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Story Publication logo December 8, 2020

‘So Many Unknowns’: Local Doctors—and Pharmacies—Will Still Decide Who Gets COVID-19 Vaccines

Volunteers from Indonesia's Red Cross prepare to spray disinfectant at a school closed amid the spread of coronavirus (COVID-19) in Jakarta. Image by REUTERS/Willy Kurniawan. Indonesia, 2020.

Veteran public health journalists from Science magazine explore what science knows—and is learning...

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Image by Prostock-studio / Shutterstock.
Image by Prostock-studio/Shutterstock.

Science’s COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.

When it comes to prioritizing who should receive the first COVID-19 vaccines in the United States and delivering the required doses, “we got a lot of work to do,” President-elect Joe Biden said at a press conference on 4 December. About 1 week from now, if the U.S. Food and Drug Administration authorizes the COVID-19 vaccine made by Pfizer and BioNTech for emergency use as expected, the initial doses of it should begin to reach hospitals like the five run by Scripps Health in San Diego, which Chief Medical Officer Ghazala Sharieff oversees.

And because the demand will surely outstrip supply for many months, the government has asked its vaccine advisers to recommend to Sharieff and her medical colleagues around the country who should go first. Converting those recommendations into practice at the hospital, clinic, or pharmacy level presents many quandaries, especially when it’s not yet clear how many doses will go to each location. “If we get 4000 doses for the hospital system, that’s going to be very constrained,” Sharieff says. (Both the Pfizer-BioNTech vaccine and a second one from Moderna, which this month could also be authorized for emergency use, require two doses.)

The U.S. Centers for Disease Control and Prevention (CDC) has sketched out a prioritization scheme that starts with three phases. On 1 December, its independent Advisory Committee on Immunization Practices (ACIP) nearly unanimously endorsed CDC’s proposal for phase 1a, which calls for initially offering a vaccine to about 21 million health care workers and 3 million residents of long-term care facilities. But a debate is growing on the order of the next two phases, 1b and 1c, which ACIP has not yet voted on. For phase 1b, CDC suggests vaccinating “essential workers” like teachers, meat packers, police, and bus drivers. Phase 1c in this plan would be adults over age 65 and adults of any age who have high-risk medical conditions. Immunizing essential workers could curb the spread of COVID-19 the most, but the latter group is at greater risk of dying from the disease.

For phases 1b and 1c, the U.S. government vaccine effort, known as Operation Warp Speed, has partnered with pharmacies across the country to administer shots, in addition to health clinics and hospital systems like Scripps. But how will the physicians and nurses at Sharieff’s hospitals know whether someone is an essential worker? How will a pharmacy confirm that someone has hypertension? “Since further prioritization hasn’t been recommended yet I’m not sure we’ll be able to answer this yet,” a CDC spokesperson told ScienceInsider. (ACIP hasn’t scheduled a date for votes on these phases.)

Even determining who is in phase 1a remains somewhat cloudy and likely will require Sharieff’s hospitals to make choices about which of its employees qualify. ScienceInsider recently spoke with her about that issue and others related to vaccine priorities. “This is all very fluid,” says the veteran emergency room physician.

This interview has been edited for clarity and brevity.

Ghazala Sharieff. Image courtesy of Scripps Health.
Ghazala Sharieff. Image courtesy of Scripps Health.

Q: How do you as a distributor of the actual vaccine determine whether a person truly is eligible and in a priority group?

A: [Phase 1a] is a little easier. We know which of our staff are working in the intensive care unit [ICU], the emergency departments, and the hospitalists. So we can validate very easily where they work and if they’re on the front line, and that includes environmental services workers and staff on our COVID floor—not just the doctors. And then as we get more doses [and move to phases 1b and 1c], it depends on how many doses we get. It really is about resource allocation and who meets the criteria. If you are over 65, or have diabetes or have high blood pressure, you’d get prioritized as high risk.

Q: Are you concerned about how it’s going to work when it hits the ground?

A: I’m actually not worried yet. We have a vaccine work group at Scripps that we started well before everybody else started theirs. There are going to be more vaccines coming around the corner. It may be that you only get a certain amount of Pfizer vaccines, but starting first quarter, we may have other vaccines as well. Keep in mind that people may not want to get the vaccine right up front anyway.

Q: How many doses do you anticipate getting to Scripps Health in December if the Pfizer-BioNTech and Moderna vaccines receive emergency use authorizations?

