Protecting our Patients: APSF Recommends that Anesthesia Professionals be Included in the First Phase of Vaccinations

December 21, 2020

Receiving COVID-19 Vaccine

KEY POINTS

  • Patient safety is our top priority.
  • The goal of protecting the public’s health is inextricably intertwined with the goal of protecting healthcare workers who serve the public.
  • Two vaccines with approximately 95% efficacy have recently received emergency use authorization by the FDA.
  • The initial supply is scarce.
  • The National Academies of Sciences, Engineering and Medicine developed recommendations, adapted by the CDC, on the equitable allocation of a COVID-19 vaccine.
  • The routine care of patients in the perioperative period places anesthesia providers in the earliest phase of vaccination as recommended by the National Academies of Sciences, Engineering and Medicine.
  • The public must trust that healthcare workers will not transmit SARS-CoV-2 to them.

At the time of this writing there have been over 17 million cases and 300,000 deaths in the United States due to the novel coronavirus (SARS-CoV-2).1 We are in the midst of an alarming surge of cases following the outbreak in early 2020. Many hospitals across the country are at or over capacity with a real risk of deterioration in the quality and safety of patient care.

Anesthesiologists, intensivists, nurse anesthetists, and anesthesiologist assistants care for patients at the frontlines of this pandemic which include patients with confirmed or unknown SARS-CoV-2 status. Due to the inherent nature of performing aerosolizing procedures and handling infectious waste, they have a high risk of contracting COVID-19. Mitigating against that risk are safety principles that are in the best interests of patient and personal safety. These include the use of appropriate personal protective equipment (PPE).

In addition to other public health measures, one of the strategies to reduce the transmission of SARS-CoV-2 and the resultant public health consequences of COVID-19 is the development of safe and effective vaccines. Currently, there are 63 vaccines in clinical trials and an additional 85 in preclinical trials. As of December 19, 2020, two have received emergency use authorization by the Food and Drug Administration (FDA) for use in the United States.

  • The Pfizer/BioNTech mRNA vaccine (BNT162b2) has an efficacy rate of 95% with apparent immunity occurring around day 12 following the first of two recommended doses.2-4 Vaccine efficacy is estimated at 52% following a single dose, with full immunity at seven days following the second dose.
  • The Moderna/NIH mRNA vaccine has an efficacy rate similar to BNT162b2.5 As this vaccine was approved December 18, 2020, its initial distribution and subsequent administration has not yet occurred but is immediately pending.
  • 9 million doses of BNT162b2 were distributed last week, with a combined 7.9 million doses of both vaccines scheduled for distribution in the coming week.

In anticipation of a program to vaccinate the public against COVID-19 with an initial limited supply, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) asked the National Academies of Sciences, Engineering and Medicine to make recommendations on the equitable allocation of a COVID-19 vaccine. A panel of experts published a “Framework for Equitable Allocation of COVID-19 Vaccine” which was adapted and implemented by the CDC.6,7

The Anesthesia Patient Safety Foundation fully supports the “Framework for Equitable Allocation of COVID-19 Vaccine”. The committee developed four risk-based criteria that are to be used to set priorities.6 These include:

  1. Risk of acquiring infection: Individuals have higher priority to the extent that they have a greater probability of being in settings where SARS-CoV-2 is circulating and of being exposed to a sufficient dose of the virus.
  2. Risk of severe morbidity and mortality: Individuals have higher priority to the extent that they have a greater probability of severe disease or death if they acquire infection.
  3. Risk of negative societal impact: Individuals have higher priority to the extent that societal function and other individuals’ lives and livelihood depend on them directly and would be imperiled if they fell ill.
  4. Risk of transmitting infection to others: Individuals have higher priority to the extent that there is a higher probability of their transmitting the infection to others.*

Anesthesia professionals clearly have specific risk with criteria 1, 3 and 4, while criteria 2 is an individual risk not necessarily associated with a professional cohort. The report went on to recommend a four-phased approach to equitable COVID-19 vaccine allocation.

The first phase, Phase 1a, is specifically relevant to anesthesia professionals and includes but is not limited to high-risk health workers who are involved in direct patient care who risk exposure to bodily fluids or aerosols. Anesthesia professionals are directly involved in intubations and extubations (aerosol-generating procedures), and frequently suction secretions from their patient’s oropharynx. Moreover, anesthesia professionals are often very close to their patient’s oro- and nasopharynx, thus potentially exposing the patient and themselves to viral transmission. To quote the report, “This group is included in Phase 1a for multiple reasons: their critical role in maintaining health care system functionality, their high risk of exposure to patients exhibiting symptoms of COVID-19, and their risk of then transmitting the virus to others…”. “Vaccinating these individuals not only enables them to provide these services, but also reduces the risk that they will spread the infection….”.

It’s a matter of public trust. Patients must trust that the system in which they receive care is safe and reliable. This includes ensuring that anesthesia professionals are not an infectious risk to them for SARS-CoV-2. It is paramount that each healthcare system includes anesthesia professionals in the first phase of vaccine administration.

* The four criteria are a direct excerpt from the Framework for Equitable Allocation of COVID-19 Vaccine.6 It should be noted neither the durability of immunity or protection against transmission of SARS-CoV-2 is known. While biologically plausible and even likely, the question of transmission of SARS-CoV-2 has not been fully assessed at this time. Accordingly, the CDC recommends that “vaccinated persons should continue to follow all current guidance to protect themselves and others. This includes wearing a mask, staying 6 feet away from others, avoiding crowds, washing hands often, following CDC travel guidance, following quarantine guidance after an exposure to someone with COVID-19, and following any applicable workplace or school guidance, including guidance related to personal protective equipment use or SARS-CoV-2 testing.”3

References:

  1. https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days
  2. Polack FP, Thomas SJ, Kitchin N, et al. Safety and efficacy of the BNT162b2 Covid-19 vaccine. N Engl J Med. DOI: 10.1056/NEJMoa2034577
  3. https://www.cdc.gov/vaccines/covid-19/info-by-product/pfizer/clinical-considerations.html
  4. https://www.medrxiv.org/content/10.1101/2020.12.09.20245175v1.full.pdf
  5. https://www.fda.gov/media/144585/download
  6. https://www.nap.edu/catalog/25917/framework-for-equitable-allocation-of-covid-19-vaccine
  7. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine¾United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1782-1786. DOI:http://dx.doi.org/10.15585/mmwr.mm6947e3external icon