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A critical-care nurse in New York was the first person in the U.S. to receive a COVID-19 vaccine, but the question of who else should be among the first to receive the vaccine is still being sorted out.
Earlier this month, the Advisory Committee on Immunization Practices, a body of experts that provides guidance to the U.S. Centers for Disease Control on vaccine issues, recommended that health-care workers and residents of long-term care facilities be provided the vaccine in its initial phase of distribution.
The panel offered a broad definition of health-care worker that includes roughly 21 million people working in a range of settings and functions. But there are likely to be far fewer than necessary doses to vaccinate all 21 million health care workers in the initial shipments.
“Broadly speaking, the intent was how do we preserve health-care capacity,” Grace Lee, a member of ACIP and associate chief medical officer for practice innovation at Stanford Children’s Health, said of the thinking behind the committee’s recommendation that health-care workers should be among the first to receive the vaccine.
That group not only includes doctors, nurses and nurse practitioners, but also food-service, custodial and other workers in the health-care setting, she said. “We need them in order to keep the health system running.”
Though ACIP’s recommendations have been watched closely, sorting through exactly whom among the millions of health-care workers should be prioritized for the vaccine will be left up to states and institutions. That’s why recommendations at the national level “have to be broad and flexible, they cannot be overly specific,” Lee said. “Health care is very local in some ways and so you have to be able to respond to what is critical and important on the ground.”
Maintaining capacity is about more than just front line health care
In many jurisdictions, maintaining the capacity to care for COVID patients likely will require more than vaccinating the health-care workers who deal with them directly, said Lisa Parker, the director of the Center for Bioethics and Health Law at the University of Pittsburgh. That could include health-care staff who work with cancer patients as just one example, she said.
“You want to keep other patients from becoming sicker and then putting a strain on the health-care system, so it would make sense to try to prevent those workers from becoming sick with COVID as well,” she said.
At Stanford’s health system, where Lee works, they’re pulling in outpatient partners, like pediatrician and family practitioner offices, to ensure they get access to the vaccine early, she said.
“During the winter their practice ends up being a huge chunk of respiratory illness care,” she said. “That is just a usual part of business, but they’re delivering care and some of those patients may be COVID positive. We’re pulling them in because we want to make sure we protect as much of our healthcare system as possible.”
In addition they’re also ensuring that EMS personnel have access to the vaccine in an initial distribution phase because “we see it as part of the duty to the community,” Lee said.
Once states and institutions decide who will get priority for the vaccination, actually operationalizing those recommendations can be challenging, Lee added. Because the vaccine could have side effects that would leave recipients out of work for a few days, health systems likely need to stagger vaccination to ensure an entire unit isn’t out at once.
States differ on which health-care workers will receive access to the vaccine when
States and localities have provided varying guidance on which health-care workers will receive access to the vaccine when. In New York state, officials have said that health-care workers in patient care settings will be in phase one of vaccine distribution, with ICU and emergency units having top priority. After that “all entities receiving the vaccine will be given a level of autonomy to determine the internal order of employee vaccination based on risk and within the boundaries of NYS and federal guidance.”
In Colorado, officials have said that those who have direct contact with COVID positive patients for 15 minutes or more, along with long-term care facility residents and staff, will be prioritized for vaccine distribution. After those populations are vaccinated, health care workers with less direct contact with COVID positive patients, and frontline workers — for example, EMS personal and those working in correctional facilities — will be next.
Organizations representing health-care worker groups have been and plan to continue to advocate at the state, local and institutional level for their members to be included in the initial phases of vaccine distribution.
Alison Whelan, the chief medical education officer of the Association of American Medical Colleges, which represents medical schools, said the group respects the complexity involved in deciding who within a health-care system should be provided access to the vaccine first. Given that complexity, they’re not weighing in on individual health systems’ plans, they said.
But the association does believe that medical students should be classified as health care workers for the purposes of vaccine distribution.
“Health centers have to follow the state rules and different states are interpreting the CDC guidelines differently,” Whelan said. “There are some that are saying, yes students are essential health-care workers and should be included as you do the first round. Others have said that they’re students, more like college students, and should fall in that line, which we don’t agree with.”
For one, medical students need to be involved in patient care to progress through their education, something that is key to maintaining and growing the health care workforce, Whelan said. In addition, during their education, medical students provide support to the clinical team.
“As we take a look at these last couple of weeks where hospitals quite frankly are flooded with patients and we need all hands on deck, what we know, which has been true in the past, is that students, even though they’re in a learning environment, they have very good skills, especially the more senior medical students,” said Janis Orlowski, the chief health care officer at AAMC.
School nurses in Texas are lobbying for access to vaccine shots
Health-care staff who work outside of hospital settings have also been eager to secure their place in line. Laurie Combe, the president of the National Association of School Nurses, said her organization is encouraging its members to do advocacy on the state level to get access to the vaccine. In Texas, for example, school nurses have been communicating with the state’s department of health and human services to ensure they’re named specifically in the state’s vaccine distribution plan.
Right now, school nurses are listed in the second tier of phase 1A for vaccine distribution, following hospital staff working directly with patients who are COVID positive or at risk of becoming COVID positive, staff at long-term care facilities, EMS personnel and others.
Sharmila Sandhu, the vice president for regulatory affairs at the American Occupational Therapy Association, said the group has been exploring advocacy at the federal and state level to protect both occupational therapy professionals and clients, but hasn’t yet contacted regulators.
Occupational therapists and occupational therapy assistants work in a variety of settings, including in long-term care facilities, home health care, hospitals and schools, which could have varying implications for when and how they receive the vaccine.
But one thing that is clear: “They’re in very close contact with their patients,” Sandhu said, helping them deal with activities of daily living, including getting dressed.
The government does recognize occupational therapists’ role in maintaining public health, safety, economic and national security, which should place them in a position to get the vaccine relatively early, according to the association. The Cybersecurity and Infrastructure Security Agency specifies occupational therapists and occupational therapy assistants as “essential critical infrastructure workers.”
“Based on the ACIP recommendations, this position supports that occupational therapists and occupational therapy assistants that work in settings with potential for exposure should be included in the first round of vaccinations,” AOTA wrote in a recent post on their website.
Dentists are eager to provide vaccinations
The CISA memo also lists dentists as critical infrastructure workers and dentists are advocating with state regulators to both receive the vaccine relatively early and to give it out.
“Oral health care, dentistry, is essential health care,” said Dave Preble, senior vice president, practice institute at the American Dental Association. “We’ve pretty much established that more than ever,” he said, noting that once dental offices were able to reopen after the initial phases of the pandemic, patients flooded dental chairs to treat pain and deal with preventive care that had languished during the months offices were closed.
Though the ADA believes dentists and dental office professionals should get access to the vaccine relatively early, they know that some health-care workers will be ahead of them in line, Preble said.
Dentists are “doing their best to not treat [COVID-19 positive] patients except in extreme emergency situations,” he said. “Any health-care worker group that is screening out and trying not to treat COVID-19 patients is going to be a second tier to the ones that their job is to treat COVID-19 patients. We agree with that.”
The association anticipates that dental professionals will receive the vaccine after that initial round of health care workers treating COVID patients. “The governors’ offices have basically told us that dentists are included in that top priority, although again not that top sub priority — that’s kind of what we expect,” he said.
Preble said his organization is also talking with state regulators about allowing dentists to provide the COVID vaccine, given the urgency with which officials are hoping to get the broader population vaccinated.
“Dentists give more injections than probably any other medical provider in the entire world,” he said.
