WSJ: Prioritize Based on Age

The editors of the Wall Street Journal think that over-politicization of inoculation is slowing the process:

Blame convoluted and rigid eligibility rules that have focused too much on “equity”—i.e., politics. Operation Warp Speed apportions doses to states, and then states decide how to allocate them. The Centers for Disease Control and Prevention’s guidance to states on how to prioritize vaccines focuses on worker occupation, but many states have added to the morass.

New York has been one of the worst, creating a complex formula for ranking health-care employees based on underlying risk factors, age, occupation and hospital department, among other things. Many hospitals had spare vaccines because large numbers of health-care workers declined to be vaccinated. Yet state rules barred offering shots to others.

To some extent that echoes my point that simplicity is a virtue and the more complicated the plan the more difficult it will be to follow. They advocate prioritizing based on age:

The risk of severe illness increases with age, which is why the Administration was right to urge states to administer the vaccine to anyone 65 and older. By one estimate a 70-year-old is about four times more likely to die than a 60-year-old and seven times more likely than a 50-year-old. Age is also a bigger risk factor than underlying health conditions like diabetes. There’s no reason a 25-year-old teacher or grocery worker should get a shot before a 65-year-old.

The development of Covid vaccines in record time is a tribute to private innovation and political will that cut through bureaucracy. The vaccine distribution has been an example of too much political interference. We hope the Biden team is paying attention.

That makes a certain amount of sense but there actually are reasons to inoculate a 25-year-old teacher or grocery worker. Age is the among the most important risk factors but it isn’t the only risk factor. State of health and contacts are risk factors, too.

There are any number of possible inoculation strategies. For example, we could prioritize the zip codes with the highest number of infections, going as far as to move the inoculation sites to the people being inoculated rather than the other way around. Inoculating everyone in a high risk zip code should be simpler, easier, and faster than inoculating the individuals who are notionally at the highest risk in all zip codes.

The lesson I think we are learning is that achieving “herd immunity” through inoculation won’t be as fast as people have been assuming it would be.

14 comments… add one
  • PD Shaw Link

    I wouldn’t vaccinate a teacher unless they sign a contract that they will teach in person once the vaccine is effective.

    We are heading to herd immunity one way or another. Youyang Gu’s model initially had the U.S. reaching herd immunity sometime this summer with 30% vaccinated; 30% infected. The vaccine rollout was not worse than the model expected at first, but over time it became worse. Currently, the model projects hitting 60% with 24% vaccinated; 36% infected on May 1st. (He’s moved the herd immunity level to 70%, which I don’t agree with. 22.8% of the U.S. population is under 18)

  • I’m skeptical that we’ll have inoculated 80 million people by May 1.

    PD, wouldn’t such a contract need to be negotiated with the teacher’s union? If Chicago is any gauge I don’t think getting such a contract is possible.

  • steve Link

    I think I mentioned yesterday that the one advantage of using the age criteria was simplicity. Also less likely to be challenged (successfully) by the interest groups. However, we really dont know how well it actually works in the older group. If you are going to vaccinate them then I would highly prefer they get two doses, and close to the schedule. The first dose first approach being pushed now does have its merits, and some risks, but we know that with other vaccines it takes more vaccine to be effective in the older population and it is still more likely to fail.

    PD- I thought Gu had initially predicted herd immunity at 20%-30% of infected. Looks like he is upping his numbers.



  • PD Shaw Link

    Some of the sticking point is the federal government is distributing more vaccines per capita to some states than others. Alaska has received almost twice the vaccines distributed as they have healthcare workers plus long-term care residents (190%). Half of the states have less than 80% distributed. So its difficult to evaluate which states are doing better than others because some are starting with plenty.

    I think the other issue is that hospitals have generally moved quickly through healthcare workers with systems they’ve set up. The other top priority group, long-term care residents, is handled onsite by CVS/ Walgreens. (In Illinois, 99% of such facilities have contracts with one or the other) As hospitals got to a mop up phase, the next groups don’t necessarily rely on the systems hospitals set up at the beginning.

    Which is why Champaign, IL is interesting. They appear to have jumped to “over 75” before finishing Phase 1a and 1b, plus the Governor’s call for Phase 1c to include all “over 65”. I think the hospital had underutilized capacity (in vaccines, personnel and space), but not so much as to start accepting those over 65. And while Champaign county, home to a very large university is probably diverse in many ways, its not diverse in the way that concerns are expressed. Will Champaign get restricted on future vaccine orders?

