Zvi, I agree with you that the CDC’s reasoning was pretty sketchy, but I think their actual recommendation is correct while everyone else (e.g. the UK) is wrong. I think the order should be something like:
Notably, both papers don’t even consider vaccinating essential workers as a potential intervention. The only option categories are by age, comorbidities, and whether you’re a healthcare worker. The first paper only considers age and concludes unsurprisingly that if your only option is to order by age, you should start with the oldest. In the second paper, which includes HCWs as a category (modeling them as having higher susceptibility but not higher risk of transmitting to others), HCWs jump up on the queue to right after the 80+ age group (!!!). Since the only factor being considered is susceptibility, presumably many types of essential workers would also have a higher susceptibility and fall into the same group.
If we apply the Zvi cynical lens here, we can ask why these papers perform an analysis that suggests prioritizing healthcare workers but don’t bother to point out that the same analysis applies to 10% of the population (hint: there is less than 10% available vaccines and the authors are in the healthcare profession).
The actual problem with the original CDC recommendations was that essential workers is so broad a category that it encompasses lots of people who aren’t actually at increased risk (because their jobs don’t require much contact). The new recommendations revised this to focus on frontline essential workers, a more-focused category that is about half of all essential workers. This is a huge improvement but I think even the original recommendations are better than the UK approach of prioritizing only based on age.
Remember, we should focus on results. If the CDC is right while everyone else is wrong, even if the stated reasoning is bad, pressuring them to conform to everyone else’s worse approach is even worse.
Many people on this website are hardcore social distancers, interacting only with essential workers. To them it seems natural that essential workers are the majority of the transmission and do not have immunity yet. But most people aren’t social distancing very hard at all. In Nashville, were I currently am, the bars and restaurants are often full. My immune brother when to house parties and indoor concerts on New Years Eve. I doubt that essential workers constitute even a majority of current transmission.
So we vaccinate 80 million people and reduce transmission by 50%, maybe. That would take months. Meanwhile, there are only 50 million Americans over 65, doing >90% of the dying, and we could vaccinate them in just two months.
TLDR; The transmission argument for essential workers assumes people comply with social distancing. People aren’t doing that anymore, so vaccinate the vulnerable.
That seems plausible right now, in January, at our current level of social distancing compliance. But why would the degree of distancing stay constant over vaccination? It hasn’t even stayed constant the last 8 months when nobody has been vaccinated.
So far we have a clear pattern. People voluntarily comply when the issue seems important because there are lots of infections, hospitalizations and deaths. During lulls the issue becomes less available and compliance drops. In the best case for essential worker vaccination, it produces a lull in February-March. But if you actually drop the reproduction rate then that 3x factor goes away immediately. Unless you have a reliable plan to get people to keep social distancing even when things seem over, vaccinating the vulnerable saves lives in expectation.
Don’t forget there’s another factor: Coming down with COVID can easily take someone out of the workforce for a couple of weeks.
The essential workers may be at less risk of dying, but depending on how you define “essential” having a large portion of them down for the count could put quite a crimp in your ability to hand out vaccines.
Even if this is right, it still seems incredibly dysfunctional for CDC (and other governing bodies) to not use age categories among healthcare workers, and other essential worker categories.
Zvi, I agree with you that the CDC’s reasoning was pretty sketchy, but I think their actual recommendation is correct while everyone else (e.g. the UK) is wrong. I think the order should be something like:
Nursing homes → HCWs → 80+ → frontline essential workers → …
(Possibly switching the order of HCWs and 80+.)
The public analyses saying that we should start with the elderly are these two papers:
https://www.medrxiv.org/content/10.1101/2020.09.08.20190629v2.full.pdf
https://www.medrxiv.org/content/10.1101/2020.09.22.20194183v2
Notably, both papers don’t even consider vaccinating essential workers as a potential intervention. The only option categories are by age, comorbidities, and whether you’re a healthcare worker. The first paper only considers age and concludes unsurprisingly that if your only option is to order by age, you should start with the oldest. In the second paper, which includes HCWs as a category (modeling them as having higher susceptibility but not higher risk of transmitting to others), HCWs jump up on the queue to right after the 80+ age group (!!!). Since the only factor being considered is susceptibility, presumably many types of essential workers would also have a higher susceptibility and fall into the same group.
If we apply the Zvi cynical lens here, we can ask why these papers perform an analysis that suggests prioritizing healthcare workers but don’t bother to point out that the same analysis applies to 10% of the population (hint: there is less than 10% available vaccines and the authors are in the healthcare profession).
The actual problem with the original CDC recommendations was that essential workers is so broad a category that it encompasses lots of people who aren’t actually at increased risk (because their jobs don’t require much contact). The new recommendations revised this to focus on frontline essential workers, a more-focused category that is about half of all essential workers. This is a huge improvement but I think even the original recommendations are better than the UK approach of prioritizing only based on age.
Remember, we should focus on results. If the CDC is right while everyone else is wrong, even if the stated reasoning is bad, pressuring them to conform to everyone else’s worse approach is even worse.
Many people on this website are hardcore social distancers, interacting only with essential workers. To them it seems natural that essential workers are the majority of the transmission and do not have immunity yet. But most people aren’t social distancing very hard at all. In Nashville, were I currently am, the bars and restaurants are often full. My immune brother when to house parties and indoor concerts on New Years Eve. I doubt that essential workers constitute even a majority of current transmission.
So we vaccinate 80 million people and reduce transmission by 50%, maybe. That would take months. Meanwhile, there are only 50 million Americans over 65, doing >90% of the dying, and we could vaccinate them in just two months.
TLDR; The transmission argument for essential workers assumes people comply with social distancing. People aren’t doing that anymore, so vaccinate the vulnerable.
This isn’t based on personal anecdote, sudies that try to estimate this come up with 3x. See eg the MicroCovid page: https://www.microcovid.org/paper/6-person-risk
That seems plausible right now, in January, at our current level of social distancing compliance. But why would the degree of distancing stay constant over vaccination? It hasn’t even stayed constant the last 8 months when nobody has been vaccinated.
So far we have a clear pattern. People voluntarily comply when the issue seems important because there are lots of infections, hospitalizations and deaths. During lulls the issue becomes less available and compliance drops. In the best case for essential worker vaccination, it produces a lull in February-March. But if you actually drop the reproduction rate then that 3x factor goes away immediately. Unless you have a reliable plan to get people to keep social distancing even when things seem over, vaccinating the vulnerable saves lives in expectation.
Don’t forget there’s another factor: Coming down with COVID can easily take someone out of the workforce for a couple of weeks.
The essential workers may be at less risk of dying, but depending on how you define “essential” having a large portion of them down for the count could put quite a crimp in your ability to hand out vaccines.
Even if this is right, it still seems incredibly dysfunctional for CDC (and other governing bodies) to not use age categories among healthcare workers, and other essential worker categories.
That seems irrelevant to my claim that Zvi’s favored policy is worse than the status quo.