In an ideal world, there would be enough vaccines to inoculate everyone who wanted to get immunized against COVID-19. People would get their shots on a first come, first serve basis, we’d achieve herd immunity in a matter of months and COVID-19 would become a soon-distant memory.
But with some 240 million people over age 16 who need a COVID-19 vaccine (and two doses at that), and just over 42 million administered by early February, supply is far below demand, and will likely remain that way for months to come, despite vaccine makers pushing production lines as hard as they can.
As the U.S. works through the vaccine priority groups and begins to shift into ever larger populations in coming months, the pace of doses shipped could continue to outstrip the pace of administration. So far, the shots have been reserved primarily for health care workers, people living in long term care facilities, and those over 65. Some states have begun vaccinating essential workers like law enforcement officers, teachers and those who work in mass transit. But still, all of these groups are relatively easy to reach and vaccinate since they’re all well-defined.
The next big priority group, according to the Centers for Disease Control (CDC) includes people with underlying health conditions that make them more vulnerable to COVID-19. While many are connected to the health care system by virtue of their medical conditions, there are a substantial portion of these patients who aren’t seeing doctors or getting their medical problems addressed.
According to the CDC, up to 60% of Americans have chronic conditions, some of which put them at higher risk of developing COVID-19. And 44 million Americans have no health insurance, making them less likely to have regular access to health care. The CDC lists 12 conditions ranging from diabetes to chronic obstructive pulmonary disease, heart and kidney diseases, cancer and obesity that put people at higher risk of getting COVID-19 or having complications if they do. And there are other conditions like asthma, hypertension and many more for which they are still gathering data, but so far, those conditions too might heighten those risks.
Given that there continues to be a limited supply of doses, doctors and local health officials are bracing for gut-wrenching decisions about which patients to vaccinate first, with a potential nightmare scenario of cancer patients fighting with heart patients for scarce vaccines. Should someone with cancer undergoing chemotherapy get vaccinated before someone awaiting a liver transplant? Does someone with asthma have a higher risk of getting COVID-19 than someone with dementia? “No one wants to be on the committee that makes these allocations,” says Dr. Cameron Wolfe, associate professor of medicine in the division of infectious diseases at Duke University. Just over a decade ago, Wolfe was part of his hospital’s committee that determined how to distribute scarce H1N1 vaccines during that outbreak, and knows doctors and patients can make compelling arguments for nearly every patient. It’s a problem for which there is no right answer.
Daniella Levine Cava, mayor of Miami-Dade in Florida, is concerned about how her health officials will make those distribution decisions when the time comes, and hopes for more guidance either from the federal or state government. The governor of Florida has opened vaccination up to people over age 65 with health conditions, and that’s already caused confusion and anxiety among residents, since Cava says doses ear marked for this group are still limited. “We have a lot of people desperate in that category, and very worried, very anxious,” she says. “It will be complicated to determine eligibility. There are so many different categories—how do you determine and judge who is more at risk? I’m in favor of national uniformity…This is the kind of thing that cries out for predictability—the more predictability and clarity we can have, the better.”
State health departments are inclined to stay out of such granular decisions, for two reasons. First, there’s no universal solution that works for everybody, and any strategy they might choose to use to triage patients for vaccines would be criticized. Second, the more prescriptive states are about allocating vaccines, the longer the shots take to get into people’s arms, and the greater the chance that some are wasted as doctors try to parse through the policies and spend precious time making sure they’re complying with them.
“When we get to that population, our preference would be to have the decision made between the provider and the patient,” says Dr. Jinlene Chan, acting deputy secretary of public health services for the Maryland department of health. That, Chan says, would ensure that doctors, who have the most information about their individual patients, will be able to broadly stratify patients in terms of their COVID-19 risk. That risk boils down to two vulnerabilities: first, how much risk their patients have for getting infected in the first place, which takes into account where they live and the infection rates there, and their exposure to high-risk settings such as hospitals or public venues; and second, their risk for getting severely ill and potentially dying from COVID-19.
Balancing these risks will, indeed, likely fall to doctors, and, Wolfe says, the simplest strategies might be the most efficient. A starting point to avoid the ethical and medical tangle of comparing people with different conditions is to use age as the determining factor. Older people tend to have more health issues, and when they do, their conditions are generally more intense and severe than those experienced by younger people. And that’s especially the case with COVID-19, which hits elderly people harder. “If I can’t medically stand in front of two patients and separate their arguments, how do I break the tie in cases where there is a scarce resource?” he says. “Sometimes age is the easy delineator. If someone is hypertensive with a BMI of 30, but only 25, their risk is less than someone’s who is hypertensive with a BMI of 30 but age 64.”
And if age isn’t a tie breaker, practicality may rule the day—whoever is available and can get vaccinated sooner should get the shot.
But that layers the sticky question of access on top of sensitive triage issues. So far, doses have been funneled to hospitals, health clinics and other health care centers in order to reach the first priority group of health care workers. Yet 25% of the U.S. population doesn’t see a doctor regularly, according to a 2020 JAMA Internal Medicine study, much less have access to a hospital or clinic. As a result, many of these people have chronic conditions that aren’t treated at all, or, if they are, aren’t well controlled. Reaching this group of people, and making them comfortable with getting vaccinated, is a black box that public health officials haven’t quite decoded yet.
