Who Is in Line Next?

There is an article in WIRED magazine titled "The Vulnerable Can Wait. Vaccinate the Super-Spreaders First."1 It has remade my thinking on the priority of who to consider when vaccinations for COVID-19 do start. It might recast your thinking, as well.

So before anyone suggests I might be ready to sell out the chronic disease community, I hope you will understand that I honestly am in a quandary about the order of vaccination. Incidentally, many infectious disease scientists are also in a dilemma about the priority of second and beyond populations to receive the vaccine. In this case, following the science may be a matter of choice and not be so clear-cut.

Frontline workers vaccinated first

There is almost no disagreement about who will get the vaccine first. Federal government agencies, Congress, the states, and the scientific community are primarily lined up behind the thought that frontline workers will be first. That makes sense for a large variety of reasons. Chiefly, if we do not have frontline workers vaccinated, then none of us are safe. We need doctors, nurses, pharmacists, techs, CMAs, and all the rest available to help the rest of us. 

Incidentally, a significant case can be made for teachers and other school personnel so schools can operate normally. This will free the economy to return quickly to a regular footing, and we will stop letting COVID-19 sabotage normalcy for our children. A casual look at the data suggests schools are among the safest places for K-12 students with incredibly low transmission rates. 2 But if we cannot staff these classrooms, all the safe environments in the world will not get children in school. So, an excellent case can be made to give high priority to K-12 personnel.

Santa was in line early

Who next? Well, at one point, Santa was offered early access. According to UPI and other reporting outlets, the Federal Department of Health and Human Services inked a deal to vaccinate 100 real, bearded Santas early access to a vaccine.3 The action is detailed in the article "Santa Actors Were Offered Early Vaccine as Part of Scrapped Federal PSA campaign: HHS."

Oh, and before you dismiss the idea entirely - remember that in August 2020, many in the federal government thought a vaccine would be available in November. Thus for a sense of normalcy, it was felt that if one could vaccinate Santa, he and Mrs. Claus would not turn into super-spreaders and, with some additional hygiene, maybe children could sit on Santa's lap. While this idea may sound preposterous and the agreement was later canceled, at least someone important enough to execute and agreement thought it a good idea.

Notice who was not included in the Santa agreement? Yes, people who are chronically ill or have compromised immune systems were not considered high enough priority to beat out Santa. This brings me back to the article in WIRED. In it, Cox details why people who have compromised immune systems, who are elderly, and are practicing the best social distancing guidelines might be bad choices for the second wave of COVID-19 vaccinations.2

What is the distribution for the vaccine?

In essence, some scientists believe that while vaccinating us would give us more freedom and cost fewer resources in the long run (reduced hospital admission), we would not significantly impact the spread of COVID-19. They argue that if they give me the vaccine, it will benefit me. But if they can provide the vaccine to those identified as super-spreaders, the pandemic will be halted sooner and with less overall costs.

Who is considered a super-spreader?

Who are these super-spreaders? Yes, I have come to regard these people as those I want to avoid. They are the protesters who refuse to wear masks, the young adults who throw or attend large parties, those who might engage in multiple sexual encounters with different partners, or the guy at the bar almost 24/7 complaining about how the government will never tell him what to do. These are the people who attend megachurch gatherings with no social distancing and proclaim they are protected, even as the congregants are exposed to the virus. 

In short, these are the people who frighten me the most during this pandemic. These people are not generally representative of those of us who are immunosuppressed who know that it could easily be fatal or who worry about the health of people we care for if we become ill.

Identifying super-spreaders

How would we find people who are not practicing social distancing? As it turns out, an idea has been demonstrated that could likely identify these people. Ask each patient being treated for COVID-19 to name ten friends.  By cross-referencing these lists, local or state officials would quickly find those who need to be vaccinated. The theory is that super-spreaders have many more friends than those of us who take the stay-at-home orders very seriously. 

Some scientists argue that these people need to be vaccinated early to stop the spread of the virus in the entire world. Cox writes, "Although the numbers vary from study to study, SARS-CoV-2 seems to follow the 80/20 rule: 80 percent of cases stem from just 20 percent of infected individuals."1 The theory goes that if we could find that 20 percent and vaccinate them early, we could almost stop the spread of the virus; social tracing is the answer to finding that 20 percent.

Who should be vaccinated?

Should the world use limited second-wave vaccines to protect the most vulnerable or stop the virus spread? It is not a settled issue. I want the vaccine as soon as I can get it. I always thought I would likely be part of the second wave of inoculations. After reading this article in the publication, WIRED, I understand why I might not actually be in the second wave.

Whether we are talking about this or not, scientists consider who and when people should be vaccinated. The National Academy of Science has regarded the evidence and has made a recommendation to the FDA.4 The report is titled "Framework for Equitable Allocation of COVID-19 Vaccine."

If you are interested, the FDA will be taking up the vaccine debate in the first half of December 2020. The advisory committee given recommendation authority is called the Vaccines and Related Biological Products Advisory Committee.

Who do you think should be given priority?

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