A Momentous Week in Our Pandemic Response

This guest post was written by Jorge Salinas, MD, Hospital Epidemiologist at the University of Iowa Hospitals & Clinics. 

Her saturation had dropped to 89. Fever persisted. She was being admitted. This was the telegraphic message that started a roller coaster of a week. My mother had been symptomatic for a few days but had suddenly worsened. By 7:45 that same morning, we received confirmation—shipment was completed, 975 doses were on the dock, the vaccination deployment plan was a go.

A quick morning huddle. Everyone knew their positions and what to do: teams to prepare the doses, employee health nurses to administer them, planners to manage schedules. It was nicely choreographed and rehearsed.

The New York Times, 12/18/20

ED nurse, environmental services custodian, doctor, resident. How many people received the dose before me? Ten? Twenty? Jorge, this way. Immediately after the shot, I was asked, on camera, how I felt now that I had received the precious vaccine. This was undoubtedly a triumph of science. One of the greatest medical breakthroughs in years. And I had received it. Yet, I couldn’t avoid feeling unworthy of it. Because I am part of our system pandemic response I had more access to the vaccine than those more at risk. I had reluctantly persuaded myself that being a Hospital Epidemiologist and a Hispanic physician it would be advantageous to our response. To lead by example, show my healthcare colleagues here and abroad that I have confidence in the vaccine development process, that these vaccines are efficacious and safe. Took a big swallow, don’t think of mom right now, take a deep breath, go on.   

I am not an ethicist. I believe that the fair allocation of scarce resources is one of the hardest feats in medicine. We had debated extensively: how could we allocate these first thousand doses amongst almost 20,000 healthcare workers? Who should get it? Those over the age of 65? Those working in COVID units? Those on oncology and transplant floors? Should it be a lottery? Should we factor in healthcare worker comorbidities? Why did they send only 975 doses? We decided to prioritize every frontline, doctor, nurse, respiratory therapist, trainee, environmental services worker, etc., assigned to our inpatient and outpatient COVID units. After them, healthcare workers across all lines in all other units would be given the vaccine. Most States have less than 20% of doses needed for healthcare workers at the moment. 

Source: Vox.com

By mid-week we had vaccinated hundreds of people across all work lines in the first priority group. Questions of course came in: When is my turn? Why is my unit in phase one or two? But all in all, people were gracious and kind and most are still patiently awaiting their turn. A question arose though that was a bit harder to answer. If there is a cancellation, who should get that dose? Whoever can come in faster? Here again, came another simple realization: there are barriers to vaccination, even among healthcare workers. Those in support services and trainees even within our system would have a harder time to stop doing what they are doing at work, arrange day care, or plan for the possibility of a couple of days off after their shot in case of side effects. Quickly reacting and sprinting to get into an opening could disadvantage some groups over others. We had planned for an equal allocation to all work lines in high-risk areas but it was clear that some employees have additional barriers to vaccination.

Support service workers, trainees, housekeepers. Weren’t they also at higher risk of exposure outside of work? Our data has shown that most exposures among healthcare workers were nonoccupational. Had my job as a healthcare epidemiologist biased me to focus protection mostly while at work? But what about when in the community? I realized that when deploying vaccines, we should think of high risk of exposure at work of course, but some groups had a higher risk of COVID outside of work, in addition to potential barriers to getting the first doses of vaccines even if allocated to them.

Fair allocation of vaccine doses is not easy. Aiming for fair may not even be enough. At work and in the community, we need to work extra hard to reach those with less resources, those who chronically have barriers to access to care. These lessons from my own healthcare system will guide how I think about vaccine allocation for subsequent groups. After healthcare workers and people living in long-term care facilities are vaccinated, how are we to prioritize the next groups? It is clear that we have to actively reach those at an increased risk of acquisition however hard it may be.

While it will take several months and ethical conundrums will continue to arise locally, what about the rest of the world? Mom was a laboratory technician before she had us. If she had still been working, when would a dose have reached her in distant Peru? The global vaccine pipeline is not looking very promising for resource limited countries. The same challenges seen locally are present on a world scale. Resource limited countries may not reach full coverage until very late in 2021 or 2022. Who looks after a fair allocation of vaccines on a global level?

Source: Duke Global Health Innovation Center

 

Source: The Economist

As we close this week, I feel grateful to have received the vaccine, to work in healthcare epidemiology, to continue learning from my mistakes, and I strive to be just in our protection efforts for healthcare workers and our communities. I am grateful my mother is recovering, for my colleagues taking care of her and the hundreds of thousands of people battling COVID-19 worldwide.

The next weeks and months will continue being challenging. It is clear we have entered a new phase in the pandemic, but until we reach high vaccination coverage we must continue implementing nonpharmacologic interventions, masks, avoiding indoor crowds, and maintaining our distance. We must also advocate for just allocation of medical resources in our local and global societies. Hundreds of thousands of lives can still be saved.