For now, hospitals and health systems are focusing on the lowest hanging fruit: their own patients. At least they have electronic medical records for these people, and can contact them to let them know when they become eligible for vaccination. Plus, they can mine the health records to triage them by COVID-19 risk and therefore vaccination priority. Between two patients with diabetes, for example, they can determine who has the less controlled blood sugar level and place that person higher on the list than someone whose disease is better managed.
At UCLA Health, this system generates an invitation list based on a risk score that weaves in not just the patient’s medical condition, but data from social determinants as well, such as poverty, income, education, housing, and geographic residence. These are part of the CDC’s Social Vulnerability Index, originally created to identify medically vulnerable people and target health resources to them after natural disasters such as hurricanes or infectious disease outbreaks like COVID-19. The index includes census data on 15 factors that help to stratify people’s overall health risk by acknowledging that some aspects of a person’s health status has nothing to do with his or her medical condition but rather living conditions, which in turn drives their access, or lack thereof, to health services.
“To identify our most vulnerable patients, we have an elaborate point system that incorporates age, clinical and social risk data from the medical record to risk stratify our patients,” says Dr. Eve Glazier, president of the faculty practice group at UCLA Health and an associate clinical professor at the David Geffen UCLA School of Medicine. The formula weighs factors such as age, and, say, whether a cancer patient is in remission or currently undergoing chemotherapy. Glazier says there are 120,000 patients over age 65 with chronic health conditions who are being prioritized over those over age 65 without health issues. “We are really trying to avoid the Ticketmaster free-for-all approach,” she says. “The first-come-first-serve strategy is antithetical to any approach that we would consider is fair and equitable.”
At Orlando Health, a private health system in central Florida, officials formed a committee to come up with broad guidelines for helping doctors navigate the difficult decisions they might have to make as demand for vaccine doses continues to outstrip supply. “We recently received 2,000 doses for medically vulnerable patients we are serving here,” says Dr. George Ralls, senior vice president and chief medical officer of Orlando Health. “We have 400,000 people over 65 in our network who qualify for vaccination. So 2,000 doesn’t go very far. We’re trying to find the riskiest patients and trying to give them the vaccine first.”Their system starts with age: “We fine-tuned it to pull people out who we thought were at higher risk, starting with age as the main differentiator,” Ralls says. “We stratified the group of people aged 65-70, pulled up patients with certain diseases and then looked at people aged 60-65, and worked through it like that” Patients with chronic conditions who aren’t able to get vaccinated if there aren’t enough doses in one round of vaccinations will be next in line and notified when more vaccines are shipped. “It’s going to go like that for a while,” he says. “As we continue to get small allocations of vaccine, we will apply them the best we can to patients who fit the highest risk profile.”
What’s becoming clear is that “highest risk” won’t mean the same from hospital to hospital, or county to county, or state to state. And that can lead to misunderstanding and frustration, as people with the same health condition, living in the same part of the country, might not be able to get their shots at the same time. UCLA Health is trying to head off any potential conflict by sending regular emails to their patient population outlining the system’s triaging plan, how they came up with it, and which people are getting vaccinated at any given time.
Still, some patients desperate for a shot are opting to game the system and find a hospital— even if it isn’t the one at which they are being treated—or a state-run vaccination clinic, that might get them vaccinated sooner. And that’s fine, say most doctors and public health officials, who at this point are more focused on ensuring that as many people get their shots as quickly as possible than establishing and policing complex priority policies. “We’re encouraging our patients to get the vaccine where they can get it first,” says Glazier of UCLA. “Los Angeles county isn’t using a risk stratification at their mega vaccination sites, and we are very candid about the model we are using given the amount of doses we have. If they can get vaccinated at Dodger Stadium, then we encourage them to do that.” Glazier says the UCLA system will record that vaccination in the patient’s health record and drop them from future COVID-19 vaccine invitation lists.
The challenge experts are worried about is figuring out how to help people with chronic health conditions who aren’t linked to a network like UCLA, Duke or Orlando Health—without further burdening the rollout. Not only are they harder to reach, but it will be harder for vaccinators to validate that they qualify for a shot. It’s not likely that states will require letters from doctors or other verification of their condition, since that adds a layer of bureaucracy that will further slow the push of vaccines into people’s arms. “Any time you have to prove something, that gets awkward at the point of service,” says Ralls. “I don’t know how that is going to play out, and haven’t heard anything about a plan for public distribution other than people saying they have a medical condition.” That’s a hurdle pharmacies, which are expecting to be the next large dispenser of vaccines to the public, will soon have to face as more people with these conditions turn to their local pharmacies for shots.
In Maryland, Chan says the state is working with community leaders to reach more people who aren’t connected to a doctor or health system, regardless of whether they have an underlying health condition, to make sure more residents get vaccinated. They are currently jumping off of their existing vaccination data to figure out where people aren’t getting vaccinated, and to the extent possible, determine how many people with existing health conditions might live in those areas so officials can start directing more doses there. “You can’t look at somebody and know whether they have an underlying condition or not,” she says. “So we’re working with community organizations and they’re giving us feedback about the degree of outreach we’ll need, and how we can almost walk the community to actually identify and find those individuals.”
Such efforts will take extra effort and resources, but are an integral part of the vaccine rollout—which, to date, haven’t been the focus of the COVID-19 vaccine campaign. “We’re trying to play catch up because most of our efforts so far in COVID-19 have focused on making vaccines and testing them, and not so much on delivery,” says Dr. Daniel Hoft, director of the St. Louis University center for vaccine development. Thinking more deeply about the mechanics of the rollout will be crucial to making sure that the next priority group stepping up to get vaccinated gets their shots when they need them, where they need them.