The New York Times - USA (2020-12-02)

THE NEW YORK TIMES, WEDNESDAY, DECEMBER 2, 2020 N A

Tracking an OutbreakPublic Health

After months of deliberation
and debate, a panel of independ-
ent experts advising the Centers
for Disease Control and Preven-
tion voted Tuesday to recommend
that health care workers who are
most at risk of contracting
Covid-19, along with residents of
nursing homes and other long-
term care facilities, be the first
Americans to receive coronavirus
vaccinations.
If the C.D.C. director, Dr. Robert
R. Redfield, approves the recom-
mendation, it will be shared with
states, which are preparing to re-
ceive their first vaccine ship-
ments as soon as mid-December,
if the Food and Drug Administra-
tion approves an application for
emergency use of a vaccine devel-
oped by Pfizer.
States don’t have to follow the
C.D.C.’s recommendations, but
most probably will, said Dr. Mar-
cus Plescia, the chief medical offi-
cer for the Association of State
and Territorial Health Officials,
which represents state health
agencies. The panel, called the
Advisory Committee on Immuni-
zation Practices, will meet again
soon to vote on which groups
should be next to receive priority.
Here are answers to some com-
mon questions about the vaccine
and its distribution.

Who will get the vaccine first?

The C.D.C. committee recom-
mended that the nation’s 21 mil-
lion health care workers be eligi-
ble before anyone else, along with
three million mostly elderly peo-
ple living in nursing homes and
other long-term care facilities.
A staggering 39 percent of
deaths from the coronavirus have
occurred in long-term care facili-
ties, according to an analysis by
The New York Times. But there
won’t be enough doses at first to
vaccinate everyone in these
groups; Pfizer and Moderna, the
two companies closest to gaining
approval for their vaccines, have
estimated that they will have
enough to vaccinate no more than
22.5 million Americans by Janu-
ary. So each state will have to de-
cide which health care workers go
first.
They may choose to prioritize
critical care doctors and nurses,
respiratory therapists and other
hospital employees, including
cleaning staff, who are most likely
to be exposed to the coronavirus.
Or they may offer the vaccine to
older health care workers first, or
those working in nursing homes,
who are at higher risk of contract-
ing the virus. Gov. Andy Beshear
of Kentucky said on Monday that
most of his state’s initial allocation
would go to residents and employ-
ees of long-term care facilities,
with a smaller amount going to
hospital workers.
It’s important to remember that
everyone who gets a vaccine
made by Pfizer or Moderna will
need a second shot — three weeks
later for Pfizer’s, four weeks for
Moderna’s.

Who gets it next?

The C.D.C. committee hinted last
week that it would recommend es-
sential workers be next in line.
About 87 million Americans work
in food and agriculture, manufac-
turing, law enforcement, educa-
tion, transportation, corrections,
emergency response and other
sectors. They are at increased risk
of exposure to the virus because
their jobs preclude them from
working from home. And these
workers are disproportionately
Black and Hispanic, populations
that have been hit especially hard
by the virus.
Individual states may decide to
include in this group employees of
industries that have been particu-
larly affected by the virus. Arkan-
sas, for example, has proposed in-
cluding workers in its large poul-
try industry, while Colorado
wants to include ski industry
workers who live in congregate
housing.
After essential workers, the pri-
ority groups likely to be recom-
mended by the C.D.C. committee
are adults with medical conditions
that put them at high risk of co-
ronavirus infection, and people
over 65. But again, some states
might diverge to an extent, choos-
ing, for example, to vaccinate resi-
dents over 75 before some types of
essential workers. All other adults
would follow. The vaccine has not
yet been thoroughly studied in
children, so they would not be eli-
gible yet.

Who will make decisions about
priority groups at the state level?

Each state has a working group,
composed largely of public health
officials, that has been planning
for months and making decisions
about vaccination campaigns.
Each state’s top health official and
governor will probably sign off on
final plans.

How long will states focus on one
priority group?

States don’t need to reach every-

one in one priority group before

moving on to the next, according

to the C.D.C. advisory committee.

But more federal guidance is ex-

pected on the subject.

When will the first doses be

shipped, and where will they go?

Federal officials have said they

plan to ship the first 6.4 million

doses within 24 hours after the

F.D.A. authorizes a vaccine, and

the number each state receives

will be based on a formula that

considers its adult population. Pfi-

zer will ship special coolers, each

containing at least 1,000 doses, di-

rectly to locations determined by

each state’s governor. At first, al-

most all of those sites will proba-

bly be hospitals that have con-

firmed they can store shipments

at minus 94 degrees Fahrenheit,

as the Pfizer vaccine requires, or

use them quickly.

When will a vaccine be available to

the general public, and where will

people receive it?

Federal officials have repeatedly

suggested that people who are not

in the priority groups — healthy

adults under 65 who don’t work in

health care or otherwise qualify as

essential workers — should have

access to the vaccine by May or

June, because there will be

enough supply by then. But a lot

will have to go right for that to

happen. One factor is whether, or

when, other vaccines besides Pfi-

zer’s and Moderna’s are approved.

