POST 91. December 15, 2020. CORONAVIRUS. “UPMC will first give (vaccination) priority to those in critical jobs. That includes a range of people working in critical units, from workers cleaning the emergency room and registering patients to doctors and nurses.. “Finally, if needed, UPMC will use a lottery to select who will be scheduled first.”

“It sounds alarming at first, neither vaccine is aimed at preventing you from getting an infection.

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“The Food and Drug Administration authorized Pfizer Inc. and BioNTech SE’s Covid-19 vaccine for emergency use—the first to get such a green light—late Friday, setting in motion UPMC’s push to notify individual employees who will get the opportunity to receive the earliest shots. By Monday, the first UPMC health-care workers finally had an answer to who would be offered the vaccine.

UPMC didn’t have enough to go around. On Monday it received 975 doses at its Children’s Hospital of Pittsburgh and expected another 1,950 doses to arrive Tuesday for its flagship hospital, UPMC Presbyterian in Pittsburgh. A team including doctors, pharmacists and an ethicist had agreed only days earlier how they would pick those to go first.

“It is a very difficult thing for us to all feel confident that what we’ve done is fair and effective,” said Graham Snyder, UPMC’s medical director of infection prevention and hospital epidemiology.

Hospitals are among the first to confront the ethical, legal and practical challenges of coordinating a mass vaccination campaign among employees as shots become available. Federal advisers also identified workers in public transit, food supply and education as high priority, after health-care workers and vulnerable residents in nursing homes…

Divvying up the vaccine isn’t the first time hospitals have been forced to ration critical care and supplies in the pandemic. Surgeons have decided which procedures to put off and which can’t wait as hospitals become swamped with Covid-19 patients. Limited early supply of the antiviral drug remdesivir led to federal distribution of the drug to states, which then awarded scarce supplies to hospitals.

UPMC for six weeks used a weighted lottery to decide which Covid-19 patients would get the drug. “There were many days we did not have enough,” said Doug White, a doctor and ethicist at the University of Pittsburgh. “It’s incredibly sad to not have enough,” he said.

The UPMC weighted lottery for remdesivir slightly boosted chances for patients from economically distressed neighborhoods to help alleviate disparities and reach people hit harder by the pandemic.

UPMC Presbyterian in Pittsburgh is expected to receive 1,950 doses of the vaccine on Tuesday.

For the vaccine, UPMC is expected to receive nearly 30,000 doses by the end of December. UPMC employs about 90,000 people, of which about 60,000 are health-care workers.

Of those, UPMC will first give priority to those in critical jobs. That includes a range of people working in critical units, from workers cleaning the emergency room and registering patients to doctors and nurses, Dr. White said. Those jobs keep units running, he said, but the hospital also sought to target all occupations to help ensure equal access to the vaccine and to address racial disparities in the pandemic.

Covid-19 has disproportionately hit health-care workers who are people of color, who account for about 40% of the workforce but 53% of Covid-19 cases, an analysis by the Kaiser Family Foundation shows. Black and Hispanic people accounted for a larger share of health-care employees in housekeeping, cafeterias, security, clergy and other support jobs, the analysis found.

That disproportionate impact shouldn’t be overlooked with distribution of the vaccine, which would further exacerbate disparities, said Dayna Bowen Matthew, dean of the George Washington University Law School, whose work focuses on racial disparities in health care. “The way we distribute this vaccine could either decrease or increase existing inequalities,” she said.

To pare the list down further, UPMC will give priority to employees who have the highest risk of severe disease, but this requires information about workers’ health, which employers generally can’t request.

UPMC will ask workers to confirm they have a high-risk condition, such as heart disease, but the system won’t ask for specifics. UPMC also won’t verify it is true.

“It’s an honor system,” said Dr. Snyder. “Could somebody lie and say they do, just to get ahead of the line? Yes. But I have a lot of faith in our health-care workers to answer that honestly.”

