The District plans to give priority for coronavirus vaccines to the broadest possible swath of people with preexisting health conditions — a decision that will make hundreds of thousands eligible for scarce doses of the vaccine and that some public health experts say might not make medical sense.
The plan, the details of which were confirmed by vaccine director Ankoor Shah, would offer vaccines to people whose weight and medical history would not qualify them for early access to the vaccine in almost any state in the country.
D.C. Health Director LaQuandra Nesbitt told members of the D.C. Council last week that she decided to open up vaccine access, possibly as soon as February, to such a large group in the hope of quickly vaccinating anyone who might suffer the worst outcomes if they contract the virus.
Nesbitt did not tell lawmakers which chronic conditions would be covered, however. The health department and the office of Mayor Muriel E. Bowser (D) confirmed that information to The Washington Post this week.
A promise of vaccines for people above a healthy weight could help get vaccines to poorer, majority-Black wards in the city, where vaccination rates have lagged, because a greater proportion of poorer residents are obese.
But offering vaccines to so many adults will be a logistical challenge for the city, which has struggled to keep its website and phone line for vaccine registrations running smoothly for the senior citizens and health-care workers who are currently eligible.
And the extensive list of chronic conditions — which includes habitual smoking and diseases such as cancer, heart failure, diabetes and Down syndrome — raises the question of whether residents eager to be vaccinated will be honest about whether they have one of the conditions: if they smoke, for example, or have a body mass index over 25.
“When you have something that’s that common, it becomes a question of social policy implementation: How do you get vaccines into people’s arms? It’s almost too common — it would be very hard, I think,” said David Kass, a Johns Hopkins cardiology professor researching obesity.
Kass and some other experts said some of the conditions the District is including have not been clearly proved to put people at higher risk of complications from covid-19, the disease caused by the novel coronavirus. In terms of body weight, some recommended prioritizing people with BMIs over 40 rather than anyone whose weight is above a level considered healthy.
“At some point or another, it’s not much of a discriminator anymore if you define a co-morbidity as something that almost everybody has,” Kass said.
Sara Tartof, an infectious-disease epidemiologist at Kaiser Permanente’s research department, said that in a study she helped lead on factors that increase coronavirus risk, a BMI over 40 — severe obesity — “eclipsed” almost all other risk factors. BMI over 30 also posed some risk.
“We don’t see anything in our data — and this is a very large data set that I’m talking about — I don’t see an association below 30,” Tartof said. “And for death, we don’t see a statistically significant association below 40.”
Most states and the District are vaccinating health-care workers and the elderly before anyone else. After that, practices vary widely. But the District’s plan appears to differ substantially from those of almost every state but New Mexico and Delaware in its generosity toward people with less obviously dangerous medical conditions, including asthma and high blood pressure.
Some states’ vaccine distribution plans are based entirely on age, occupation and other factors such as race or residential setting. But many promise to prioritize people with some of the conditions that the U.S. Centers for Disease Control and Prevention has listed as scientifically proved to exacerbate complications from the coronavirus. Those include cancer, chronic kidney disease, sickle cell disease, BMI over 30, smoking and pregnancy, even though data remains limited on whether pregnant people should be vaccinated.
Only a few states, including Alabama, Nevada and New Jersey, have committed to vaccinating people with all the conditions on that CDC list. Other states’ vaccine plans indicate they will omit some people — smokers in some cases, or pregnant people, or people with only one co-morbidity.
The District, however, will not only vaccinate all people with the listed conditions, but it also will give priority to people with a second set of conditions that the CDC says might increase coronavirus risk — but have not yet been proved to do so. Those conditions include asthma, cystic fibrosis, liver disease, high blood pressure and BMI over 25 — meaning, for example, a person who is 5 feet 6 inches tall and weighs more than 155 pounds, or is 6 feet tall and weighs more than 184 pounds. (You can calculate your BMI here.)
