doctoravios

You are asking a different question which we do not yet have the answer to. We do not know for certain why the absolute risk of mortality is lower in Japan compared to the US and Italy. There are likely to be many factors at play which are broadly related to reducing the number of contacts that infectious people have and reducing infectious dose when exposed to the virus (masks/ventilation etc) and I agree, there are potentially other factors which are specific to Japan and not found in the US/Italy which have an impact on absolute risk.

However, as far as the relative risk of mortality by age, I think Japan is no different to any other country (N.B. Uncertain about the case definition used here - unfortunately the source is behind a paywall):


https://www.statista.com/statistics/...ge-and-gender/

corporate-wage-slave

No, I don't always agree with doctoravios, but s/he is right. In a random population, to save one covid-19 death in someone 90 years old, you need inject only 40 people. To have the same effect in people aged 50-55 you need to inject 3955 people. Almost a 100 fold difference. That is why the UK and dependent territories phase 1 stops at the age of 50, plus the approximately 5 million people under 50 with underlying risk facts. This totals 43% of the population over 16 years, but it's the first 10% that really matters.

This debate is incredibly simple: you are either vaccinating to prevent transmission, or you are vaccinating to prevent death. Since we don't (yet) know about how vaccines affect transmission, in statistical terms we can only vaccinate to prevent someone dying. And age is just utterly overwheming. When we get information on transmission this may change. And in between I wouldn't rule out pragmatism, the UK is mulling whether to vaccinate teachers to keep the schools open for example. But if access to vaccines is in short supply then the data says that age is the only factor that matters.

FlyBitcoin

It goes to societal mortality, not individual mortality.

Small town hospital has 3 competent ICU physicians and 12 competent nurses. All are age 50 or under. What is the community impact if members of this cohort remain unvaccinated and have to quarantine for a week periodically due to close contact exposure outside of the hospital. Then the ICU capacity must be reduced due to staffing issues which affects citizens of all ages.

The point of "lockdowns" and vaccine prioritization is to preserve a functional healthcare system and allow it to work to reduce mortality. Not just "beds" but skilled staff.
If a life of a nursing home patient is saved with a vaccine but your ICU MD is out on quarantine and two people die of strokes or MI's getting sent 30 miles down the road, you have lost the bet.

You vaccinate HCW's to reduce lost time from close contact quarantine so they can save others' lives. Not to save their own lives.

radonc1

The above is not quite true.
You are also vaccinating to keep your health systems functioning.

Death isn't the only outcome with a Covid infection. You also disable the infected, either by illness or by isolation to prevent that infected person from spreading the disease. Being infected means the health care professionals are out of the provider system.

If you inoculate health care professionals, you keep your hospital system running in all its segments, not just the infectious disease department.
Besides treating Covid, hospital personal also have to care for the cardiac, oncologic, gynecologic and non-Covid patients. If you take the professionals out of the system, the hospital slows or has to shut down other "less essential" (whatever that means ) areas.

You cannot run a hospital without the staff (physicians, nurses, techs, etc). You can run a hospital without janitors (albeit not well).

A very true story. When I was training, one of my fellows was from England and part of his medical training was nursing. He was taught how to make beds, clean pans and do other "non-physician" duties. The reasoning behind this was that there would be times when he might be called on to do menial tasks, and he needed to know how to perform them.

The CDC wants vaccinations performed as they espouse it, because without the trained professionals, the health care system fails. And age is not a principal factor for inoculation when you need healthy people staffing the ER.

rustykettel

So vaccinated HCWs are exempt from quarantines, even when knowingly exposed? You're going to have a hard time explaining to the general public that they still need to wear a mask or practice other efforts after vaccination if we're going to start picking and choosing like that.

exp

Reasons why LA is being hit hard by the pandemic now.

LA had done well until around November. Then pandemic fatigue, which includes a sense that the threat was over, since LA had gone most of the year without huge outbreaks, winter weather and holiday travel.

