Putting essential workers second in line behind health care workers for a future COVID-19 vaccine would send a strong message that health equity is a key part of the nation’s vaccine distribution plan, a group of medical and public health experts concurred Monday.

“If we’re serious about valuing equity, we need to have that baked in early on in the vaccination program,” said Dr. Beth Bell, chair of the COVID-19 Vaccines Work Group for the Advisory Committee on Immunization Practices, the federal group tasked with evaluating vaccines and making recommendations to the CDC.

“These essential workers are out there, putting themselves at risk to allow the rest of us to socially distance.”

People from racial and ethnic minority populations make up 40% of the U.S. population, yet represent 50% of the COVID-19 cases and 45% of the COVID-19 deaths, Dr. Sara Oliver presented Monday during the ACIP meeting. Age-adjusted hospitalization rates are four times higher among minority groups, compared to non-Hispanic white Americans.

Those in racial and ethnic minority populations are also disproportionately represented among the roughly 66 million Americans who are non-health care essential workers: people working in food service, agriculture, education, transportation, corrections, public safety, water and waste water, etc., — jobs that can’t be done remotely and often require close proximity to others.

While Monday’s five-hour meeting didn’t end with a vote, the group voiced support for a presented framework in which health care workers and long-term care facility residents were first in line for phase 1a. Essential workers are phase 1b, while adults with high-risk medical conditions and adults 65 and over were phase 1c. The CDC also released a paper Monday explaining the ACIP’s recommendations and processes.

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Who gets a vaccine?

The meeting came just hours after the University of Oxford and AstraZeneca announced their vaccine showed an average of 70% efficacy — the latest vaccine candidate to produce promising phase III trial safety and efficacy data.

Pfizer and BioNTech had already announced more than 90% efficacy with their vaccine and on Friday asked the CDC for emergency use authorization, while Moderna also recently announced 94.5% efficacy with its vaccine and will be approaching the FDA for authorization soon.

While no exact timeline exists, it’s possible that the first doses could be available for health care workers by December. Doses are expected to be in short supply initially, with supply and access increasing in the spring and summer of 2021.

Complicated questions

The ACIP COVID-19 Vaccines Work Group, which has met nearly 25 times since its formation in April, has been grappling with two major questions: First, “should a COVID-19 vaccine be recommended?” and then, “to whom should it be recommended?”

To help determine the first answer, the group has been considering additional questions within seven different domains: public health problem, resource use, equity, benefits and harms, values, acceptability and feasibility — answers that will be updated as a vaccine is authorized or approved by the FDA.

For the first domain, the advisory group agreed that COVID-19 is an urgent health problem, having infected more than 12 million people in the U.S. and causing more than 257,000 deaths.

This undated photo issued by the University of Oxford shows of vial of coronavirus vaccine developed by AstraZeneca and Oxford University, in Oxford, England. Pharmaceutical company AstraZeneca said Monday Nov. 23, 2020, that late-stage trials showed its coronavirus vaccine was up to 90% effective, giving public health officials hope they may soon have access to a vaccine that is cheaper and easier to distribute than some of its rivals. | John Cairns, University of Oxford

Regarding resource use, if 20% of the U.S. population is infected with COVID-19, the direct medical costs could be $163 billion. Related costs, which include premature deaths, long-term health impairment and mental health impairment, have been estimated at $8.5 trillion, according to the ACIP presentation.

Thus, the answer to the question “Is COVID-19 vaccine ‘X’ a reasonable and efficient allocation of resources?” was a resounding yes.

A question of equity

Equity is a more complicated question, and group members were asked to consider how vaccine distribution could reduce, not increase, health inequities.

That includes addressing factors like cost, access and opinions about vaccines.

Despite the vaccine being promised for free, are offices going to be allowed to charge a $45 or $55 office visit co-pay? Because that may be too big of a barrier for individuals, especially those without insurance, said Lynn Bahta, immunization clinical consultant at the Minnesota Department of Health and ACIP committee member.

What if people aren’t connected to traditional forms of public health messaging?

Public health officials may need to identify community thought leaders and influencers and proactively reach out to them, working together to help spread information or change people’s perception of the vaccine, said Dr. José Romero, chief medical officer for the Arkansas Department of Health and advisory committee chairman.

What about vaccine hesitancy?

“I think that interest in a vaccine is modifiable,” said Dr. Peter Szilagyi, a professor of pediatrics at UCLA and ACIP member, who noted that when people can see themselves represented in the vaccine trials, they may feel more comfortable with the resulting product. Both Moderna and Pfizer have published demographic data regarding their vaccine trials.

Szilagyi also emphasized that hesitancy about a COVID-19 vaccine is intertwined with the concept of trust, which can be built through transparent processes, “such as we’re having here,” he said.

Trust will also build as people are open and honest about their own vaccine reactions, which are not going to be a “walk in the park,” said Dr. Sandra Fryhofer, the ACIP liaison from the American Medical Association. “They’re going to know they had a vaccine, and they’re probably not going to feel wonderful, but they gotta come back for that second dose.”

Both Pfizer and Moderna’s vaccines are a two-dose regimen.

As with any vaccine, a feeling of discomfort should be taken as a sign that it’s working and the body is responding appropriately, said Dr. Patricia Stinchfield, the ACIP liaison representative from the National Association of Pediatric Nurse Practitioners.

She encouraged providers to consider using the words “immune response,” instead of “adverse reactions,” which can seem “scary” to people, and to emphasize that a sore arm, body aches or even a fever are normal.

The time to promote vaccines is now

These conversations about vaccines and getting one when the time comes need to be happening now between doctors and patients, said Dr. Amanda Cohn, ACIP executive secretary, because “we need those seeds to be planted early.”

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If the country really wants to see a national vaccine distribution campaign that is not only feasible and equitable, but addresses hesitancy, increases education and provides access to all who want a vaccine — it will require a major investment.

Dr. Bell reminded the group about the 2009 H1N1 pandemic during which there was significant focus on vaccine manufacturing process, yet very little attention given to vaccine implementation.

While she’s thrilled with the $10 billion in federal funding spent to develop and produce vaccines, it can’t stop there, she said.

“I’m really concerned that the funds are not available to implement the vaccination program the way we desire it to be implemented,” she said. “All of our recommendations here really are conditioned on adequate funding to implement this program. I urge the relevant authorities to allocate those funds.”

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