Finally, if needed, UPMC will use a lottery to select who will be scheduled first.” (A)

“Hospitals in general are advised to target the members of their workforces at highest risk, but the institutions are left on their own to decide exactly who that will be, Colin Milligan, a spokesperson for the American Hospital Association, said by email.

“It is clear that the hospitals will not receive enough in the first weeks to vaccinate everyone on their staff, so decisions had to be made,” Milligan wrote.

At Intermountain Healthcare in Salt Lake City, the first shots will go to staff members “with the highest risk of contact with Covid-positive patients or their waste,” said Dr. Kristin Dascomb, the medical director of infection prevention and employee health. Within that group, managers will determine which caregivers are first in line.

At UW Medicine in Seattle, which includes Harborview Medical Center, an early plan called for high-risk staff members to be selected randomly to receive first doses, said Dr. Shireesha Dhanireddy, medical director of the infectious disease clinic. But the University of Washington hospital system expects to receive enough doses to vaccinate everyone in the high-risk tier within two weeks, so randomization isn’t necessary — for now.

“We are allowing people to schedule themselves,” Dhanireddy said, and encouraging staffers to be vaccinated near the end of their workweeks in case they have reactions to the vaccine.

Trial results have shown that the shots frequently produce side effects that, while not debilitating, could cause symptoms that might keep someone home for a day or two, such as fever, muscle aches or fatigue.

Noting that guidelines call for no more than 25 percent of any unit to be vaccinated at once, Sifri, of UVA Health, said, “We want to make sure that not everybody has the vaccine on the same day so that if there are some side effects, we don’t end up being short-staffed.”

Once the initial 3,000 doses are distributed at UVA Health, the hospital plans to rely on what Sifri described as “a very strong honor code” to allow staff members to decide where they should be in line. They’ve been asked to consider professional factors, like the type of work they do, as well as personal risks, such as age or underlying conditions, like diabetes.

“We’re going to ask team members, using the honor code, to determine what their risk is for Covid and to determine whether they need to have an early vaccine sign-up time or a later vaccine sign-up time,” he said.

The plan was chosen after health care staff members soundly rejected other options. For example, few favored a proposal to allocate doses via a lottery, like the chaotic birthday-based system depicted in the 2011 pandemic horror film “Contagion.”

Hospital officials also stressed that they are trying to devise distribution plans that ensure that vaccines are allocated equitably among health care workers, including the social, racial and ethnic groups that have been disproportionately harmed by Covid-19 infections. That requires thinking beyond front-line doctors and nurses.

At UVA Health, for example, one of the first groups invited to get shots will be 17 workers whose job is to clean rooms in the special pathogens unit where severe Covid-19 cases are treated.

“We acknowledge that everybody is at risk for Covid, everybody is deserving of a vaccine,” Sifri said.

In many cases, it will be clear who should go first. For instance, although Dhanireddy is an infectious disease doctor who consults on Covid-19 cases, she is happy to wait.

“I wouldn’t put myself in the first group at all,” she said. “I think that we need to protect our staff that are really right there with them most of the day — and that’s not me.”

But hospitals must remain vigilant about relying on workers to prioritize their own access, Dhanireddy said. “Sometimes, self-selection works more for self-advocacy,” she said. “It’s great that some individuals say they would defer to others, but sometimes that’s not actually the case.”

For some health care workers, not being first in line is fine. Because the vaccine is initially authorized only for emergency use, hospitals won’t require employees to be inoculated as part of the first round. Between 70 percent and 75 percent of health care staff at UVA Health and Intermountain Health would accept a Covid-19 vaccine, internal surveys showed. The rest are unsure — or unwilling.” (B)

“…Initially, supply will be very limited, meaning states have to make difficult decisions about who should get the first allocations.

