POST 92. December 17, 2020. CORONAVIRUS. “..each state — and each hospital system — has come up with its own (vaccination) plan and priorities. The result has been a sometimes confusing constellation of rules and groupings that has left health care workers wondering where they stand.” — (July 4th Trump appointee email “…we need to establish herd, and it only comes about allowing the non-high risk groups expose themselves to the virus. PERIOD,”)

“In the scramble to vaccinate millions of health workers, difficult choices about who comes first — and who must wait — have started to surface. So far, the effort is concentrated in hospitals. Workers treating Covid-19 patients in intensive care units and in emergency departments have in recent days been beaming symbols of the virus’s demise.

But there are roughly 21 million health care workers in the United States, making up one of the country’s largest industries, and vaccinating everybody in the first wave would be impossible. That has left entire categories of workers — people who are also at risk for infection — wondering about their place in line…

There are broad gray areas, he said: primary care doctors in areas with high infection rates, workers who handle bodies, firefighters who respond to 911 calls, dentists, pathologists who handle coronavirus samples in labs, hospice workers, chaplains…

These are hard choices and will become even harder as the vaccine becomes more widely available for the general public and states begin wrestling with the question of who is an essential worker…

The Centers for Disease Control and Prevention has laid out categories but they are broad, so each state — and each hospital system — has come up with its own plan and priorities. The result has been a sometimes confusing constellation of rules and groupings that has left health care workers like Dr. Baker — as well as professional societies of groups such as pathologists, dentists and medical examiners — wondering where they stand.” (A)

“As frontline healthcare workers around the country receive the first doses of a Covid-19 vaccine, mental health providers worry they may not be included, even though they are often working in hospitals and clinics and may be exposed to Covid-19. The crux of the matter rests with how individual states end up interpreting broad federal guidelines for vaccine distribution. These states will be the ultimate arbiters of who are “essential workers” that qualifies for early inoculations. A CDC committee approved guidance to states in early December that vaccines should go to health care workers “who have the potential for direct or indirect exposure to patients or infectious materials” and to “residents of long-term care facilities.”

Mental health groups worry that wording leaves too much room for interpretation. Without more specific directions, “we would be at the mercy of each state to recognize the importance of mental health and substance use providers,” Reyna Taylor, the head of policy at the National Council for Behavioral Health, said in an email…

Mental health providers should be part of the first group of recipients of these vaccines because they face unique risks treating patients in person, Taylor said. Many take walk-in appointments and provide primary care. In mental health emergencies, she said, providers may have to treat someone before they can learn whether the person has Covid-19 or not. “When you’re providing services to someone who’s in a mental health or substance use crisis, you’re not thinking about Covid-19, you’re thinking about saving someone’s life from that crisis,” she said. Even if they aren’t in crisis, “the nature of serious mental illness and substance use disorder [means] there is at times a lack of awareness of their symptoms, including the symptoms of Covid-19,” she added in an email, and as a result providers “have to treat everyone who walks in as if they are Covid-19 positive.”..

There are not enough vaccine doses to give all the eligible healthcare workers and long-term care residents of the first group recommended by the CDC. That will force states to decide who in the priority group should be vaccinated and who should wait until more vaccine doses are manufactured…

Whether mental healthcare is part of the first subgroup getting the vaccine will be up to each state’s interpretation of the guidelines, Bahta said. Some may decide that mental health and substance use providers belong in the first phase, “Phase 1a,” while others might group them in the “1b” category, which the committee has not yet voted on but may include essential workers like bus drivers, teachers and police officers. “There will be a multitude of variations on how this plays out,” she said in an email…” (B)

“Here’s a look at what to expect from the coming coronavirus vaccination campaign.

Who can get a vaccine and when?

December

Who might get vaccinated: Health care workers and nursing home residents

December is a month for some big decisions. The US Centers for Disease Control and Prevention’s Advisory Committee for Immunization Practices has voted to recommend that 21 million frontline health care workers and support staff and 3 million residents of long-term care facilities who have been hardest hit by the pandemic be in the first group.

