Covid-19 Vaccine Distribution Recommendations

Friday, the National Academies of Science, Engineering and Medicine (NASEM) issued the final version of its Framework for Equitable Allocation of Covid-19 Vaccine. Recognizing that once a vaccine is approved (in some form or another), demand will be much higher than the available supply of doses, NASEM suggests that the distribution process be structured in phases and guided by ethics and equity considerations. The process would prioritize ensuring the resilience of the health care system that serves the most vulnerable populations, followed by access by those most vulnerable to severe disease or death. According to NASEM, the phases should be structured as follows:

Phase 1a covers approximately 5 percent of the population and includes front-line health workers (in hospitals, nursing homes, or providing home care); workers who provide health care facility services such as transportation and environmental services who also risk exposure to bodily fluids or aerosols; and first responders. This group has a critical role in maintaining health care system functionality, high risk of exposure to patients exhibiting symptoms of COVID-19, and higher risk of then transmitting the virus to others, including family members.

Phase 1b covers approximately 10 percent of the population and includes people of all ages with comorbid and underlying conditions (for example, cancer, serious heart conditions, and sickle cell disease) that put them at significantly higher risk of severe COVID-19 disease or death. Based on data from the COVID-19 Associated Hospitalization Surveillance Network, adults with two or more comorbid conditions make up the large majority of those hospitalized for COVID-19 in the U.S. Also included in this phase are older adults (age 65 and over) living in congregate or overcrowded settings including nursing homes, long-term care facilities, homeless shelters, group homes, prisons, or jails. This group faces the joint risk factors of severe disease and reduced resilience associated with advanced age and of acquisition and transmission due to their living settings, in which they have limited opportunity to follow public health measures such as maintaining physical distance.

Phase 2 covers approximately 30 percent to 35 percent of the population and includes K-12 teachers and school staff (including administrators, environmental services and maintenance workers, and bus drivers), and child care workers, who play a vital role in children’s education and development. Also included are critical workers in high-risk settings who cannot avoid a high risk of exposure to COVID-19, such as workers in the food supply system and public transit. In addition, this phase includes people of all ages with comorbid and underlying conditions that put them at moderately higher risk, defined as having one of the conditions listed by the Centers for Disease Control and Prevention (CDC) as being associated with increased risk of severe COVID-19, and potentially some rare diseases as well. Phase 2 also includes people in homeless shelters or group homes for people with disabilities and those in recovery, as well as staff who work in those settings, as many of the individuals in this group have chronic health care needs and challenging living settings that increase potential exposure. In addition to people in prisons, jails, and detention centers and staff working in those settings, all older adults not included in Phase 1 should be included in Phase 2, as adults age 65 and older account for approximately 80 percent of reported deaths related to COVID-19.

Phase 3 covers approximately 40 percent to 45 percent of the population, and includes young adults, children, and workers in industries such as colleges and universities, hotels, banks, exercise facilities, and factories that are both important to the functioning of society and pose moderately high risk of exposure because there are likely to be some protective measures implemented in these work settings. Young adults between the ages of 18 and 30 typically have broader social networks than older adults, increasing their risks of infection and transmission, but they are less likely to become severely ill or die due to COVID-19, making them, along with children, targets for transmission prevention. The report notes that broad immunization of children will depend on whether COVID-19 vaccines have been adequately tested for safety and efficacy in these age groups.

Phase 4 covers everyone residing in the U.S. who did not have access to the vaccine in prior phases.

Contact Tracing & Supportive Quarantine and Isolation

A new article in the New York Times examines why contact tracing – a central pillar of public health response to widespread infectious disease – has not worked well in the U.S. and other Western countries? In part, Western systems were overwhelmed by the number of cases they faced. Another major contribution, according to the piece, was the failure of Western governments to stand up supportive test-trace-quarantine/isolation systems that would protect the jobs and living situations of those who tested positive or were identified as contacts, allowing them to safely and voluntarily stay home during the extended period at home.

Beholden to privacy rules, Western officials largely trusted people to hand over names to contact tracers. But that trust was not repaid, in large part because governments neglected services that were crucial to winning people’s cooperation: a fast and accurate testing system, and guarantees that people would be housed, fed and paid while they isolated….

Just as important, officials overlooked the impact of raging mistrust in government and a thicket of conspiracy theories about the virus’s spread. Fearful of plunging themselves or their friends into a painful period off work, infected patients have handed over a paltry number of contacts and often flouted self-isolation rules. Contact tracers are struggling to reach people who test positive, and being rebuffed once they do.

A new paper in Health Security discusses how the New York City Health + Hospitals system established its Isolation Hotel program (now the Take Care Hotel Program) to address such concerns within the city’s most vulnerable populations.

Stay-At-Home, Mask & Social Distancing Enforcement

Responding to worsening Covid-19-related health indicators, New York City mayor DeBlasio has announced proposed new restrictions in 20 Brooklyn and Queens neighborhoods. In 9 of the zip codes, all schools and non-essential businesses would be closed, and indoor and outdoor dining at restaurants would be prohibited. In the other 11 zip codes, indoor restaurant dining would be prohibited, but schools would stay open. These restrictions would need to be approved by New York’s Governor Andrew Cuomo to go into effect.

Governor Cuomo, in an effort to stem rising local levels of nonadherence with in place virus safety measures like mask wearing and social gathering limits, also has sent a warning to leaders of the state’s local governments: start enforcing public health rules or your community will face fines of up to $10,000/day.

State Emergency Orders

Late last week, the Michigan Supreme Court overturned a number of the Emergency Orders issued by their governor, indicating that the 1945 statutory authority under which she issued those orders was an improper delegation of responsibility by the legislature to the executive branch of government. This will not remove the state’s mask mandate or other protective measures, however, as many of the public health orders also were issued under other state laws whose powers have not been challenged.

Family Law

“No mask, no child custody.” A story from Florida discusses how some family courts are viewing parental refusal to take steps to minimize Covid-19 risks for their children.