As early doses of COVID-19 vaccines arrive in Michigan, there’s no dispute over who’s first in line: frontline hospital workers and medical first responders who have battled the virus for months.
Next up, according to state plans: staff and the mostly elderly residents of long-term facilities that account for more than a third of the state’s overall coronavirus death total, which has surpassed 11,000.
But with initial doses of the Pfizer/BioNTech vaccine still scarce, county health departments and local hospitals are faced with difficult choices on how to prioritize vaccines after these top-level groups.
“These are incredibly difficult decisions,” Jeffrey Byrnes, a Grand Valley State University philosophy professor and medical ethicist, told Bridge Michigan.
“This is a real high wire act. This is the kind of thing that 10, 20 years ago would have been drafted as a hypothetical and perhaps overly dramatic textbook problem. Now we are facing this in real time.”
State guidelines in Michigan suggest that next in priority should be others in the healthcare field who also face risks, including dentists, pharmacists and outpatient, urgent care and home health care workers.
After that come difficult choices on other essential workers. This includes teachers and other staffers at schools and day-care centers, workers in food supply, utilities, transportation, at homeless shelters, jails and funeral homes.
For the past several weeks, Byrnes has been advising officials at the Kent County Health Department as it lays out plans for vaccine distribution to essential workers in the coming weeks and months.
Like 44 other local health departments across the state, Kent County will have to ration its vaccine supply until more vaccines become available.
Should a city bus driver get a shot before a grocery store worker? Do public school teachers get priority over staff at a homeless shelter?
“We have been planning for this for months,” said Mary Wisinski, immunization program supervisor for the Kent County Health Department.
“You make multiple plans and try to anticipate every contingency and that’s kind of where we are at right now.”
Those contingencies include uncertainty over the supply.
Michigan is on track to get an estimated 84,000 doses of the Pfizer vaccine this week, approved Dec. 11 for emergency use by the U.S. Food and Drug Administration. But health officials learned Wednesday the state will get just 60,000 doses next week. That’s enough for 30,000 health workers (the vaccine requires two doses) in a state with more than 600,000 in the industry.
Confusing matters, Pfizer officials said in a statement Thursday it has “million more doses sitting in our warehouse” but had not received federal instruction where to send them.
The FDA on Friday approved a second vaccine by drug maker Moderna, which is expected to ship nearly 6 million U.S. doses next week.
It’s not clear how long it will take Michigan to provide vaccines to health workers and the state’s more than 100,000 residents of nursing homes and other long-term facilities.
Even within hospitals, distribution of the COVID vaccine remains a work in progress, with some hospital systems surveying staff on who wants to get the first vaccines, and who wants to wait. At Beaumont Health, a spokesperson for the Detroit metro hospital system said the first to get vaccines “were randomly selected out of a larger pool of eligible employees and physicians.”
So far, no system in the state has yet mandated the vaccine for COVID, as they have done in the past with more established vaccines such as those for the flu.
Arthur Caplan, a bioethics professor at NYU Grossman School of Medicine, told the New York Times that other health care workers could be worthy of consideration for initial vaccines, including primary care doctors in areas with high infection rates, chaplains, hospice workers and pathologists who handle coronavirus samples in labs.
“Right now, they are asking, ‘Where am I in all of this?’ That’s turned into quite a behind-the-scenes tussle,” Caplan said.
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At some point hopefully early in 2021, Michigan’s COVID vaccines will be expanded to K-12 school staff, workers “who keep critical infrastructure open and functioning,” staff at homeless shelters, jails and day centers as well as non-hospital labs and mortuary services, according to the state plan. People with underlying health conditions and those 65 and older are next in line, before the vaccine is made available to anyone 16 and older.
Michigan Department of Health and Human Services guidelines do not call for early vaccination for an estimated 35,000 state prisoners, even though more than 100 inmates have died of the virus and prisons have logged nearly 20,000 inmate cases of COVID-19. Groups including the American Medical Association have said prisoners should be given higher priority, with one AMA board member arguing, “Being incarcerated or detained should not be synonymous with being left totally vulnerable to COVID-19.”
Depending on how the vaccine supply chain unfolds ─ still an unknown variable at this time ─ widespread distribution to the general public may not materialize until late spring or summer.
State health officials have set a goal of vaccinating 70 percent Michigan adults, about 5.4 million adults, by the end of 2021.
As the supply of vaccines ramps up, Michigan’s Department of Health and Human Services said its planned phases will begin to overlap.
“It is important to note that vaccination in one phase may not be complete before vaccination in another phase begins. There may be vaccination of individuals in different phases that occurs simultaneously,” it said in a recent update of its plans.
In the Upper Peninsula, Marquette County Health Department health officer Jerry Messana has been in virtual meetings for vaccine distribution since July.
