A week after the U.S. Food and Drug Administration granted emergency-use authorization to Pfizer’s novel coronavirus vaccine, and with another vaccine from Moderna on the way, the question of whom to vaccinate first looms larger than ever.
Vaccinations have begun at hospitals, clinics, and pharmacies all over America. In line with guidance from the U.S. Centers for Disease Control and Prevention, every state is reserving initial doses of the two-dose vaccine for frontline health care workers and residents and staff of nursing homes—populations that are uniquely vulnerable to the virus owing, respectively, to their exposure to infected people and co-morbidities.
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The rollout has been far from seamless, with a bottleneck pitting governors against a federal government they say is sending mixed messages about how many doses they can expect, and when.
A CDC advisory panel on Sunday proposed that essential workers and people over 75 be the top priorities for vaccination after front-line health workers and people in nursing homes. But even with broad guidance from the CDC in place, the appearance of favoritism is inescapable, inspiring a raucous protest at a California hospital where employees said remote staffers were skipping ahead of people treating COVID-19 patients.
Enter Edwin Michael, an epidemiologist at the Center for Global Health Infectious Disease Research at the University of South Florida. He’s pushing a radically different, and highly controversial, strategy: prioritize younger people, from essential workers outside the medical field to the rogue superspreader party crowd that can’t seem to quit, no matter the risks.
Michael is in charge of modeling the pandemic for the center, where he runs computer simulations projecting how and where the virus might spread, and kill, in coming months. And as supplies of vaccine remain limited, he believes states should prioritize the people who are most likely to spread COVID, rather than people who are most likely to die from it.
That approach could both allow the economy to stay open and end the pandemic earlier than the predominant strategy, he argues. Which, in turn, could save lives in the long run, he claims.
“If you ask me, the strategy really should be to target essential workers—health, grocery, transit, other workers—first so that basic functions of a society are safeguarded, and then target the groups that contribute most to community transmission,” Michael told The Daily Beast. “Paradoxically, these would be the younger sections and the working adult groups who are not likely to be most at-risk of severe illness.”
Naturally, other experts questioned Michael’s theory. The safe and ethical strategy is to save lives now, they said. Especially since we don’t know for sure just how the nationwide vaccination effort will play out in coming months.
“In this emergency situation we now find ourselves in, preventing deaths right now is a greater priority than the theoretical benefits of vaccinating healthy young adults first for benefits that will take place over a longer time horizon—time when clinicians and vulnerable people will die from COVID-19,” Anthony Alberg, a University of South Carolina epidemiologist, told The Daily Beast.
The debate will remain a largely academic one as long as states continue to broadly adhere to CDC guidance. But controversy over vaccine strategy could grow more urgent if supply bottlenecks continue to crop up. That’s certainly possible, after officials in several states claimed the feds cut their projected second allocation of doses compared to the first allotment.
The uncertainty could weigh on states’ social-distancing measures. With new COVID cases and deaths spiking across the country, several states have re-imposed restrictions on large gatherings and indoor dining.
The prospect of further lockdowns expanding economic pain makes the case for vaccinating younger people first a stronger one, Michael said.
“If we want to re-open the economy as quickly as possible safely, then we need to curb transmission as quickly as possible,” he said. “Given that the primary source of transmission in the community is the 20-to-50 age group, then this is the group that needs to be targeted to reduce transmission as quickly as possible.”
“This could be done by keeping older folks and other vulnerable, severely-at-risk groups safe through social-mitigation measures until the vaccines can be ramped up to vaccinate them,” Michael added, acknowledging his approach may not be “politically” viable.
Alberg, for one, noted he had heard similar arguments made about other vaccines, like those for influenza. And in theory, he said, the case might not be an absurd one. But the COVID-19 pandemic is not just another disease outbreak.
“Under the present circumstances, with a raging pandemic, it makes perfect sense to focus on protecting our health care workforce so that we can continue to deliver medical care to sick COVID-19 patients,” he said, “and to focus on the most vulnerable among us, with elderly in institutions being at the top of the list.”
Likewise, Jennifer Reich, a University of Colorado sociologist who studies immunization, told The Daily Beast she was uncomfortable “pit[ting] different communities against each other” in a theoretical debate over long-term vaccination strategy.
There’s a lot we don’t know about Pfizer’s vaccine, as she noted. “As of now, these vaccines are authorized for emergency use because they seem to prevent serious disease and death,” she said. “The goal of immunizing those most likely to spread the disease only makes sense if we know these vaccines prevent infection and transmission.”
While Pfizer’s large-scale, phase-three trials strongly indicated the vaccine was safe and prevents infection, it could take months—and millions of vaccinations —before we see how the vaccine works in the real world. Specifically, it is not yet clear how it might impact transmission by people who are protected from illness.
“Until then, these are vaccines that matter for saving lives and limiting demands on health care systems,” Reich said.
And even as vaccinations slowly ramp up, no one—in the health care industry, nursing homes, essential industries, or anywhere else—should let down their guard, Reich stressed. “People need to continue to wear masks, socially distance, and do what they can to limit transmission,” she said.
The vaccine “is not yet a ‘get out of your house’ card,” she added. Not for hospital staff, nursing-home residents, essential workers, young people—or anyone.
In other words, while there is an epidemiological case for prioritizing shots for some of the same young people needlessly risking pandemic disaster with their own behavior, not even a vaccine is enough to immunize society against them.
At least not yet.
