Dr. Marty Makary: COVID vaccinations of most vulnerable need to speed up — here’s what to do


The United States has stumbled out of the COVID-19 vaccination starting gate. Over three weeks after the Food and Drug Administration issued an emergency use authorization for the first vaccine, we still have most of our supply sitting unused — as thousands of Americans die daily from the coronavirus.

According to Bloomberg News, as of Tuesday night just over 17 million doses of the Pfizer-BioNTech vaccine and the Moderna vaccine for COVID-19 had been distributed in the U.S., but only a little over 5 million shots had been given.

So what’s going on? Here are the major problems with America’s vaccine rollout, with some suggestions on how to vaccinate the most vulnerable among us more quickly.

AMID SLOW VACCINATIONS, US HOSPITAL LEADERS CALL FOR FEDERAL HELP

CDC guidance was late

Like a college student handing in a term paper two weeks after the deadline, even though he had nine months to work on it, the Centers for Disease Control and Prevention career staff

released their guidance after the first vaccine was authorized and being administered to Americans.

States and hospitals were sitting on their vaccine supplies waiting on the CDC. Even worse, when the CDC did release its guidance, it was flawed.

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First, the guidance did not stratify America’s 23 million health care workers. Instead, it placed someone like a healthy 32-year-old dermatologist specializing in Botox injections in the same priority group as a 63-year-old intensive care unit nurse with diabetes and asthma.

Second, the guidance did not start with the oldest Americans, an easy-to-implement allocation strategy that maximizes the preservation of human life. Some 80% of COVID-19 deaths have been in people over age 65. The disease has killed more than 357,000 people in the U.S. so far.

In fact, the CDC director urged the allocation committee to use the basic approach of vaccinating older Americans early on — a strategy has been adopted by other countries with great success. Israel, for example, has already vaccinated approximately half of its citizens who are over age 60.

Fortunately, Florida has rejected the complex CDC guidance for a simple age-based strategy, which avoids confusion and streamlines messaging like a boarding process. Florida Gov. Ron DeSantis, seeing long lines of high-risk seniors, appropriately concluded: “It makes no sense for someone that’s 42 to jump ahead of somebody that’s 70-years-old.”

DR. MARTY MAKARY DECRIES PEOPLE ‘CUTTING IN LINE’ TO GET CORONAVIRUS VACCINE

We are vaccinating people who are already immune

Tragically, because of poor CDC guidance, we are using precious vaccines to vaccinate people who are already immune to COVID-19.

The vast majority of people who have already been infected with the coronavirus have built up the antibodies and memory B and T cells to fight it off themselves. But the CDC guidance did not deprioritize them unless they had the infection in the last 90 days.

Natural immunity may last as long or nearly as long as vaccinated immunity — a question that will be answered over time. But so far, after one year of the pandemic, reinfections are rare and when they do occur they are mild.

Keep in mind that the vaccines are not perfect. COVID-19 infection occurs in approximately 5% of vaccinated individuals. Right now, while our vaccine supply is limited, those who have had the infection should be stepping aside in the vaccine line.

The government held back more than half of the vaccine

 Director of the National Institute of Allergy and Infectious Diseases Dr. Anthony Fauci and the old guard medical establishment decided to reserve a second vaccine dose for every person who receives an initial dose, plus a 5% buffer supply.

It may sound smart to reserve those second doses, but it ignores the data that partial immunity after the first dose can be 80-90% effective.

Given the high rate of carnage from this pandemic and the scarcity of the vaccine supply, more American lives would be saved if we use the entire current vaccine supply on first doses, and then follow up with second doses after every high-risk American has been offered an initial dose. This is highly achievable in a short period of time as evidenced by our track record giving the flu shot to half of Americans some years.

People at low risk are cutting in the vaccine line

After a summer of corporate and political statements about Black Lives Matters, Americans with power and access are cutting in the vaccine line.

Because the CDC guidance was late and unclear, vaccine administration centers have scrambled to develop their own tiered allocation systems for who gets the vaccine. Some have done it well and others poorly, magnifying inequities in our health care system.

Some facilities also received more vaccine doses than they have patients and staff, fostering cronyism in who gets the surplus.

In the first two weeks after the FDA authorized the life-saving vaccine, hospital board members, young members of Congress, spouses of physicians, receptionists in cosmetic surgery offices, and young firefighters have been getting the vaccine, while society’s most vulnerable wait around as sitting ducks in our pandemic war. 

Low-risk Americans who cut in the vaccine line using their access and power are essentially telling our society’s most vulnerable members “your life matters less.”

Just because you can get the vaccine now doesn’t mean you should. Those with access should pause and assess their own individual risk as our short supply forces vulnerable Americans to wait.

Failure to use dialysis centers

Kidney disease is the most common risk factor for COVID-19 deaths. Every year, U.S. dialysis centers give kidney patients the flu vaccine early and efficiently. Yet the nation’s vaccine plan did not ship the vaccine to any of America’s 7,500 dialysis centers.

Sending the vaccine to dialysis centers would have enabled them to swiftly protect those most vulnerable. Similarly, pharmacies, which are integrated into communities and the routines of seniors, should be better utilized as vaccination partners rather than focusing on hospitals as vaccination hubs.

Hospitals sitting on vaccine surpluses should immediately offer them to older members of the community.

On a personal note, I can’t justify taking the vaccine myself before my 74-year-old friend in Baltimore, who is Black and high-risk because he has renal disease. My personal case fatality rate is very low. And while I work in health care, I do not work on the frontlines of treating patients with COVID-19.

My surgical patients are tested before their operations. We also have impeccable protocols. I’m not criticizing clinicians who get the vaccine. My personal decision might be different if I spent more time in the intensive care unit and took more emergency calls. But that’s not me.

Given my low personal risk of mortality and my low risk of getting the virus in my limited clinical work, I have joined a growing chorus of health care professionals who have taken a pledge to not get the vaccine until every high-risk American has been offered it first.

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Authorize the Oxford-AstraZeneca vaccine

Finally, the FDA needs to stop playing games and authorize the Oxford-AstraZeneca vaccine.  It’s safe, cheap ($2-$3 a dose), and is the easiest vaccine to distribute. It does not require freezing and is already approved and being administered in the United Kingdom.

Sadly, the FDA is months away from authorizing this vaccine because FDA career staff members insisted on another clinical trial to be completed and are punishing the company for inadvertently giving a half-dose of the vaccine to some people in the trial.

It’s like the FDA is holding out, pontificating existing excellent data and being vindictive against a company for making a mistake while thousands of Americans die each day.

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Ironically, those in the Oxford-AstraZeneca trial who inadvertently received half the initial vaccine dose had lower infection rates. And this week Dr. Moncef Slaoui, the chief adviser to Operation Warp Speed, acknowledged that using half a dose might be a good broader strategy for the U.S. to double our supply as long our supply is severely constrained. That’s a good strategy that makes sense.

It’s not too late to take corrective measures to get the vaccines to the people who need them most. Let’s think through our priorities and pivot so those who are in the greatest danger can be rescued from this deadly plague.

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