Certainly conflicting public health info. such as no outdoor dining probably led to growing refusals by people to continue observing measures. The outdoor dining was more an effort to reduce mobility, which had grown since the spring, with more and more traffic on the roads.

But some other factors unique to LA, such as higher overcrowding -- more than 1 person to a bedroom -- from high housing costs:

https://www.latimes.com/california/s...-wildly-in-l-a

skybluesea

Maybe I should have been more clear.

A vaccine is a 2nd best solution, and the choice about who should live or die from lack of immediate supply directly arises from the vast failure in multiple states to enact effective policies and for the local population to change their ways.

Japan and others are NOT having this debate under duress, regardless of the age question, simply because the 1st best solution has been effective, and this has bought lots of time to avoid the calamity being experienced elsewhere.

And what our Western Pacific neighbors are also NOT experiencing are overwhelmed hospitals and elimination of all but the most essential non C-19 procedures to make room. So how many deaths from heart attacks, car accidents, etc. that are impeded by poor hospital access will be counted as C-19 related ? Likely none so the circumstances of who gets the vaccine is just small part of the overall health care challenge to get us through these difficult times.

FlyBitcoin

"Knowingly Exposed" and "Exempt from Quarantines" were not in my post. Also the point of the post was a rationale for giving HCW's a vaccine instead of using just age alone. At no point did I reference running around the community maskless as if one is "Captain Invincible" post-vaccine. HCW's have been telling the "general public" to wear masks since March because that is what we do at work and outside of work. Not sure what kind of picking and choosing you mean. You really think that one day when all groups are being vaccinated that HCW's will be told to not wear masks to WalMart but you will still have to? I really don't understand. The data will tell us what to do, but most likely we will ALL be wearing masks in public for the remainder of 2021, for a variety of reasons. Doing the "Star bellied Sneetches" approach with vaccine cards granting "status" is not a good look for society.

I was talking about availability of vaccinated HCW's, wearing PPE, to potentially be able to WORK after a typical close contact in the community. HCW have lives and families too.

We don't have the hard data right this second, but stay tuned. Moderna has good preliminary data showing the vaccine group had reduced asymptomatic transmission after dose 1. More data coming very soon, likely by the end of the second HCW dose window (end of January). Again, any reduction in asymptomatic transmission in a vaccinated worker PLUS robust PPE in the HCW setting will likely change quarantine guidelines for front line HCW's especially when staffing is low to preserve the skilled workforce for all.

From Moderna's FDA application ... https://www.fda.gov/media/144453/download

rustykettel

And what would be the protocol if they weren't vaccinated?

I think you'll a little too close to the trees to see the forest. The general public is not going to take a nuanced approach to a select group of people who are vaccinated can now do something (such as continue working) while the rest cannot after vaccination and must continue full measures. The specifics won't matter as much as the apparent hypocrisy.

doctoravios

I can see we are not going to agree on this, but that is OK. In fact, I think it is good to have this kind of discussion so that forum readers can see how difficult it is to agree on the management of limited resources, and that it is also possible to respectfully disagree with others on this.

Whether it is right to prioritise healthcare workers above the elderly is one question. But the other is how to prioritise within the group of healthcare workers. I cannot see how there can be any other fair way of doing this other than age and I think it is hypocrisy for someone like me (a healthcare professional under the age of 40) to advocate that I should get the vaccine ahead of a healthcare worker over the age of 60 knowing that they are at much greater risk of serious adverse outcomes from COVID-19 than I am.

Surely you must at least agree on this?

Edit: It is also worth adding, although we don't have sufficient evidence to model because we haven't yet seen the impact of the current population vaccination approach, I suspect that the impact of reducing hospital/ITU admissions in the elderly would far outweigh the impact of reducing morbidity/mortality in young healthcare workers with a limited supply of vaccine. With an unlimited supply of vaccine (and incomplete take-up), it would be another story. Likewise, if the vaccine were 100% effective and provided life-long immunity (as they are for measles and hepatitis B, amongst others), the case for prioritising younger healthcare workers might be greater. But that is unlikely to be the case for the current vaccine candidates.