He consulted with township and school officials, administrators at Marquette Branch Prison and Marquette County Jail and Northern Michigan University, as the department maps strategy for vaccinating essential workers in what the state calls Phase 1B.
Critical to that plan: Just how many essential workers are in the county?
Thus far, Messana’s partial list includes an estimated 1,200 school workers with direct contact with children, at least 200 police and dispatch workers and about 400 firefighters. He’s still gathering the number of grocery workers.
“We’re trying to put our fingers on that,” he said. “You have stores like Meijer, but then you have any number of party stores and other grocery stores.”
But Messana said it’s a near certainty that initial vaccine shipments will fall short of that total, which may force local health officials to make judgment calls on how to roll out vaccinations.
“I think some people will feel they should be [vaccinated] before somebody else. It’s going to raise some questions in the community.”
Messana cited a hypothetical choice, one that could be shaped by the area’s average annual snowfall of 12 feet.
“If we have 1,200 teachers and staff and only 150 vaccines, it might make sense to get the public works and snowplow drivers done first.”
But in the long run, Messana said, those designated as essential workers all will get their chance at vaccination ─ a process that may take a month or two to play out.
“We are doing the best we can to follow the guidelines. We will get together with the [health department] medical director, the leadership team, the clinical staff and we will make those calls.”
Messana said officials are still working out the logistics of reaching people to vaccinate.
“We haven’t gotten to the point of how we are going to administer that, whether we go there or they come here,” he said.
Unlike some rural health departments, Marquette has specialized freezers needed to safely store the Pfizer vaccine at the recommended ─94 degrees Fahrenheit. Other departments are relying on hospitals for storage of vaccine allocations, even as they remain in charge of its distribution.
As medical director for four U.P. health departments covering 10 counties, Bob Lorinser told Bridge he has been immersed in COVID-19 vaccine planning with area officials since assuming his post seven weeks ago.
Lorinser said he doesn’t expect much conflict as agencies carry out the next wave of vaccinations.
“When we have these discussions, there is an understanding there may be limitations with the [supply of the] vaccine. But I don’t see a fight. I’m not hearing people say firefighters are more important than police or people in food or water or power.’
“I think people just want to know, ‘When is my turn?’”
In the last phase before vaccines are released to the general public ─ what the state calls Phase 1C ─ people ages 16 to 64 with underlying health conditions that put them at high risk for COVID-19 along people 65 and older can be vaccinated.
Byrnes, the ethicist, said fairly distributing vaccines to those with underlying conditions could be tricky. Health officials must be vigilant to ensure low-income people, Black residents and other more medically vulnerable groups have similar access to the vaccine.
“It's just so intuitive to say that we want to give this vaccine to the people who need it most. But we could be identifying the people who are already well acquainted with the health care system and have good access to health care,” he said.
Byrnes said that could leave out many who may not have seen a doctor in years.
“We know the virus has had a disproportionate impact on lower-income minority communities,” he said.
To date, the death rate from COVID-19 for Blacks in Michigan is more than twice that of whites.
A statewide survey of registered voters by the Detroit Regional Chamber found that just a third of Black voters said they will take a COVID-19 vaccine, compared to 58 percent of white voters.That suspicion appears to be driven by deep-seeded doubts among African Americans about government health treatment, tied in part to the decades-long Tuskegee medical experiment that used unwitting Alabama sharecroppers as human guinea pigs in a study of untreated syphilis.
The state is already engaged in outreach initiatives to minority communities, aimed at driving up awareness of the safety and benefits of COVID-19 vaccines.
“We should make sure we get this to every corner of our community, and of course the corners of our community have suffered more from the virus itself,” Byrnes said.
Determining if someone truly has an underlying condition is not a decision Kent County wants to arbitrate. Wisinski, Kent’s immunization supervisor, expects vaccinations for those with health conditions to proceed on the honor system.
“I think we will take people’s words. I can’t imagine that we will be asking them for documentation for that when they come in.”
On Tuesday, Eric Kane, a physician at Beaumont Hospital Trenton, downriver of Detroit, received the Pfizer vaccine. That’s no surprise, given his current hospital rotation.
“I’m working the COVID intensive care unit this month,” he told Bridge.
While he’s glad to be among the first to get a vaccine, Kane said he also understands the need to set a hierarchy for who gets the vaccine and when.
“I don’t know who’s figuring that out, but I trust them. I understand how the process works.”
Kane said he has parents in their 80s, living independently in Battle Creek, whom he hasn’t seen in person for more than a month out of caution for their safety. He realizes they probably won’t get a chance at a vaccine for many weeks.
“They understand that because of the vaccine limitations, they will have to wait. They are just happy I’m protected right now and that they will be protected when it’s their turn."