Once the vaccine becomes widely

available, most people will be able

to get it in doctor’s offices and at

pharmacies.

Can employers like hospitals or

grocery stores require their em-

ployees to be vaccinated?

Employers do have the right to

compel their workers to be vacci-

nated. Many hospital systems, for

example, require annual flu shots.

But employees can seek exemp-

tions based on medical reasons or

religious beliefs. In such cases,

employers are supposed to pro-

vide a “reasonable accommoda-

tion”; with a coronavirus vaccine,

a worker might be allowed to wear

a mask in the office instead, or to

work from home.

Can I choose which vaccine I get?

This depends on a number of fac-

tors, including the supply in your

area at the time you’re vaccinated

and whether certain vaccines are

found to be more effective in cer-

tain populations, such as older

adults. At first, the only choice is

likely to be Pfizer’s vaccine, as-

suming it is approved. Moderna

asked the F.D.A. for emergency

authorization on Monday; if ap-

proved, it would most likely be-

come available within weeks after

Pfizer’s.

Are there any side effects?

Some participants in both Pfizer’s

and Moderna’s trials have said

they experienced symptoms in-

cluding fever, muscle aches, bad

headaches and fatigue after re-

ceiving the shots, but the side ef-

fects generally did not last more

than a day. Still, preliminary data

suggests that, compared with

most flu vaccines, the coronavirus

shots have a somewhat higher

rate of such reactions, which are

almost always normal signs that

the body’s immune response is

kicking in.

How do I know it’s safe?

Each company’s application to the

F.D.A. includes two months of fol-

low-up safety data from Phase 3 of

clinical trials conducted by uni-

versities and other independent

bodies. In that phase, tens of thou-

sands of volunteers get a vaccine

and wait to see if they become in-

fected, compared with others who

receive a placebo. By September,

Pfizer’s trial had 44,000 partici-

pants; no serious safety concerns

have been reported.

The F.D.A. will also review the

data for each vaccine seeking au-

thorization and share it with its

advisory committee, which will

meet publicly — in the case of the

Pfizer vaccine, on Dec. 10 — to ask

questions and make a recommen-

dation to the agency. The F.D.A.

will then decide whether to ap-

prove the vaccine for emergency

use.

Do I need the shot if I had Covid?

Probably. Although people who

have contracted the virus do have

immunity, it is too soon to know

how long it lasts. So for now, it

makes sense for them to get the

shot. The question is when.

Some members of the C.D.C. ad-

visory committee have suggested

Covid survivors should be toward

the back of the line.

“At the beginning, when it’s a re-

source-limited vaccine, my opin-

ion is that we need to try and tar-

get as best we can to those that we

know are susceptible,” Dr. Robert

Atmar, an infectious disease spe-

cialist at Baylor College of Medi-

cine who serves on the committee,

said during a meeting of the panel

last week.

IMMUNIZATION PLANNING

Everything You Wanted

To Know About the Shot

By ABBY GOODNOUGH

WASHINGTON — An inde-

pendent panel advising the Cen-

ters for Disease Control and Pre-

vention voted Tuesday to recom-

mend that residents and employ-

ees of nursing homes and similar

facilities be the first people in the

United States to receive coronavi-

rus vaccines, along with health

care workers who are especially

at risk of being exposed to the vi-

rus.

The panel, the Advisory Com-

mittee on Immunization Prac-

tices, voted 13 to 1 during an emer-

gency meeting to make the rec-

ommendation. The director of the

C.D.C., Dr. Robert R. Redfield, is

expected to decide by Wednesday

whether to accept it as the agen-

cy’s formal guidance to states as

they prepare to start giving peo-

ple the shots as soon as two weeks

from now.

“We are acting none too soon,”

said Dr. Beth Bell, a panel member

and global health expert at the

University of Washington, noting

that Covid-19 would kill about 120

Americans during the meeting

alone.

States are not required to follow

the panel’s recommendations, but

they usually do. The final decision

will rest with governors, who are

consulting with their top health of-

ficials as they complete distribu-

tion plans.

The new recommendation is the

first of several expected from the

panel over the coming weeks, as

vaccines developed by Pfizer and

Moderna go through the federal

approval process, on the thorny

question of which Americans

should be at the front of the long

line to get vaccinated while supply

is still scarce. The panel described

it as an interim recommendation

that could change as more is

learned about how well the vac-

cines work in different age groups

and how well the manufacturers

keep up with demand.

The roughly three million peo-

ple living in long-term care and

those who care for them are a rela-

tively clear target; 39 percent of

deaths from the coronavirus have

occurred in such facilities, accord-

ing to an analysis by The New

York Times. But states and health

systems will ultimately have to

decide which of the nation’s 21 mil-

lion health care workers should

qualify to receive the first doses,

as there won’t be enough at first

for everyone.

Pfizer and Moderna have esti-

mated that they will have enough

to vaccinate, at most, 22.5 million

Americans by year’s end, with the

required two doses, a few weeks

apart. The C.D.C. will apportion

the supply among the states, with

the initial allocation proportional

to the size of each state’s adult

population.