A: That’s a problem. All we know is that the state has 327,000 doses of the Pfizer vaccine. They will allocate to the county and then the county will let us know how many. That process has yet to be finalized. I don’t know if they’re going to base it on market share [of patients] or how the distribution is going to work. It’s frustrating. How do you plan for something when you don’t know what you’re going to get? What you don’t want is for people to say they want the vaccine and then they don’t show up. Trying to organize something when you don’t know how many doses you’re going to get in the first place and that it might be 2 weeks away is complicated. So we’re trying our best.

Q: Do you think hospitals are going to have to say, “If you have 1000 doses or less, here are the critical staff that should go first”?

A: We have already had a chief medical officers meeting in San Diego and we actually came up with different tiers, who’s on the front line and ambulatory clinics, and then all the way down to engineers. We have four tiers of people and we put it in our back pocket. It’s not public. It’s a draft, and we don’t have the authority over anything. The state may give us different directions. The second phase would be the outpatient clinics.

Q: For phase 1a, what about when the radiologist, who works at home and reads x-rays there, comes into the clinic and says, “Give me the vaccine. I’m a doctor.” And you say, “Well, you don’t see patients in the hospital.” And the doctor says, “I have privileges. I can.” You’re going to be confronted by people doing that, and I wonder what the process is.

A: I’m on the California Hospital Association vaccine work group. Right now, the conversations aren’t even as advanced as what you’re asking because it’s a work in motion. The focus is on the short term allocation. We’re actually waiting for the federal government to give whatever guidelines they have to the state. The state gives it to the county and the county gives it to us.

Q: You have this other dilemma: Hospital staff who are faced with the most exposure are the ones who frequently use the most personal protective equipment. Maybe they don’t need the vaccine as urgently?

A: Every day they go to work afraid, because they are in the high-risk areas. The vaccine is another layer of protection. They are actually getting sick—we have outbreaks, like everybody else has, and they also have community exposure outside of Scripps at birthday parties and the like. The other thing is you can’t afford to have those kinds of high-risk people sick. We’re in the middle of a huge surge in San Diego, and if the ICU work force is getting sick, I can’t take care of patients.

Q: Essential workers before most of the elderly—really? You’re going to give a grocery worker who is 20 years old and runs the cash register a vaccine before my 90-year-old mother? Do you have the freedom to make your own decision? Do you anticipate that the prioritization scheme will be a guidance or a regulation?

A: I think it’s going to be a guidance. Are they going to tell us who gets it first among frontline health care workers? We don’t know yet and that’s a problem. But they’re not going to say specifically, first do cardiologists and then do the surgeons—they’re not going to get into that level, because each site knows. If you have a university setting, you might say surgeons should go first, but I might say, no, that doesn’t make sense, because the surgery residents in that setting are the ones that are involved, they’re the hospitalists. But as an attending [who oversees the residents], maybe I don’t have to go into every COVID room. On our end, we send the attendings into the COVID rooms before the residents, because we feel like that’s our obligation. So we want a little bit of flexibility that way.

Q: It sounds like you need phase 1b and phase 1c to be a guidance and not a regulation.

A: Correct. That’s exactly what we’ve been advocating for. The 1a recommendations make sense, but 1b and 1c may not make sense. And in 1a, let us decide what we need to do within the category. Give us some leeway there because we know internally what our practices are.

Q: What impact do you think the vaccine is going to have on your hospital team, especially given the timing of the rollout and the surge that’s occurring now and is likely to continue—and may even be exacerbated by the holidays and travel?

A: It’s hard to predict. Two weeks after the holidays, people start getting sick, right? And then the third week is going to be the hospitalization. So we’re going to be well into January just seeing the effect of Thanksgiving. We’re not going to be able to vaccinate everybody right off the bat—even if I do first tier health care workers, it’s not going to be everybody in that tier.

Q: I would imagine that because of the prioritization scheme, a significant number of elderly people and people with comorbidities will get vaccinated and stop showing up in your ICU with COVID-19 at some point.

A: How many people want to get the vaccine? I think the title, Operation Warp Speed, frankly, has scared a lot of people. There are studies saying 50% or 60% of people don’t want to get the vaccine. If you assume everybody’s going to get the vaccine who is at high risk, you might be right. But we don’t know yet. And even in my discussions with medical officers, there definitely are employees who say they want to wait a little bit and see what all these studies show. They’re perfectly happy wearing a mask. There are so many unknowns. 

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