Making sound decisions during a growing COVID outbreak is like shooting at a moving target. The main targets now are the Pfizer and Moderna vaccines.
Studying anatomy at the beginning of medical school meant being assigned a cadaver and encountering the finality of death. From there it meant knowing the bones and nerves and arteries and veins as well as body organs and gender differences, but one thing we did not identify or care about was skin color. Since it made little anatomical or physiological difference, we immediately saw past it. It was only in the clinical years when our perceptions and biases came into play, and as we developed into physicians, it became crucial that the science of the body supersede the emotion-driven misperceptions of the mind.
“Follow the science” is an expression that has been overused and misused by politicians and the news media during the COVID pandemic, even as they jump to non-scientific conclusions, but what it really means is trying to identify trends and treatments during a burgeoning outbreak — in other words, shooting at a moving target with real contextual information rather than hyper embellished biases. Among the main targets right now for this real science are the BioNTech/Pfizer vaccine authorized for emergency use last week by the Food and Drug Administration, and the Moderna vaccine the FDA authorized Friday night.
Medical decisions from start to finish
Who is going to get these vaccines first? This needs to be a medical decision from beginning to end. Health care workers makes sense, since many of us are seeing COVID patients on the front lines. If we contract the virus, we can quickly spread it to each other, to our friends and families, or to our vulnerable patients. We can also be messengers to society about the safety of the vaccine.
The Pfizer and Moderna vaccines have been in the works since late January, when the structure of the virus became available online. Messenger RNA technology (genetic signaler) has been available since the 1990s but it was only recently when scientists figured out how to cloak it in a way where it didn’t trigger an immune reaction which destroyed it. Our bodies use MRNA all the time to signal our cells to make certain proteins, but this one is synthetic.
What’s truly exciting, and an explanation for the 95% effectiveness (after two shots) seen in the late stage Pfizer and Moderna trials, is that once the cells make the signature spike protein of the virus, the immune response includes not just neutralizing antibodies but also the killer T cells that live virus vaccines induce. We don’t know just how long this immunity will last, but promising studies show that this virus behaves like SARS in terms of immunity, and it is likely that immunity may last for years.
Long term health facilities and nursing homes also make sense as a top priority group, because age, obesity, and underlying health conditions are all risks for severe disease. And it is very difficult to isolate suspected cases in a nursing home. This is why though 6% of the COVID cases occur in long term facilities, almost 40% of the COVID deaths take place there. The 1.4 million nursing home residents will be right at the front of the line, which is where they belong.
Front of the COVID-19 line: How to ensure VIPs don’t receive special treatment
Outbreaks in prisons are also quite common, occurring more frequently than in the general population, the death rate is higher, and the risk of spreading COVID beyond the walls of the prison via staff has proven to be significant. They too should receive priority for the vaccines.
Add to the priority list essential workers who come into contact with the public frequently, the elderly, the obese, and those with preexisting conditions as well as those who live in underserved areas where many of the outbreaks have occurred.
Social conditions should be a factor
Should Black and Hispanic people be prioritized because these groups have been ravaged by COVID? Gov. Andrew Cuomo of New York thinks so and he is not alone. He said in a press conference this week, “110 leaders signed on from the state saying that don’t continue the discrimination that we have seen through COVID, where black, brown, and poor communities were left behind with higher death rates, higher infection rates, COVID doesn’t discriminate. Neither should the United States of America.”
This comment resonated with me, and brought back my medical school days of learning that we are all the same inside and out. But I also considered a new study just published in the Journal of the American Medical Association Network Open the Population Health group at NYU Langone Health.
The study concluded that though Black and Hispanic populations account for a much higher proportion of COVID cases and deaths for their population size, especially in major cities where they face the effects of poverty in much higher numbers, at the same time they were not more likely to be hospitalized. This was most likely due to less timely care and poorer health coverage, as well as resistance to intervention. Once in the hospital, Black people were less likely to die from COVID than white people, a testament to the equality of hospital care, at least at NYU, as well as the important fact that Black and Hispanic populations are not inherently susceptible to poor COVID outcomes.
Other factors are in play too, including poor housing, unequal access to health care, and poverty. All these factors should help determine who should get the historic vaccine first.
Dr. Marc Siegel, a member of USA TODAY’s Board of Contributors and a Fox News medical correspondent, is a professor of medicine and medical director of Doctor Radio at NYU Langone Health. His latest book, “COVID: the Politics of Fear and the Power of Science,” was published last month. Follow him on Twitter: @DrMarcSiegel
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