Coronavirus Files: CDC endorses boosters for at-risk workers; Triage scores biased against Black patients

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THE CORONAVIRUS FILES

By Amber Dance

Black COVID-19 patients at disadvantage during COVID triageAs hospitals overflow with delta patients, parts of the U.S. are at or close to the point when doctors have to choose who gets treatment based on who is more likely to survive. But at least one common method used to score a person’s chances of survival seems to undervalue Black lives, according to two new studies. A popular, 25-year-old scoring system based on measures from several organ systems gave higher ratings — indicating lower chances of survival — to Black COVID-19 patients than other races admitted at Yale New Haven Health System Hospitals in Connecticut. Nonetheless, the actual survival rate of Black patients was no different from others. At the time of the study, the health system was not using the scores to decide who got care, such as use of limited ventilators. But if they did, “We could end up disproportionally steering resources away from Black patients,” cautioned Benjamin Tolchin, director of Yale New Haven Health’s Center for Clinical Ethics, in a press release. Some states rely primarily on this organ-system score in their rationing protocols, while others combine it with other information. In Idaho, physicians have recently been forced to use the organ-system scores to make rationing decisions as hospitals filled up, according to the Yale release. One solution the Yale study authors suggest is to modify the triage scores to give marginalized patients a bit of an edge, potentially making up for some of the socioeconomic disparities. They also caution that their findings might not apply to health care systems in communities different from New Haven. CDC director greenlights boosters for high-risk workers In a surprise move made in the wee hours of Friday morning, CDC director Dr. Rochelle Walensky overruled the recommendation of the agency’s vaccine advisory committee, which had declined to approve Pfizer booster shots for people who are at high risk of exposure at work. The decision was just one more twist in the complex and ongoing debate over who should get a booster and when. On Wednesday, the FDA officially granted emergency authorization to Pfizer’s vaccine for a third dose, six or more months after the last one, in people older than 65, adults at high risk for severe breakthrough infections, and people who are at high risk for exposure due to their occupation (such as health care workers and teachers) or living situations (for example, those in homeless shelters). This matched the recommendations of the FDA’s own advisory committee. The task then fell to the CDC to decide more precisely who would be eligible for the shots. The CDC’s advisory board, made up of external experts, cast a complex series of votes on Thursday: Yes to boosters for those over 65 and residents in long-term care facilities, as well as adults with underlying medical conditions. No on boosters for those who risk exposure at home or work. The latter decision garnered immediate derision from some quarters. Epidemiologist Elizabeth Pathak of the Women’s Institute for Independent Social Enquiry tweeted that the denial of boosters to health care workers was a “TRAVESTY” with “no logic to this decision.” Johns Hopkins epidemiologist Keri Althoff asked, “How do we ensure hospitals/clinics and schools are staffed if we do not allow healthcare workers and teachers access to #COVID19 boosters?” STAT reporter Helen Branswell speculated that if the committee had had the option of limiting boosters just to health care workers, they might have supported the extra shots. That logic anticipated Walensky’s subsequent move to authorize shots for people exposed at work but not where they live. While the committee was not asked to address boosters for people who got Moderna or Johnson & Johnson vaccines originally, some members expressed support for a mix-and-match approach, as Benjamin Mueller and Apoorva Mandavilli reported for The New York Times. Further discussion on boosters for those brands should come soon (see J&J item below), so there will be more wrinkles to this story. As Dr. Wilbur Chen, a CDC committee member from the University of Maryland, put it during the discussions, “The implementation part of this is going to be fraught with such complexity that the people with the best health literacy will get boosters.”

Kids ages 5–11 may get first shots by HalloweenPfizer announced last Monday that its vaccine safely and effectively induced coronavirus antibodies in children as young as 5. The finding sets the stage for potential emergency use authorization from the FDA by the end of October, some experts have predicted. But there are still several steps that must happen first, as explained by Jacqueline Howard at CNN. Safety considerations — heart muscle inflammation is associated with vaccination in rare cases — will surely be a topic of discussion. In the Pfizer trial, which was too small to reliably indicate the rate of heart inflammation, side effects included fever, aches, and sore arms. But many parents may be reluctant to have their kids immunized, write Sarah Mervosh and Dana Goldstein at The New York Times. Only about half of adolescents had started a vaccine course by mid-August. Some parents worry about the small size of the trials and lack of long-term data, especially since most children do not suffer severe COVID symptoms. However, rising case rates and hospitalizations of otherwise healthy children have led pediatricians and lawmakers to consider the matter urgent. Cases among children have increased exponentially during the delta wave, with more than 925,000 children testing positive in the last four weeks, according to the American Academy of Pediatrics. “Until we look at the data, I can’t comment on this, other than to say: We need a vaccine for children,” Paul Offitt, a vaccine expert at Children’s Hospital of Philadelphia and member of the FDA’s vaccine advisory committee, told The Washington Post. Pfizer has said it expects results for children under 5 later this fall, which might set up further authorizations by the new year. Two shots better than one for J&J While Pfizer took the lion’s share of media attention last week, Johnson & Johnson also offered major news: a second shot, two months following the first, boosted efficacy against moderate to severe disease from 72% to 94% in its U.S. studies. That would put the vaccine on par with two-dose regiments of the RNA vaccines from Moderna and Pfizer. When the delay between shots was six months instead of two, the booster resulted in twice as many antibodies. While the company’s data has not yet been reviewed, it has been submitted to the FDA, where it adds another wrinkle to the nation’s complex, multistage booster rollout, writes Lauren Morello at Politico. While only about 14.6 million Americans received J&J’s vaccine so far, “the data could also help increase use of the vaccine in the U.S. and globally,” writes Matthew Herper at STAT. The original one-and-done dosing was once seen as an advantage, particularly for people in hard-to-reach areas, but the vaccine still has a bit of an edge over the mRNA options for ease of storage and transport, because it requires less extreme cold temperatures.

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