I wrote this essay one day after the unbelievable assault on the US Capitol. The news for almost 48 hours was completely focused on this event. In the meantime, each day saw a new record for deaths caused by Covid-19 in the United States. 4,051 Americans died from Covid-19 infection on January 7.
Not only is the pandemic continuing to surge with no real attempt to control spread of the virus, but the immunization strategy which has been promoted to be the cure for the pandemic has been a complete failure. The reason for the failure is the absence of a clear national strategy for immunizing the population. The lack of this strategy is then compounded by a confusing and muddled plan for vaccine distribution. As a result, after 4 weeks, only 25% of available vaccine had been administered, and in many cases it was not going to the population at greatest risk. There was a report of a pharmacist in a free-standing pharmacy who pulled two young men off the street to get two vaccine doses, because the pharmacy was closing and they had not used all of the prepared vaccine. News reports in Austin documented that patients who were not in the Texas priority groups were receiving the vaccine for the same reason – the vaccine doses were not where they need to be. The response in Texas is to open up vaccination to everyone. This has created confusion, long lines, shortages of vaccine in specific locations, and worst of all, leaves vulnerable populations at risk.
The reason that the management of the pandemic is such a mess is first due to the lack of a coherent national strategy. Unfortunately, politicians have taken the lead on the state level strategy in Texas, resulting in nothing less than chaos. It is time for public health officials and physician leaders to take over the management of the pandemic in Texas. The governor and the attorney general should stay out of the way.
We had an opportunity to “flatten the curve” of the pandemic over the recent holiday (see the last Pandemic Update). Our political leaders continue to argue that the effect of a non-essential shut-down would be too devasting to the economy. Is that more important than thousands of lives?
With regard to the control of viral transmission in the community, the last CDC guidance issued the end of October 2020 was primarily focused on strategies to reopen communities after achieving control of community transmission. I can find nothing explicitly outlining the recommended strategies for managing substantial, uncontrolled community transmission – except for a recommendation to “shelter in place”. The decision to go to a shut-down should be based on the rates of community transmission, rates of hospitalization, and the availability of healthcare resources to treat patients. Maximizing the response to these metrics would certainly reduce severe infections and deaths. I would say that we are in the red zone in Texas across all of these metrics.
We need for state and local public health professionals to do the right thing and take control of the Texas strategy for managing the pandemic. Politics has no place in public health decisions during a pandemic.
Here is what I would recommend from the public health perspective. First thing is to stop interstate and international mass transit. This is not about the travel – which on its own is generally non-essential. The purpose of this restriction is to keep people from doing things during travel that they would not be doing if they stayed home – traveling thru airports, riding trains, eating in restaurants, staying in hotels, and attending in-person meetings and events. Second, we should shut down all in-door non-essential activities and outdoor activities that attract large crowds. This includes schools, gyms and fitness facilities, churches, bars, restaurants, theaters, sports venues, amusement parks and other outdoor events. These are all high-risk activities. I will argue that it is not possible to significantly reduce the risk of these activities, even if you implement strong hygiene protocols. The reason is that most of these activities involve in-person interactions in the travel to and from these activities. A great example is the bars that have received restaurant certification in downtown Austin. These bars are following the recommended guidelines for infection control in their facilities, but at most locations you find lines of people waiting to get in with no social distancing or mask-wearing.
What about the immunization strategy? In this case, the CDC has recommendations for vaccine prioritization, that for some reason, the state of Texas has chosen to ignore. The first CDC priority (phase 1a) is healthcare personnel and long-term care facility residents. This should mean all healthcare personnel, including private clinics and facilities. In this phase, vaccination should be mandatory. We must remember that you are taking the vaccine not only to protect yourself, but also to protect others. This cannot be accomplished completely in these high-risk settings if individuals opt-out of vaccination. The second CDC priority is frontline essential workers and individuals over age 75 (phase 1b). In this group, the vaccine should be mandatory for individuals who have significant inter-person interactions: EMS workers, firefighters, police, daycare workers, and public transit workers. The vaccine can be voluntary for groups who do not have regular inter-person interactions. Vaccine should be distributed to healthcare facilities with the capacity to store, prepare and administer the immunization to large populations referred to that facility.
The state of Texas initially opened vaccination to the CDC phase 1c population, individuals over age 65 and over age 16 with underlying medical conditions. The problem with this strategy is that vaccine is being delivered to private clinics and pharmacies that apparently do not have the logistic systems in place for effectively prioritizing vaccine administration. You also are seeing that patients who meet criteria for vaccination cannot get the vaccine because they do not have a relationship with the private clinic or pharmacy that has vaccine supply. It would be better at this phase and for subsequent vaccination of the full population to establish an independent network of vaccine centers. This would include health department clinics and pharmacies like CVS and Walgreens that have in-store clinics and pharmacists. The fact is that most physician offices have not been vaccine providers for several years – they are referring their patients to the pharmacy chains. There may be some large private clinics who have the capability to immunize large populations, but they should not restrict vaccine to their patients only.
It would have been ideal to have a national strategy for management of the pandemic and vaccine administration prior to the vaccine roll-out. It may not be too late to reorganize and get it right. I call on public health professionals and physician leaders to step up and get the politics out of this pandemic.
Waterloo to Austin 