If There Aren’t Enough Vaccines for All Health Care Workers in California, Which Doctors, Nurses or Aides Will Get It First?

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A sign on the entrance to a pharmacy reads 'COVID-19 Vaccine Not Yet Available' on Nov. 23, 2020 in Burbank, California. (Robyn Beck/AFP via Getty Images)

When California receives its first shipment of COVID-19 vaccines in early December, experts agree health care workers will be the first to get it.

But while the state’s medical workforce includes 2.4 million people, officials say the first vaccine shipment is expected to contain just 1 or 2 million doses — forcing the state to “sub-prioritze.” So who moves to the front of the line: a 65-year-old emergency room nurse or a 30-year-old home health aide?

“These are the difficult decisions that we are wrestling with,” said Dr. Oliver Brooks, chief medical officer at Watts Healthcare Corporation in Los Angeles and co-chair of the group charged with writing the state’s vaccine allocation guidelines.

Those guidelines are in draft form right now and will be refined over the next several months as scarce vaccine supplies trickle out. The Food and Drug Administration is expected to authorize the first vaccines in the coming weeks, and federal officials have said states will begin receiving doses 24 hours after they're approved.

The state is drawing guidance for its overall distribution plan from the National Academy of Sciences, which recommends prioritizing people according to three main criteria: those who are at high risk of getting the virus; those most likely to suffer complications or to die if they become sick; those whose illness could have a negative impact on society.

This third principle — societal impact — is what puts health care workers in the top tier: If a doctor or paramedic is out sick for three or four weeks, their absence impacts the well-being of the community in a much more profound way than, say, a sick video game designer.

The details of these distribution plans are left to individual states to decide and implement, and California officials have emphasized that fairness and equity are top goals. They’ve established an advisory group comprised of 70 community organizations and medical associations to provide input.

“We must work together to ensure that vulnerable Californians, those most at risk, have equitable access to the vaccine,” said Dr. Erica Pan, acting state public health officer. “All of our preparations for the vaccine are guided by the need for safety, equity and transparency in the process.”

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Which Health Care Workers Get Priority?

The state is applying the same principles to deciding which health care workers should be prioritized over others — chance of getting it, chance of a bad outcome, societal impact of getting it — and adding three additional criteria to the consideration: the type of health care facility, the location of the facility and the characteristics of the people who work there.

For example, California’s draft plan puts acute care hospitals and congregate care facilities, like nursing homes and assisted living, at the top of its list since those workers are most at risk of contracting the disease. Primary care clinics and dental offices are lower down.

But the state has more than 1 million staff working at acute care hospitals alone, so the first shipment of vaccine may not cover everyone even in the state’s top tier of medical providers.

A chart of health care workers by facility type. (California Department of Public Health)

From there, the state might consider the location of the facility using principles of equity and the state’s “vulnerability index,” which measures social determinants of health in neighborhoods, like access to housing, education and transportation.

“Let’s say we say acute care hospitals get first pass,” Brooks said. “There are five in L.A. County. So should it go to the three that are in a low- to moderate-income area, versus somewhere that's a higher income?”

If the state decides hospitals in low-income areas get priority, then officials further narrow the decision by looking at which employees in those hospitals should get it.

“What personal characteristics would we look at?” Brooks asked, at a recent meeting of the community advisory committee. “Occupation, age, gender, race and ethnicity, co-morbid conditions?”

Occupation and age are the most likely, he added, since the state has more reliable, actionable data on those categories. This suggests nurses and EMTs would get the vaccine before hospital janitors or drivers, and older nurses might get priority over younger nurses.

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None of this has actually been decided yet. The state gathered feedback from community stakeholders at an advisory committee meeting on Nov. 25, and Gov. Gavin Newsom indicated a more formal plan for health care workers could be presented as early as Dec. 1.

But this is just the beginning. Once health care workers are vaccinated, the state will have to decide how to allocate the next shipments of vaccines among the elderly, essential workers, prison inmates, teachers, children and everyone else. The majority of Californians will not be vaccinated until spring or summer 2021.

“We’re having this discussion because there won’t be enough vaccine for everyone,” Brooks told the committee. “What I want the community vaccine advisory to focus on is ensuring that we have a process in place to allocate accordingly and ensure that that process is fair.”