Dr. Christian Ramers responds to your questions about vaccine storage, distribution and when certain groups will be eligible to get the vaccine. Ramers is the assistant medical director with Family Health Centers of San Diego and an adjunct assistant professor specializing in infectious diseases at San Diego State University’s School of Public Health. He also sits on San Diego County’s vaccine clinical advisory group.
Q: Doug Shimansky of Rancho Penasquitos asks: “So, the question I have is my sister-in-law and my friend both got their vaccines up in Northern California and they’re 65 and older. Why do we have the delay in San Diego? Is it because we don't have enough vaccines or we just aren't able to handle the distribution?”
Part of the reason is because you have several different entities giving their own guidelines of who gets the vaccine next. Remember, this started with the National Academy of Sciences and then the CDC has the Advisory Committee on Immunization Practices. The state of California has now stepped in and they're pushing some guidelines out as well. And it's trying to balance many competing factors. We don't want these guidelines to slow down the distribution of vaccines.
And then vaccine numbers are being distributed at different rates to different counties. So the reason some people in lower tiers may be getting vaccine first is because a vaccinating entity may have leftover doses that they wanted to reserve for a higher tier, such as Phase 1A or health care workers and let's say some people miss the appointment or decline the vaccination, what do they do with those leftover doses? I think everybody has said that you are encouraged to use them in lower tiers.
There's also been a little bit of mixed messaging coming from the state where the state says Phase 1B is age 65 and up, whereas we know that people age 75 and up are higher risk, and that's what the original recommendation was. So different counties and different entities are at slightly different levels there. We're all moving towards the same thing and I think it's going to be just a matter of the supply pushing through where we're going to get through these phases in an orderly fashion.
Q: A common question we get from people is when will they be able to get the vaccine? We know there's a tiered system, health care workers and those in long-term care facilities were first. The county recently allowed people 75 years and older at its sites. You sit on the county's vaccine clinical advisory group that is supposed to inform roll out eligibility in these later tiers. What input did the group provide ahead of the county's announcement this week to expand to people seventy five and older?
So the advisory committee puts forth recommendations and we're getting it from all sides as well, from CDC and from the state and from what we think should be done.
Phase 1B, clearly when you broaden the group down to age 65, you get hundreds of thousands of more people. And yet we know that those that are 75 and older are the highest risk. So there's this sort of two-tiered thing, where we want to open as fast as we can, we don't want the rules to slow people down so much, but we still need to be prioritizing those who are at most risk. And then moving into further Phase 1B by occupation, we just don't have enough vaccine doses really available to get too deep into that.
Q: Deborah Mendelson, who lives in San Marcos, wants to know when she will be eligible. She wrote in online that she’s 60 years old, works as an independent home health caregiver and cares for two elderly individuals each in their own homes. She's wondering, what tier does that put her in and what documentation would she need to show?
Phase 1A, which is health care workers. Our health officer Dr. Wooten, has defined a health care worker in the broadest sense possible. So somebody who is a certified in-home caregiver, in my opinion, and I think in most vaccinators opinions, would be a health care worker by all intents and purposes and should be included in Phase 1A. That's where we come up with this number of about 500,000 or so people that really should be in Phase 1. And we're still trying to work through that as we move forward into the next phases.
Q: Hospicio Ortega wanted to know when he, too, can get the vaccine, he is 69 years old and diabetic. So he's wondering when and how pre-existing conditions will be factored in in the order of vaccine distribution?
It's a really good question and it's evidence of just how confusing this can be because the state has said, Phase 1B can actually move down to 65 years old and above, but we don't have enough vaccine to cover all of those people. And so the county has prioritized 75 and above in that specific Phase 1B group. Pre-existing conditions are not really even being considered right now at this phase, we're just going based on age. And if you look at the county's website, we're at Phase 1B, now doing 75 and older. We're going next to 65 and older. So really this person is going to be next in line once that announcement happens. Pre-existing conditions don't really get factored in until Phase 1C.
Q: Joyce Mallowy of Oceanside has two questions for you. First she asks “how are they keeping all these types of vaccines at the correct temperature?”
Minus 70 degrees is tough. And then as soon as you take it and thaw it out from minus 70 degrees, there's a limited half life for that vaccine to still be viable. And really, this is the really difficult implementation work from the state and the county working together — where are those freezers? Where can they reasonably store the vaccine? And then when you need to get it out to further and further away from that freezer, how can you ensure that there's going to be enough people there to receive the vaccine? This is why me, as somebody that works in clinics, in some of our smaller clinics, it may not be the best place to give vaccine because let's say you have five high-risk people that need to be vaccinated. We thaw a vial of that vaccine and we can only find five. We need another five people to get vaccine. And one thing that has been emphasized over and over and over is we cannot waste this vaccine. So if you have five people in front of you that are high risk and you open a vial, you need to find another five, maybe by going down a tier or so to make sure those vaccines end up in people's arms.
Q: And now to Joyce's second question, given that the U.S. is rushing to give people their first shot without a guarantee that the second dose will be available, she asks, do we have evidence showing that the vaccine will be effective if the second shot is given after the 21 and 28 day windows?
The answer to that is we don't have evidence. We have our scientific assumptions. We have a little bit of evidence from the clinical trials where they tested people in that short period between dose one and dose two. And we saw maybe a 50 to 80 or 90% efficacy in that very short period. But there are no guarantees how long that immunity is going to last. And my own opinion and that of many other scientists is, is that we really should use these vaccines as they were studied, which is 95% efficacy with two doses and it doesn't even start until about a week or two after that second dose.
