Expert panel recommends U.S. join international vaccine pool, contribute vaccine to low-income nations

The United States should join an international Covid-19 vaccine pool and should contribute 10% of the country’s vaccine for redistribution to low-income countries, a panel of experts convened by the National Academies of Sciences, Engineering, and Medicine recommended Friday.

The group’s final report, the Framework for Equitable Allocation of COVID-19 Vaccine, suggested the country would both increase its chances of access to effective Covid-19 vaccines and regain a position of global health leadership if it were to join the COVAX Facility, a vaccine purchasing pool being set up by the WHO, Gavi, the Vaccine Alliance, and the Coalition for Emergency Preparedness Innovations, known as CEPI for short.

“Amid the catastrophic COVID-19 pandemic, the United States should consider it a moral duty, as a leading nation and member of the G7/G20, to embrace its humanitarian legacy by re-engaging and leading on the international stage in support of lower-resourced nations,” said the report from the 18-member committee on equitable allocation of vaccine for the novel coronavirus.

Bill Foege, co-chair of the panel and former CDC director, told STAT he had anticipated there might be some division among members of the panel on the issue of joining the COVAX Facility, which at least 156 countries have joined. There was none, he said.

“Everyone agreed the U.S. needs to engage the global community. … That the world needs us to get back into the leadership role,” Foege said in an interview Thursday before the release of the 237-page report,

The White House has publicly rejected the idea that the United States might join the global vaccines pool, because of the WHO’s leadership position in the work. President Trump blames the WHO for mishandling the Covid-19 pandemic and has served notice that the U.S. will pull out of the global health body next July.

Foege said the United States should be able to find a way to work with Gavi, the creation of which was led by U.S. efforts. Gavi helps low- and middle-income countries purchase vaccines.

“We need the world because in the worst-case scenario, what if none of our vaccines work and we have to go globally to buy vaccines? … The other thing is we really need to be able to get samples of the virus from different parts of the world to detect changes. So, we’re dependent on the world and the world’s dependent on us,” Foege said.

The panel, set up at the behest of Francis Collins, director of the National Institutes of Health, and Robert Redfield, director of the Centers for Disease Control and Prevention, was tasked with creating guidance for who should be first in line for Covid-19 vaccine when supplies become available, but are initially scarce. Its mandate suggested its recommendations could both serve as a foundation for vaccine prioritization decisions both in the U.S. and abroad.

The group’s recommendations for who should get first access to Covid-19 vaccines remains effectively the same as those outlined in a preliminary report released in late September. Health workers in high-risk jobs and front line workers are first on the list, followed by people of all ages who have health conditions that put them at significantly higher risk of severe Covid-19, and older adults living in congregate settings. The latter group includes people over age 65 living in long-term care, in crowded, multi-generational households, or in prisons.

On the issue of the distribution of vaccines in the U.S., the committee recommended that in the early stages of vaccine release, each state should be allocated a portion of the available vaccine doses that reflects their proportion of the national population. If a state’s residents represent 5% of the U.S. population, they would get 5% of the allocated doses.

The committee recommended that the CDC hold back a tranche of 10% of the doses, to give it flexibility to respond to emerging transmission hotspots, or to prioritize particularly vulnerable areas — places where socioeconomic conditions are such that the risk to people living there is unusually high.

That is part of an attempt to address the deep inequities in the way the pandemic is playing out in the United States, where Black and Latinx communities have experienced a disproportionate amount of disease.

Data amassed by the CDC has shown that about 60% of the confirmed Covid cases and 50% of the deaths in the country have been among people that the CDC defines as racial and ethnic minority groups, even though they make up only 40% of the population.

The document is not definitive plan for vaccine allocation, but guidance for other groups that will be responsible for more “rubber-meets-the-road” level planning. It will inform the Advisory Committee on Immunization Practices, an expert panel that crafts vaccination guidance for the CDC, and state, local, and tribal health authorities, who must identify the actual people in their regions who fall into the priority groups.

The report suggests Americans should be vaccinated in four phases. In addition to the first, described above, the second stage includes a wide number of groups including teachers and school staff, critical workers in essential industries, people in homeless shelters, group homes, and jails and prisons, people with health conditions that put them at moderately increased risk from Covid-19, and all older adults not covered in phase 1.

Phase 3 includes children and teens under 18, even though testing of the vaccines in the U.S. development pipeline has not yet expanded to include children and teens. Foege acknowledged being uncomfortable about the fact there aren’t yet data to support use in children and teens.

He also worries about the fact that vaccination may begin before there is a clear picture of whether the vaccines are effective in people age 85 and older, a concern shared by other experts.

“One of challenges we’re going to have here is that we still don’t yet know how effective the vaccines are in these different age groups and those with … underlying [medical] conditions,” said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy. “The group had to make a decision without those data, so it’s not a criticism at all. It’s just the fact is that if we see very low protection afforded to people with comorbidities and older age, then we’re going to have to ask ourselves if we go back to the drawing table and reconsider,” added Osterholm, who was not on the panel.

Marc Lipsitch, an epidemiologist at Harvard’s T.H. Chan School of Public Health, said he had no criticisms of the report’s prioritization plans.

“It is clearly a thoughtful document that has considered and integrated many kinds of evidence to make a rational and humane set of recommendations in a very short time, based on the best evidence available,” Lipsitch said, who was also not a part of the panel.

He did suggest, though, that some of the groups were so large — the adults with medical conditions that put them at severe risk, for instance — that there might be challenges providing enough vaccine for all of the phase 1 individuals in the early days. For instance, 31% of Americans are obese, and 11% have diabetes; both conditions increase the risk of severe Covid-19 disease.

The government has estimated there may be 100 million doses of vaccine available by the end of the year, with enough to vaccinate all Americans by March or April. Most of the vaccines being developed with U.S. government assistance will require two doses per person.

Operation Warp Speed, the ambitious plan to fast track development of Covid-19 vaccines, has been helping to finance ongoing production of vaccine doses for the six vaccines it is currently supporting, even though its not yet known if any, some, or all will actually work.

STAT asked the Department of Health and Human Services Thursday for detailed information of how many doses have been stockpiled and the rate at which more doses will be made in coming weeks. A department spokesperson offered the previously released information about the timeline to vaccine for the nation, but did not directly respond to STAT’s questions.

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