether providers will have to move on.
As vaccines are made available to more people, this opens the door to many more logistical and ethical issues. The initial launch was already difficult and fragmented, and moving quickly to the next much larger groups could mean that it will become even more difficult to control. In Phase 1a, most people are being vaccinated by their health employer, county health department, or federal pharmacy program. Phase 1b will be more complicated.
Will a teacher, for example, be vaccinated by the school district where he works, his own health care provider or the county where he lives? Will vaccinators ask for identification to verify people’s age or proof of occupation, or will they trust the honor system?
And how to prioritize who should go next is up for debate. Dr. Bob Wachter, head of the UCSF medical department, proposed that, once all health professionals and people over 55 are vaccinated, a lottery system determines when the remaining millions of Americans will be vaccinated.
“In the past two weeks, the distribution of vaccines in several of the main healthcare systems – which rely on world-class computer systems and have robust human resources departments that can track their employees – has evolved into line leaps, cheating and protests loud about who goes first, ”Dr. Ashish Jha of Wachter and Brown University wrote in an opinion piece in the New York Times on Thursday. “If vaccinating a few thousand health professionals is so complicated, we can only imagine the chaos that is to come as we try to vaccinate a few hundred million Americans. … Few would love the idea, but it would be fair and apolitical, and people would know that their number will be called sometime in the coming months. “
Catherine Ho is a writer for the San Francisco Chronicle. Email: [email protected] Twitter: @Cat_Ho