FlyBitcoin

When the general public is fully vaccinated, we will know all of the data regarding transmission post-vaccine and durability of response, and need for quarantine. HCW's will provide much of that data using their own vaccine experience as most of us are enrolled in post-vaccine trials.

However, when HCW's are vaccinated early, society gets the benefit of their increased availability in a high demand job where they are mandated to wear PPE at all times while at work.

FlyBitcoin

We only disagree on the aspect of vaccinating younger healthcare workers as a need to keep them on the front lines since their need to quarantine after close contact off duty will likely be rewritten, if not done so already. That improves delivery of rationed healthcare to all. If healthcare was not rationed in most areas right now, the prioritization of HCW over age loses support.

In the US, different states are struggling with how to stratify inside of the "HCW" cohort. Some have created lengthy questionnaires that have slowed down administration for all, and are now backing off the administrative red tape (Arizona for example).
Others simply use the database of active medical and nursing licenses, because the allocation of vaccine should cover all HCW by mid to late January. Not all HCW will want the vaccine, and some like you will choose to wait until later in the line, which is honorable.

As another post mentioned, if community spread was waning, we could take a much more scientific approach to stratification. But in this environment, we need to get the shot in as many arms as fast as possible. I have seen great arguments made for using age as the only stratification once you get past the front-line essential workers. Because age deciles over 50 dwarf all preexisting conditions risk factors. Stratifying based on obesity is truly insane, unless we intend to use it as a restaurant bailout as people try to gain weight to jump the line.

As it appears that the bottleneck is administration of the shots, not vaccine production here in the US, hopefully soon we will get to a point where everyone who wants one, gets one by March at the latest, and others who choose to wait until their circle of friends don't have a reaction, can then receive when ready. Then the challenge will be how to get the last 40% vaccinated because our vaccine administrators are sitting idle.

ADDENDUM: Not to mention we have no idea when to vaccinate people who have had COVID before. One dose or two? That is a sizeable and very heterogeneous group of people with very different exposures and durable immunity.

doctoravios

So you are saying that a 60 year old physician with 2 decades more experience and a greater risk of death ought to have less priority than a 40 year old physician? I think we will have to disagree on that.

These administrative difficulties/bureaucracy are exactly why the simplest thing to do would be to stratify the HCW cohort by age. And I am not choosing to wait until later in the line, my provider is prioritising HCWs by age so I haven't been offered it yet and am not likely to be until well into January.

Yes, we agree on this.

Yes, this is an important unknown. As you say, there are a lot of administrative issues in delivering the vaccine and these could even outweigh available supply (especially once other vaccines become available). I actually think there is an argument for just giving everyone under the age of 50 (perhaps even those who are elderly) a single dose, at least for the Pfizer vaccine which demonstrated substantial efficacy 14 days after the 1st dose. While supply/capacity to transport and administer is limited, this may be a more effective strategy from a population health perspective.

FlyBitcoin

No. I am saying they should be in the same group.
No reason why an injection slot today should go unfilled because a 60 year-old MD is unsure if he/she wants it right now but a 40 year-old ER Nurse does.

But I don't view the competition for slots within that group over the first 4 weeks of vaccine rollout to be significant. Whether you get injection 1 today or next Tuesday is probably insignificant in the grand scheme of things. We are all working and not all of us can come at the same date/time. Need to maximize the appointments and not let one go unfilled. Today vs April for a front line HCW probably is significant.

The lack of data on durability of a single dose regimen is our biggest weakness right now for the current vaccines. What a bonus it would be to get everyone a single dose first, and what a disaster it might be if that entire cohort is unprotected this fall when the virus re-emerges.

stimpy

Can I ask if there is a requirement or significant pressure on HCW's in the US or UK to get the vaccine? In the EU that does not seem to be the case, at least from what I've seen. I wonder what the case is in China?