  • PD Shaw Link

    @Dave, when our city’s public schools finally opened last week to some in-person learning (hybrid model w/ A & B days), most teachers opted out. Kids go to school and watch a computer projection of a teacher with retired teachers hired back to monitor kids. The actual teachers aren’t being put at any risk, and if they can’t commit to doing their job, they don’t deserve any priority.

  • Here in Chicago the CPS has finally lurched uncontrollably to the position they should have taken a year ago: no work no pay. Understandably, Chicago teachers would rather lounge on the beach in Puerto Rico on full salary than teach.

    I would not be surprised if the CTU were to go out on strike over it.

  • PD Shaw Link

    @steve, when Gu first set up his “Path to Herd Immunity” projections he expressly disavowed lower HIT based upon heterogenous factors. I think he believes in that theory, but does not have a quantifiable basis to utilize it. I would say the same thing about his increasing the assumptions of infectiousness based upon the UK variant.

    I disagree with you on the “over 75” stuff, but a big issue with employment sector prioritization, is that proof of employment will be required, which is probably not optimal for those not good with paperwork, and it will necessarily include employed people not in jobs of concern. If an optimal priority list requires a one hour interview to evaluate individual job functions and health risks, then its not an emergency.

  • CuriousOnlooker Link

    Ring-fence vaccination is a valid strategy.

    I will refer to the UK as to why they chose age based vaccination. They list out the reasoning along (and the footnotes showed they used a computer model to verify the math).

    What’s driving decisions
    1) The trials were focused on direct protection, and so there is little actual evidence it prevents transmission. Theoretically the vaccines prevent transmission but it is not proven.
    2) Morbidity is exponential with age

    Feed that into a model and age based prioritization gets the most reduction on mortality and reduces load on the health care system the fastest.

    I’m looking at the graphs of vaccination; the UK is starting to speed away in vaccination, while Europe is struggling.

    My take away is mRNA vaccinations have inherit bottleneck issues in continental polities like the EU and US. To speed up vaccination, there needs an easier to store approved vaccine like the UK. Or a relaxation in the vaccination schedule (delayed 2nd dose).

  • steve Link

    If you go through people’s existing health network, they wont need an hour interview. To be clear, I am not really opposed to vaccinating the over 75 group, they are high risk, I am just saying that we dont know if the vaccine will work. We do know that if we do only one shot it is even less likely to work (based upon experience with other vaccines).


  • To be clear, I am not really opposed to vaccinating the over 75 group, they are high risk, I am just saying that we dont know if the vaccine will work.

    I’m against it for several reasons:

    • The vaccine itself is a greater risk to them than to other populations
    • We don’t know how effective the vaccines will be in them
    • There are other ways of protecting those who live in care facilities
    • There are too many of them
    • Present supplies of the vaccines are limited
  • steve Link

    Latest data. Overall, 68% of staff vaccinated, 90% of clinical and 35% of non-clinical. Of those not vaccinated it tilts heavily towards women under 36 and minorities.

    We are ready to start on group 1B including those over 65. Requests to the state have gone unanswered for the last couple of days but there is some optimism they give us the go ahead soon. The logistics for 1B will be pretty tough. So right now the state is our limiting step.


  • PD Shaw Link

    I’m not convinced by the one shot arguments other than it did not make sense to hold the second shot as opposed to trusting the supply will be there and I don’t think its worthwhile to fetishize the timing of the booster. People seem to mean different things about this topic though.

    It looks like my County announced its gone to Phase 1B today, including vaccinating everybody over 65. I see no reservations available on the online enrollment system, so this might be entirely theoretic, but they did issue new local guidance.

    The County says that one of their chief constraints is the 15 minute wait following the vaccine with social-distancing, so they are looking to set up additional clinic space. So far 7.5% of the County has received their first dose.

  • So far 7.5% of the County has received their first dose.

    That highlights a point I have been making. We are now one month into inoculating people. Maybe as time goes by we’ll be able to inoculate more than 7.5% of the population per month. That could be true as people gain confidence in the vaccines and if the main constraint isn’t manpower.

    But if manpower is actually the greatest constraint and rather than more people presenting themselves over time fewer do which also could happen (if those who’ve already been inoculated are the “low-hanging fruit”) this could be a very long process indeed.

  • steve Link

    We are getting another shipment of vaccine. Going to start 1B. We are getting more aggressive about seeking manpower. I will volunteer. Will do more of my admin work at night and on weekends. Means working 70 hours a week instead of 60, but you’re only young once. Trying to convince some of our retired people out to help.



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