To help guide these decisions, the CDC’s Advisory Committee on Immunization Practices (ACIP) released an interim recommendation on December 1 for the highest priority group (“Phase 1a”) to include health care workers (HCWs) and long-term care (LTC) residents; we estimate that this populations together represents about 17.6 million people.  ACIP also provided further guidance regarding sub-prioritization within these groups. While ACIP has yet to finalize recommendations on subsequent prioritization (expected soon), according to presentations and materials provided in recent ACIP meetings, the committee is likely to recommend that (non-health care) essential workers be the next priority group (“Phase 1b”), followed by persons age 65 and older and those with conditions that place them at high risk for severe illness from COVID-19 (“Phase 1c”).  These groups are much larger, which will likely make the next stages of prioritization much more difficult given that supply will still be limited (according to ACIP, there are an estimated 87 million essential workers, 53+ million seniors and more than 100 million individuals with high-risk medical conditions).

States look to and often follow ACIP guidance, but the federal recommendations are not binding and some states may choose to depart from the prioritization sequence outlined by ACIP, which could mean that initial access will depend on where people live. To see where states stand on prioritization, we collected and reviewed all statements and releases from state officials that reference the criteria they will use to prioritize vaccines during Phase 1 (these prioritization criteria build on and add detail to states’ initial vaccine distribution plans, which we already examined here). We did not assess how individual facilities (such as hospitals) will allocate vaccines once they arrive at their doors….

Our review finds that almost all states hew to ACIP regarding initial allocations of a COVID-19 vaccine (Phase 1a) and have looked specifically at ACIP for decision-making.  Beyond that, a good number of states are still developing criteria for Phases 1b-c.  Given that ACIP has yet to issue recommendations for these phases, states may be waiting for further guidance. However, based on ACIP’s preliminary framework, there are some differences between state priorities and where ACIP is likely to land, primarily related to the prioritization of seniors and/or those with high risk medical conditions relative to non-health essential workers. Moreover, these later prioritization decisions are likely to be more difficult given the large numbers of people in these groups and continued limits on vaccine supply.” (C)

“It sounds alarming at first, neither vaccine is aimed at preventing you from getting an infection.

“These COVID vaccines are preventing clinical disease, we don’t know if they prevent transmission,” Dr. Beyrer said.

It’s important to know the difference between infection and disease. Dr. Moss said just because you are infected or have transmitted coronavirus doesn’t mean you get sick.

“So you know, everyone who gets disease has an infection, and the infection causes the disease,” Dr. Moss said. “But not everyone who is infected has the disease.”

That is where Moderna and Pfizer have aimed their vaccines: preventing people from getting sick.

“What’s being measured in the trials is whether or not they prevent disease, mild, moderate and severe disease,” Dr. Moss explained.

This isn’t rare for vaccines. Dr. Moss said most vaccines don’t actually stop a virus from entering your body.

“That requires a really strong kind of immune response to prevent infection,” he said.

Simply put, we don’t know if these vaccines prevent infection, but we do know their primary job is to stop the virus from becoming a disease or lessen the disease.” (D)

Doctor, Did You Wash Your Hands?®  at  http://doctordidyouwashyourhands.com/

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(A)Covid-19 Vaccine’s Initial Scarcity Leads to Tough Choices for Hospitals, By Melanie Evans, https://www.wsj.com/articles/covid-19-vaccines-initial-scarcity-leads-to-tough-choices-for-hospitals-11607989321

(B) Hospitals scramble to prioritize Covid vaccine for their workers. Who gets them first? By JoNel Aleccia, https://www.nbcnews.com/health/health-news/hospitals-scramble-prioritize-covid-vaccine-their-workers-who-gets-them-n1251067

(C) How are States Prioritizing Who Will Get the COVID-19 Vaccine First?, by Jennifer Kates, Josh Michaud, and Jennifer Tolbert, https://www.kff.org/policy-watch/how-are-states-prioritizing-who-will-get-the-covid-19-vaccine-first/

(D) VERIFY: Moderna, Pfizer vaccines may prevent disease, but not infection, by Matt Gregory, https://www.wusa9.com/article/news/verify/verify-moderna-and-pfizer-vaccines-may-prevent-disease-but-not-infection/65-f65cb7ee-24dc-48d0-bc08-8cfb3423a3b6

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