The only member of the com-

mittee to vote against the recom-

mendation was Dr. Helen Talbot,

an infectious-disease specialist at

Vanderbilt University, who ex-

pressed discomfort with putting

long-term-care residents in the

first priority group because the

vaccines’ safety had not been

studied in that particular popula-

tion. “We enter this realm of ‘we

hope it works and we hope it’s

safe,’ and that concerns me on

many levels,” she said before the

vote.

But most panel members who

offered opinions said they thought

the high death rate among that

group made it imperative to in-

clude it.

Dr. José Romero, the chairman

of the panel, said that he felt

strongly that its process had ad-

hered to its core principles of

“maximizing benefit and minimiz-

ing harm,” promoting justice and

addressing health inequities. Dr.

Beth Bell, the co-chair, acknowl-

edged that all of the members

would have liked more data from

clinical trials but said that be-

cause of the pandemic emergency,

“we need to act.”

The panel, whose 14 voting

members have expertise in vacci-

nology, immunology, virology,

public health and other relevant

fields, has hinted that the next pri-

ority group it will recommend for

vaccination — “Phase 1b” — will

be so-called essential workers, a

huge group numbering more than

85 million. A division of the De-

partment of Homeland Security

has come up with a list of workers

states should consider counting in

that group; it includes teachers

and others who work in schools,

emergency responders, police of-

ficers, grocery workers, correc-

tions officers, public transit work-

ers and others whose jobs make it

hard or impossible to work from

home.

After essential workers, the

committee is leaning toward rec-

ommending vaccination of adults

with medical conditions that put

them at high risk of coronavirus

infection, such as diabetes or

obesity, and everyone over 65. But

some states might diverge to an

extent, possibly choosing, for ex-

ample, to vaccinate residents over

75 and then some types of essen-

tial workers.

All other adults would follow

the initial groups. The vaccine has

not yet been thoroughly studied in

children, so people under 18 would

not be eligible yet.

For at least a month or two,

there will not be nearly enough

vaccine to cover everyone in the

initial groups. Dr. Moncef Slaoui,

who leads the Trump administra-

tion’s Operation Warp Speed, said

Tuesday morning in an interview

with The Washington Post that

Pfizer and Moderna would be able

to provide an additional 60 to 70

million doses in January “if all

goes well.” Since each person gets

two shots, that would only be

enough for 55 million people at

most through the end of January

— about 22 percent of the nation’s

roughly 255 million adults.

Production will continue to in-

crease in February and March, Dr.

Slaoui said, with the hope that two

new vaccines, from AstraZeneca

and Johnson & Johnson, will gain

F.D.A. approval.

“So very quickly, we start hav-

ing more than 150 million doses a

month in March, April, May,” he

added. He and other federal offi-

cials have said that the general

public is likely to be able to be vac-

cinated by May or June.

On Tuesday, the C.D.C. panel

specifically suggested that within

the long-term-care population,

residents of nursing homes, who

tend to be the most frail and sus-

ceptible to Covid, should get the

first vaccines in the event that

there aren’t enough, along with

staff members who have not had

the virus within the last 90 days.

Within the much larger catego-

ry of health care workers, the pan-

el said that health systems should

consider prioritizing those who

have direct contact with patients

and their families and those who

handle infectious materials. Dr.

Nancy Messonnier, who leads the

C.D.C.’s National Center for Im-

munization and Respiratory Dis-

eases, told the panel that most

states and large cities “believe

they can vaccinate all of their

health care workers within three

weeks.”

But whether they reach that

goal depends on how much vac-

cine they get, and how quickly.

Gov. Andy Beshear of Kentucky

told reporters on Monday that his

state had more than 200,

health care workers but would re-

ceive only 38,000 doses in its first

shipment.

Long-term-care facilities in-

clude nursing homes, with about

1.3 million residents; assisted-liv-

ing facilities, with 800,000 resi-

dents; and residential care facili-

ties, which tend to be small and ca-

ter to specific populations. The

federal government has con-

tracted with CVS and Walgreens

to deliver vaccines to most such

facilities nationwide.

Several members of the panel

urged that small community doc-

tors’ offices not be left off the ini-

tial priority list. “Transmission

dynamics suggest providers who

care for patients earlier in their

course of illness may be at higher

risk,” said Dr. Jeffrey Duchin, a

member of the panel who is in

charge of public health in Seattle

and King County, Wash.

Dr. Grace Lee, a panel member

and a pediatrics professor at Stan-

ford, said special attention should

be paid to health care workers in

lower-paying positions, such as

nursing assistants, food workers

and janitors, who may fear for

their job security if they push to

secure a spot toward the front of

the vaccination line.

“I am very mindful of the equity

concerns,” Dr. Lee said.

THE C.D.C.

Vaccine Panel Says Nursing Homes Deserve Priority

An analysis showed 39 percent of coronavirus deaths have occurred in long-term care facilities. A

panel advised that nursing home residents and at-risk health care workers get the vaccine first.

JOHN MOORE/GETTY IMAGES

By ABBY GOODNOUGH

Jan Hoffman contributed report-

ing.

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