Jan. 20, 2021
To Members of the Baylor College of Medicine Community:
First, a bit of good news.
The viral numbers reported by the TMC are showing signs of improvement. The effective R(t) is less than one (indicating the viral presence in the community is declining) for the first time since Oct. 18. Test positivity rates are slightly lower. The rate of new COVID hospitalizations has actually declined somewhat, and hospital census levels look like they have stabilized. It appears we may have crested this wave, which is very good news.
Good news, but we have many miles to go. Statistically, Aug. 6 is the hottest day of the year in Houston. Aug. 7 is still pretty hot. We may be on the backside of this surge, but it will take weeks to get hospital numbers back to sub-crisis levels. Let us all hope this viral moderation continues.
It is the third week of the new year, and the third time I am going to write predominantly about vaccines. It is fundamentally the most important issue confronting us as a nation at this moment, which is a bold statement given the range of issues we face. Rapid deployment of vaccine to achieve herd immunity by the summer (or fall at the latest) is our path to ending the pandemic and resuming our normal lives. Failure to execute on this priority will prolong the struggle, and cost many more lives. The emergence of new, more infectious strains drives an even greater sense of urgency. The improvements we are starting to see could be rapidly reversed if a more infectious strain becomes dominant.
So how are we doing in our vaccination effort? Nationwide, I would give us maybe a C+, and I have always been an easy grader. As of Jan. 15, over 31 million doses of vaccine had been distributed, and just over 12 million administered, an administration rate of 39%. At this rate, we are probably two years away from reaching herd immunity (Note: The point we achieve herd immunity is very difficult to predict, so two years is a rough estimate). Texas has done materially better than much of the nation, and better than any other large state. If everyone was vaccinating at Texas’ rate, we would have about 5 million more shots in arms.
To fully understand the vaccine challenge (at least to the extent I understand it), I would suggest you reread my messages from Dec. 16, Jan. 6 and Jan. 13. To summarize those three messages:
- The current vaccines are safe and effective. We have now vaccinated over 12 million people, there have been no deaths directly attributable to the vaccines, and the relatively rare allergic reactions have been easily treated.
- Do not try and get vaccinated if you do not qualify (1A or 1B status). It places stress on an already stressed system.
- Your best path to receive vaccine is to stay in communication with your primary care physician, especially if affiliated with a health system. Regularly check the web site of your provider organization, along with communications from your state and county health departments.
- One of our greatest challenges today is the mismatch of demand for vaccine against supply and the lack of predictable supply chain. How reliable would your consumer experience be at your local coffee shop if they did not know week to week if they were going to have coffee beans? A lumpy supply chain drives inefficient processes, increases error rates and creates a poor consumer experience.
- Community problems demand community solutions. Effective distribution of vaccine will require a broad-based approach, including health systems, health departments, retail pharmacies, physician offices, and high-volume venues. There is no single correct answer, and collaboration among community leaders will be critical.
I would like to add a couple of new thoughts to this list.
First, the nature of this problem will change over the next several weeks. The challenges we face today are fundamentally different from the ones we will face in the spring, when new vaccines are anticipated to be approved. We are currently in an extremely supply-constrained environment. Our available vaccines are complex to transport, and require expert handling and investment in special equipment to safely store. The supply falls far short of demand. Inadequate supply distributed to a relatively small number of providers produces the kind of consumer confusion we have seen.
Eventually the dynamic will change. Vaccines will be approved that do not require special super-cold freezers to store, and which can be manufactured in larger quantities. Administration will be technically much simpler and we will have supply in excess of demand. Instead of the public asking “how can I get vaccinated?” providers will be asking “how can I use all this vaccine?”
The solution in the current environment of constraint almost certainly requires health systems and large physician practices (like Baylor Medicine) take a leading role. Stop for a second and reflect on the Israeli vaccination experience, generally acknowledged to be among the most successful in the world. Israel believes it may achieve herd immunity by April, and has a few distinct advantages on this journey. The population is generally geographically concentrated. Every citizen is registered with a health system and linked to those systems with excellent electronic medical records, communications, and data systems.
In the United States, every health system and large physician practice is like the Israeli system in miniature. Patient populations are well defined, and medical data is electronic. Health systems and practices know who qualifies to be vaccinated based on age and can identify which patients have at-risk conditions. They have established channels of communication to reach patients. Add to those advantages the fact that these organizations are in the business of delivering health care services. They have operational expertise to build and scale efficient operations, and qualified personnel to run vaccination programs (although the ongoing national surge places competing demands on the utilization of this staff).
As we move from an environment of constrained supply to excess supply – from the winter vaccine trickle to the spring flood – the problems will be different. Everyone is currently focused on the here and now. We should spend some time now planning for the spring and how we will create a collaborative distribution system. Health departments, small-to-moderate sized physician offices, retail pharmacy operations, and the business community will all play an increasingly critical role.
Finally, we must actively balance vaccination speed and precision. We all want vaccinations to proceed as quickly as possible. At the same time, we want a degree of precision in how the vaccine is to be distributed. Groups that are at higher risk based on age, medical conditions, occupation, ethnicity or socioeconomic status should be prioritized.
Unfortunately, to a degree speed and precision are competing priorities. Establish too detailed guidelines around vaccine eligibility – who and when with which vaccine – adds complexity and risks slowing the process down. Keeping rules to a minimum may help speed the process, but risks leaving groups behind. We cannot forget those without access to primary care; those without transportation; those without the time or technological sophistication to be actively “working” the vaccine system. Every community and vaccine providers in those communities need to make a deliberate effort to reach the most vulnerable among us.
This is a complicated process; it will get better.
James T McDeavitt, M.D.
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