Health care workers and long-term care facility residents should get Covid-19 vaccine first, CDC vaccine advisers say

It will be easiest to vaccinate these groups — they’re already in institutional settings and the nursing home residents can get vaccinated at the same time their caregivers are being immunized….

January

Who might get vaccinated: More health care workers, other essential workers like emergency medical technicians, firefighters and police

If two or more vaccines get approved by the FDA, January might be when discussion really starts on who can get vaccinated and when….

Several groups of independent experts have weighed in on how to allocate vaccines, including the National Academies of Science, Engineering and Medicine and Johns Hopkins University.

They’ve all laid out basic principles that include protecting the country’s health care system, protecting the most vulnerable people, controlling the spread of the virus and being equitable across society.

ACIP will need to meet to decide on the details off all these phases.

January might include some of the rest of Phase 1 of a four-phase vaccine rollout.

Phase 1b is roughed out to include essential workers, including emergency medical technicians, as well as frontline workers at very high risk of infection, such as food workers. This phase may also include older adults living in congregate settings or crowded conditions.

There’s a also a proposed Phase 1c, which might include people of all ages with underlying conditions such as diabetes and kidney disease who are at significantly higher risk of dying or getting severely ill from Covid-19.

February

Who might get vaccinated: More essential workers and high-risk adults

By February, states may have hit their stride on vaccinating residents. Vaccination campaigns may move beyond hospitals and nursing homes, rehabilitation centers and other such facilities to pharmacies and medical practices…

March

It’s possible that the US will still be in Phase 1 of vaccination in March, simply because of the sheer numbers involved. Anyone healthy and under 65 who is not an essential or high-risk worker would not be thinking about vaccination yet.

April

If more vaccines have been approved and brought online, it’s possible Phase 2 of vaccination could begin by now.

This group has not been decided yet, but Phase 2 might include K-12 teachers and staff and other child care workers, as well as other critical workers such as retail workers and transportation workers. This group could also include people in homeless shelters and all people over 65 who were not already included in phase 1…

May

Young adults and children would have to wait until Phase 3 and under other scenarios that’s likely to be May at the soonest — perhaps June or later, depending on what ACIP decides, what the vaccine supply looks like and how smoothly distribution is going…

Which vaccine should I get?

At first there will be little choice — both Pfizer and Moderna are providing a new type of immunization called an mRNA vaccine. It’s considered especially safe because it does not use a whole virus — just a piece of genetic material — and both seem especially effective, providing 95% protection against symptomatic disease.

What’s not known is how long that protection might last, whether either vaccine protects against asymptomatic disease and whether either stops people from spreading the virus to others.

Vaccines coming later might offer harder choices. AstraZeneca’s vaccine uses what’s called a replication deficient virus to deliver a piece of genetic material from the coronavirus. So does Johnson & Johnson’s vaccine. There’s not a lot of safety data about these vaccines yet, and no evidence the viral vectors could be harmful. Nonetheless, some doctors may be reluctant to offer them to patients with compromised immune systems, including those with rheumatoid arthritis or multiple sclerosis who are taking immune-suppressing drugs; pregnant women; people taking certain cancer treatments and others..” (C)

“In coming days, squads of CVS and Walgreens employees, clad in protective gear and carrying small coolers, will begin to arrive at tens of thousands of nursing homes and assisted-living facilities to vaccinate staff and residents against the coronavirus.

It promises to be a crucial milestone in America’s battle against a pandemic that has inflicted especially severe carnage on nursing homes. At least 106,000 residents and staff of long-term care facilities have died from the virus, accounting for 38 percent of the country’s Covid-related fatalities.

But even before it begins, the mass-vaccination campaign is facing serious obstacles that are worrying nursing home executives, industry watchdogs, elder-care lawyers and medical experts. They expect nursing homes to be the most challenging front in the mission to vaccinate Americans.

Some residents and staff are balking at taking the vaccine. Short-staffed facilities are concerned about workers calling in sick with side effects, straining resources just as some frail residents are likely to experience fever and fatigue from the shot. Most nursing home employees work in shifts; will it be possible to vaccinate everyone over the course of just a few visits from CVS and Walgreens?

