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Deciding Who Should Be Vaccinated First

Last month, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (A.C.I.P.) recommended that COVID-19 vaccines be given first to frontline health-care workers and adults over the age of seventy-five. Earlier in the month, A.C.I.P. had released preliminary recommendations and suggested that it would place the greatest emphasis on protecting frontline workers, in part because those workers are disproportionately members of hard-hit communities of color. But the new recommendations bring the C.D.C. more in line with Canada and the majority of European countries, which have released plans focussing on older people, and which most public health officials believe are likely to save the most lives.

I recently spoke by phone with Barry Bloom, an immunologist and professor at the Harvard T. H. Chan School of Public Health. He is also a member of the Massachusetts governor’s COVID-19 Vaccine Advisory Group. During our conversation, which has been edited for length and clarity, we discussed how the virus has affected different populations, how to balance the needs of older Americans and frontline workers, and whether health officials have done a good job of communicating with the public.

What did you think about the latest round of A.C.I.P. recommendations?

I’m going to say some simple things. The first premise of all of this is that every life counts equally. That may sound strange, but when you have a scarce resource—and my prediction is that once the vaccine rolls out nationwide, you will see the demand rise beyond what the supply can accommodate—trying to set a value that every life counts means famous people and hustlers should not get in front of the line. It’s an obvious point, but that’s been very much on our minds.

Forty per cent of all deaths are from people in nursing homes and congregate settings, and, if the object is to save lives, they have to be given high priority. Second—and it’s particularly obvious now, but was predicted in all the discussions prior to this—we have limited hospital capacity to deal with COVID and every other hospitalizable condition. Protecting people who keep our hospitals functioning—which, in the first iteration, in March, was bending the curve to keep the hospitals from crashing—is very much on everybody’s mind here. Hence, people who have face-to-face contact and face the most direct risks with COVID had to be prioritized in the allocation of COVID vaccines. I think thereafter things become more complicated.

A.C.I.P. is now giving more prioritization to people over seventy-five. There’s been some dissent from public-health professionals who think that they should have even gone further with age, like, down to sixty-five. I’m curious whether you think that the prioritization of age has been sufficient.

The prioritization of age is so important because people over the age of sixty-five account for about eighty per cent of the deaths. The issue that was raised at the A.C.I.P. meeting that I must say has concerned me is that there was no difference in apparent risk in the data presented by the C.D.C. between the ages of sixty-five to seventy-four and over seventy-five. The one objection that was raised by one of the members of A.C.I.P. was that, if the risks aren’t significantly greater, why not include sixty-five-plus-ers.

I’ve thought about that, and the sixty-five-plus age group was not the priority in Massachusetts. We are having a scheduled meeting on Wednesday, as we do every week, and I just think we should rethink that. There are a couple of reasons, in my view, why that would make sense, and one of them is that the risks are about the same. And if the risk is the same, you would be saving as many lives by extending the prioritization to that category. [Bloom added, after the phone interview: “There was a big discussion, and it’s a trade-off, essentially, between frontline health workers who are exposed and the issue of age, which the C.D.C. has released very striking data on—that the single largest predictor of death is clearly age, and single comorbidities are lower than that. So the discussion was: Do you open it up to everyone over sixty-five? The numbers would be enormously greater, and things are going slowly, so, with the thought that the priority was protecting people at the greatest risk of death, start with the seventy-five-plus, then COVID workers doing direct-facing care, long-term care facilities, police and fire, corrections, shelters, and home-based healthcare workers.”]

The second is almost trivial but really quite important practically. These are clear-cut decisions. You know who is sixty-five, and who is seventy-five. When you get to people with comorbidities, it’s a much more difficult situation to ascertain, and how can you be sure who has high-risk conditions, and whose doctor is willing to write a note that they have high-risk conditions? My sense would be, administratively, to protect the integrity of the program as well as to save more lives, I would like to see us drop the age to sixty-five and prioritize that before we get into high-risk conditions and the issue of categories of essential workers, and that’s going to be, again, a very difficult set of decisions that different states, I think, will value in different ways. Those are hard decisions that affect the integrity of the process, which I’m concerned about. If you want people to trust vaccines, they have to trust the process that enables people to get vaccines, and also protect the people who are at risk, who are not always the people who are prioritized.

The preponderance of illness is three-to-five times greater for African-Americans, Hispanics, and Native Americans, and they are traditionally disadvantaged. If you have a tool to save lives, and they’re at the greatest risk, how do you do that in a way that is equitable? That’s what our group has struggled with and, I think, A.C.I.P. has struggled with.

My understanding is that if you prioritize frontline workers more than people over sixty-five or seventy-five, you are prioritizing more people of color, who have a disproportionate number of frontline jobs, whereas, with seniors, that’s not the case. But the data used by the C.D.C. itself seems to show that you would protect the most number of people of color, too, by protecting seniors, because of how likely seniors are to die from the virus. Is that your sense?

That’s my sense too, and so in the age category, for me, it’s a clear-cut decision that saves more lives, and it’s defensible and clear and ascertainable. Beyond that is where things get stickier and, for example, when you get to things such as how to deal with essential workers versus people with comorbid conditions. They’re lumped together in the A.C.I.P. report. That’s going to be dicey, how each state would sort that out. We separated them in Massachusetts, and people at high risk for dying because of comorbid conditions were placed higher than essential workers.

Can you talk a little bit about the frontline workers who you think should be at the top of the list? Are you taking anything into account other than lives saved? Are there certain workers who should be protected because of their importance to keeping the economy going, keeping schools going?

It is clear that frontline health workers in hospitals are not at the highest risk for dying or getting serious illness. They have protective equipment. On the other hand, they’re at risk every minute of every day, and, when you go through the lists, the physicians actually have a lower risk than the nurses, for example, and other affiliated workers in the hospital. The object there was to keep hospitals open, and that is an independent decision parallel to but separate from just saving lives. That’s what every group that thinks about this is worried about.

A big debate in Massachusetts, and I think everywhere, is what the definition of an essential worker is, and they come in two speeds: those with the highest exposure to people with COVID—and that’s a reasonable category—but there are also other people, such as schoolteachers, who are unlikely to be at the highest exposure rate, or at the highest risk of dying, and yet the damage that everyone accepts is destroying the socialization and education of kids. I think that every state is having to wrestle with how to evaluate those things, and one ends up with different perspectives in these various committees.

Do you lean a certain way about these decisions with lives saved versus other benefits? How do you think your responsibility through?

I’m at a place that I think has one of the three best epidemiology and epidemiological-modelling groups in the world. We have data coming in every day from all over the world. We know what the scientific numbers are, and the tendency is to believe that the numbers have to drive things. But I was put on the governor’s group, and there are a couple of things that strike me as interesting. One was that the governor of Massachusetts put together a committee to consider this, as opposed to sitting down with the people in the Department of Health, getting a letter from the C.D.C., and saying, “We will do what the C.D.C. told us to do.” I found that extraordinary. The second thing that I found extraordinary is that the committee is composed of a group of people whom as an academic I would never have the opportunity and privilege to hang out with: a religious leader, the head of community health centers, the mayor of a town outside Boston with among the highest incidence rates of COVID infection, public-health officials from the state, the head of emergency planning at a major hospital, a state senator, and a representative from Western Massachusetts, a rural, generally underserved area.



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