More than half the adults in the District — and 72 percent of those living east of the Anacostia River — have a BMI over 25, according to the health department.
“For people who have some of the chronic health conditions, we don’t know that they have higher risk yet from a science perspective,” Nesbitt told members of the D.C. Council last week. “We don’t want to make an erroneous decision to exclude them.”
New Mexico, like the District, appears to be planning to prioritize people with health conditions from either CDC list, according to a Washington Post analysis of vaccine plans released since the rollout began and compiled by the law firm Littler. Delaware plans to offer vaccines to people on the second list in its Phase 2 vaccinations — after the higher-risk conditions but before the general population.
But other states seem to have disregarded the second CDC list in their vaccine planning.
Shah, the pediatrician directing D.C.’s vaccine program, said the District might roll out vaccines to people with some conditions on the list before others, to manage the volume of patients. But he committed to making sure people with all of the conditions on the two CDC lists have access to vaccines before the general population.
“We are seeing incredibly high uptake across the city,” Shah said. “People want to get vaccinated.”
The District, like states across the country, has divided its vaccination plan into phases and tiers. In Phase 1A, the city started vaccinating health-care workers and nursing home residents. The current phase, 1B Tier 1, adds people over 65.
This phase has proved frustrating for many of the District’s more than 80,000 seniors, who have found that the website for registration is finicky, phone call wait times are lengthy and the thousands of appointments available each week are snapped up within minutes or hours.
After data showed that seniors in affluent neighborhoods were getting the vast majority of appointments, although poorer parts of the city have seen far more coronavirus cases and deaths, city officials last week reserved some vaccine appointments for seniors in underserved areas.
The District plans to launch Phase 1B Tier 2 next week, beginning with teachers and law enforcement personnel, and then moving on to other prioritized groups including grocery store employees. The tier after that includes more essential workers.
Residents with chronic medical conditions fall in the first tier of the third phase, 1C, and come before the remaining essential workers, including ride-share drivers and journalists.
City leaders originally said they hoped to begin 1C vaccinations as soon as Feb. 1. But Shah said that given the ongoing high demand from seniors — and the limited supply of vaccines coming from the federal government — he does not expect to meet that target.
While many seniors and health-care workers are registering with the city and getting vaccinated at pharmacies at Safeway, Giant and community clinics, Shah said the city plans for more people with chronic conditions to register and get vaccinated through their doctor’s offices.
Their doctors will already know how much they weigh and whether they smoke or have another chronic condition, to determine whether they qualify for a shot, Shah said.
But those who don’t have a physician associated with a health system equipped to administer the vaccine still will be able to sign up through the city and get vaccinated at a pharmacy or clinic.
Shah said that to protect those people’s privacy, they will simply be asked a yes-or-no question: Do you have one of the chronic conditions on this list? Those who say yes, live in the District and are at least 16 years old will get a vaccine, no further proof required.
“With a lot of this, it’s the honor system, attestation,” Shah said. “As a health department, as a city, we have to strike that balance of ensuring the right people are getting in line without creating barriers for them.”
Fatima Cody Stanford, an expert on obesity from Harvard Medical School, called the District’s plan to vaccinate all people above a healthy weight “amazing” from a public health perspective.
“Obesity is a disease state characterized by significant inflammation,” she said. “What we know about covid is it’s also a state characterized by significant inflammation. . . . We can call this the perfect storm. When a patient with obesity gets covid — it’s a recipe for not good things.”
Other experts raised concerns — and not just about whether the heightened risks from the coronavirus apply only to people with severe obesity.
Nancie Jo MacIver, a Duke University immunology professor, said she is conducting research on why flu vaccines don’t work as well long-term in patients with obesity and wonders whether the coronavirus vaccine may be similarly affected.
The possibility, she said, would give her pause before prioritizing weight in a coronavirus vaccination campaign.
“You could take a moment and say, ‘Hmm, are we going to give vaccination as a first priority to a group where we don’t necessarily know it’s going to be as effective?’ ”
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