The virus has devastated residents and staff members in more than 28,000 long-term care facilities across the country.

While some states began vaccinations in nursing homes this week, the broader nationwide effort will start over the next few days. And there remains widespread confusion about a key element: how nursing homes will get consent to vaccinate residents who aren’t able to make their own medical decisions. A CVS executive said such residents’ legal representatives will be able to provide consent to nursing homes electronically or over the phone, but officials at multiple large nursing home chains said they weren’t aware of that.

If residents or their representatives haven’t given consent before CVS or Walgreens employees show up, it is not clear whether or when they will have another chance to be inoculated.

“Given the pace of this rollout, I am very concerned that nursing facilities won’t have the time or capacity to really explain the vaccine to residents and their families,” said Nicole Howell, a state-funded ombudsman in California whose office works with 29,000 long-term care residents.

Because of the large number of facilities they must visit, CVS and Walgreens only have the capacity to go to each location two or three times. The Pfizer and Moderna vaccines both require two doses, separated by a few weeks, which means that at most nursing homes, all staff and residents will have to receive their shots on the same days…

But the more employees who get the vaccine, the more who are likely to experience side effects — and that could cause more problems.

“If even as little as 10 percent of your staff calls off the next day — while at the same time all of the residents are irritated, upset and having adverse effects — you’ve created a perfect storm,” said Chad Worz, chief executive of the American Society of Consultant Pharmacists, which represents pharmacies that serve long-term care providers.

There is no federal requirement for people to give consent before getting vaccinated, but it is standard practice and is often needed for billing purposes. States have different requirements about how medical consent can be given and what information needs to be provided to the person who is consenting. The Centers for Disease Control and Prevention’s guidance is that residents or their representatives should receive a fact sheet about the coronavirus vaccine and then consent to receiving it.

The task of getting consent is not always straightforward at nursing homes. Many residents, like those with dementia, aren’t capable of giving it on their own. Instead, nursing homes need to get the permission of their family members or other legal representatives.

CVS and Walgreens have created paper and digital consent forms that nursing homes can use. Consent must be given in advance; the pharmacies need to know how many doses of the vaccine, which must be kept very cold, to bring with them.”  (D)

“A top Trump appointee repeatedly urged top health officials to adopt a “herd immunity” approach to Covid-19 and allow millions of Americans to be infected by the virus, according to internal emails obtained by a House watchdog and shared with POLITICO.

“There is no other way, we need to establish herd, and it only comes about allowing the non-high risk groups expose themselves to the virus. PERIOD,” then-science adviser Paul Alexander wrote on July 4 to his boss, Health and Human Services assistant secretary for public affairs Michael Caputo, and six other senior officials.

“Infants, kids, teens, young people, young adults, middle aged with no conditions etc. have zero to little risk….so we use them to develop herd…we want them infected…” Alexander added.

“[I]t may be that it will be best if we open up and flood the zone and let the kids and young folk get infected” in order to get “natural immunity…natural exposure,” Alexander wrote on July 24 to Food and Drug Administration Commissioner Stephen Hahn, Caputo and eight other senior officials. Caputo subsequently asked Alexander to research the idea, according to emails obtained by the House Oversight Committee’s select subcommittee on coronavirus.

Alexander also argued that colleges should stay open to allow Covid-19 infections to spread, lamenting in a July 27 email to Centers for Disease Control and Prevention Director Robert Redfield that “we essentially took off the battlefield the most potent weapon we had…younger healthy people, children, teens, young people who we needed to fastly [sic] infect themselves, spread it around, develop immunity, and help stop the spread.”..

“So the bottom line is if it is more infectiouness [sic] now, the issue is who cares?” Alexander wrote in a July 3 email to the health department’s top communications officials. “If it is causing more cases in young, my word is who cares…as long as we make sensible decisions, and protect the elderely [sic] and nursing homes, we must go on with life….who cares if we test more and get more positive tests.”” (E)

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