Maximizing COVID-19 vaccine equity and minimizing death in South Carolina and beyond

That hospitals in South Carolina (SC) began COVID-19 vaccinations in mid-December of 2020 is a marvel of human ingenuity, resilience, and courage. Tragically, however, more than 5,000 confirmed South Carolinian lives have now been lost due to COVID-19. Although SC is above the national average for vaccination, many say the pace is too slow. Medical students, including myself at the University of South Carolina School of Medicine, received vaccination access via their clinical affiliate, Prisma Health, due to remaining Phase 1a vaccines after the institution’s direct care teams were vaccinated. This included other individuals not engaging in patient contact, which is in line with the Advisory Committee on Immunization Practices (ACIP)’s broad definition of health care personnel (HCP). Even so, many of these individuals, myself included, are too low risk for current prioritization to maximize equity and minimize death.

Student vaccination serves to protect students who are and will soon be engaging in clinical rotations and patients who will contact students. Still, the decision to vaccinate all students and corporate members should be met with inquiry at a time of limited vaccine and soaring COVID-19 cases across the country. According to The State newspaper, Governor Henry McMaster called upon the SC Department of Health and Environmental Control (DHEC) last Thursday to increase vaccine distribution transparency to “maintain the public’s confidence and participation in the COVID-19 vaccination effort.” Proving tremendous transparency, SC DHEC agreed, and we now know that thirty-four facilities (henceforth, “vaccine HQs”) in our state have been allocated 129,675 COVID-19 vaccinations as of January 4, 2021.

SC has greater than 150,000 health care professionals and more than 17,000 individuals in long-term care facilities, revealing insufficient vaccine doses for these two groups deemed the highest need by current SC DHEC and ACIP Phase 1a categorization. Therefore, it is not surprising that I am hearing of frontline health care providers outside vaccine HQs who still lack access to vaccines. Even physicians in other states are expressing their anguish regarding this issue. This painful reality is not easy to accept. In my view, it would be ideal if these groups were prioritized over first and second-year medical students and low risk, vaccine HQ corporate populations for which patient contact can be minimized during a period that CDC director Dr. Robert Redfield has called “the most difficult in the public health history of this nation.” Vaccination speed is not everything. For further public transparency at the state level, accessibility of the vaccine to the student and corporate employees of vaccine HQs who are not “performing direct medical care to suspected and/or confirmed COVID-19 patients” should be made known. The current situation is “acceptable” only because ACIP’s definition of HCP remains so broad, I speculate, to ensure the reliability of complex health care systems that often require individuals who don’t engage in patient care to function optimally. In addition, current guidelines from the American Association of Medical Colleges (AAMC) regarding patient care activities for medical students lack recommendations regarding vaccination to medical students.

SC DHEC guidelines state that the “overarching principle in Phase 1a is averting deaths.” Medical students including Oscar Chen, Dennis Li, David Hong, and Abhi Ganguly, argue that “health care students on clinical rotations receive the COVID vaccination in subsequent vaccine rounds,” primarily because these groups are on the average young, healthy and make up a low proportion of death due to COVID-19. After subtracting the 30 to 32 percent of COVID-19 related deaths in SC that occur in long-term care settings, adults 65 years or older still account for half of total SC deaths, making them the largest age group to have died from COVID-19 in SC. Unfortunately, this vulnerable group is on the Phase 1b-c vaccination schedules. It seems unjust for relatively low-risk groups without absolute requirements for clinical care activities to receive the vaccine solely because of their association with vaccine HQs before those experiencing the most death, much less those outside vaccine HQs at the frontlines in Phase 1a.

It is in the best interest of a state’s highest risk groups for medical schools and universities who have not yet been allocated student vaccination to continue considering alternatives to traditional clinical exposure for health care professions students, particularly those in pre-clinical training phases that can be modified to avoid direct patient care. Making this commitment and relaying this to vaccine distribution sites can free up vaccines for Phase 1a-c high-risk groups and reduce COVID-19 fatalities. As vaccine access arrived unexpectedly early at my school, such risk categorization seems either overlooked or considered nonpragmatic. And indeed, parceling medical students and some corporate employees into different risk categories seems against current ACIP guidelines due to their apparently all-encompassing definition of HCP, even though further risk categorization would prioritize the highest risk groups. Medical student Lauren Burgoon’s argument for the vaccination of entire medical student bodies seems to be in the right based solely on the guidelines. I fully believe this vaccine’s safety has been rigorously demonstrated and want to make sure that I convey that to fellow community members of all backgrounds; this is why I ultimately went through with receiving the vaccine myself. Still, with so many other high-risk groups dying disproportionately, at what unmeasurable cost does the failure further distinguish levels of risk among Phase 1a individuals come?

Rapid acceleration of SC pathways and across the nation for vaccine access to frontline workers outside vaccine HQs and those at least 65 years old outside long-term care settings needs higher prioritization immediately. U.S. and international medical school, university, and public health organizational leaders should perform further inductive, medical ethics analysis regarding current phasic vaccination schedules’ fundamental inequities. Current full corporate and student prioritization before our highest risk groups does not seem optimally in line with ACIP’s four guiding ethical principles of “1) maximize benefits and minimize harms; 2) promote justice; 3) mitigate health inequities; and, 4) promote transparency.”

Devin M. Kellis is a medical student.

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