Feds Order States to Expand Covid-19 Vaccine Targets as Deaths Surge

The Trump administration ordered states to use Covid-19 vaccines set aside for second doses to get the shots to more people more quickly.

A medical worker in December in Jersey City, N.J., receiving a vaccine for Covid-19.
Credit…Bryan Anselm for The New York Times

Sheryl Gay StolbergAbby Goodnough

WASHINGTON — The Trump administration, racing a surging Covid-19 death toll, instructed states on Tuesday to immediately begin vaccinating every American 65 and older, as well as tens of millions of adults with medical conditions that put them at higher risk of dying from coronavirus infection.

The federal government will release all available doses of the vaccine instead of holding about half in reserve for second doses, Alex M. Azar II, the health secretary, said, adding that states should start allowing pharmacies and community health centers, which serve largely poor populations, to administer the shots.

The announcement came with a cudgel: States will lose their allocations, Mr. Azar said, if they do not use up doses quickly. And starting in two weeks, state vaccine allocations will be based on the size of a state’s population of people 65 and older, not on its general adult population. It was unclear, however, whether that would hold past Jan. 20, when President-elect Joseph R. Biden Jr. takes office.

“This next phase reflects the urgency of the situation we face,” Mr. Azar said. “Every vaccine dose that is sitting in a warehouse rather than going into an arm could mean one more life lost or one more hospital bed occupied.”

Mr. Biden’s transition team had said just days ago that the incoming administration would release almost all doses from the government’s reserves. Mr. Azar responded at the time that doing so would jeopardize the system set up to ensure second doses would be available.

Tuesday’s reversal reflected the slow start of the vaccine rollout, though the pace has picked up considerably over the past week. Some states, including Florida, Alaska, Michigan and Texas, have already begun vaccinating people 65 and older — who number more than 50 million nationwide — leading to long lines and confusion over how to receive a shot.

The new policy could exacerbate that confusion. Many states have been following their own carefully laid timelines for getting the vaccine to priority groups — including teachers, emergency responders, grocery store employees and other types of essential workers, whom Mr. Azar did not mention at all in his announcement.

At least one state, Arkansas, does not intend to heed Mr. Azar’s directive. Dr. Jose Romero, the Arkansas health secretary and chairman of the advisory group that wrote the vaccine recommendations for the Centers for Disease Control and Prevention on immunization, said in an interview that Arkansas’ Republican governor, Asa Hutchinson, would stick to his plan of opening vaccinations to people 70 and older and some essential workers starting Monday.

“He wanted this approach, and it was well thought out,” Dr. Romero said.

So far, only Texas has offered shots to both people 65 and older and all residents with at least one chronic medical condition. The C.D.C. has estimated that more than 100 million adults have conditions — such as obesity, which affects at least 40 percent of adults, and diabetes — that put them at increased risk of severe illness from Covid-19.

Other states had planned to widen access to older residents gradually over the next month. Ohio, for example, was to start vaccinating people 80 and older next week, people 70 and older on Feb. 1 and those 65 and older on Feb. 8. Florida has been overwhelmed with demand from its 65-plus population, with new online registration portals quickly crashing and people spending hours on the phone or in long lines, often in vain.

The two companies making vaccines that have emergency approval, Pfizer and Moderna, are both ramping up production. In an interview Tuesday with CNBC, the Pfizer chief executive, Dr. Albert Bourla, said Pfizer and its German partner, BioNTech, have increased their global production estimate this year to two billion doses from 1.3 billion.

“We have much more than they can use right now,” he said.

The C.D.C. recommended last month that after vaccinating health care workers and residents of long-term care facilities, states should vaccinate people older than 75 and certain “frontline” workers who cannot do their jobs from home. Only after that, the C.D.C. advised, should states turn to people ages 65 to 74 and adults of all ages with high-risk medical conditions. The C.D.C. recommendations were not binding, but many states have largely been following them while demand still far exceeds supply.

The advisory group that came up with the recommendations had emphasized that essential workers are often low-wage people of color, who have been hit disproportionately hard by the virus.

“A lot of our members are feeling like this is just beginning to move too fast,” said Dr. Marcus Plescia, the chief medical officer for the Association of State and Territorial Health Officials. “What we’re going to get to is a first-come, first-served approach to vaccine distribution, and that’s just not going to be equitable.”

Mr. Biden is expected to announce details of his own vaccination plan — which will include federally supported mass vaccination clinics — this week. The Biden transition team declined to comment on Tuesday on the new Trump administration policy. But a person familiar with the president-elect’s plans said Mr. Biden had also been planning to expand the universe of those who are eligible to be vaccinated.

Mr. Azar said the Trump administration always expected to shift from holding back doses when it was confident in the supply chain.

Dr. Paul Offit, a professor at the University of Pennsylvania and a member of the Food and Drug Administration’s vaccine advisory panel, praised the administration’s decision, likening the current situation to the Titanic, where there were not enough lifeboats to save everyone, “and you have to decide who you are going to let on.”

Covid-19 Vaccines ›

Answers to Your Vaccine Questions

While the exact order of vaccine recipients may vary by state, most will likely put medical workers and residents of long-term care facilities first. If you want to understand how this decision is getting made, this article will help.

Life will return to normal only when society as a whole gains enough protection against the coronavirus. Once countries authorize a vaccine, they’ll only be able to vaccinate a few percent of their citizens at most in the first couple months. The unvaccinated majority will still remain vulnerable to getting infected. A growing number of coronavirus vaccines are showing robust protection against becoming sick. But it’s also possible for people to spread the virus without even knowing they’re infected because they experience only mild symptoms or none at all. Scientists don’t yet know if the vaccines also block the transmission of the coronavirus. So for the time being, even vaccinated people will need to wear masks, avoid indoor crowds, and so on. Once enough people get vaccinated, it will become very difficult for the coronavirus to find vulnerable people to infect. Depending on how quickly we as a society achieve that goal, life might start approaching something like normal by the fall 2021.

Yes, but not forever. The two vaccines that will potentially get authorized this month clearly protect people from getting sick with Covid-19. But the clinical trials that delivered these results were not designed to determine whether vaccinated people could still spread the coronavirus without developing symptoms. That remains a possibility. We know that people who are naturally infected by the coronavirus can spread it while they’re not experiencing any cough or other symptoms. Researchers will be intensely studying this question as the vaccines roll out. In the meantime, even vaccinated people will need to think of themselves as possible spreaders.

The Pfizer and BioNTech vaccine is delivered as a shot in the arm, like other typical vaccines. The injection won’t be any different from ones you’ve gotten before. Tens of thousands of people have already received the vaccines, and none of them have reported any serious health problems. But some of them have felt short-lived discomfort, including aches and flu-like symptoms that typically last a day. It’s possible that people may need to plan to take a day off work or school after the second shot. While these experiences aren’t pleasant, they are a good sign: they are the result of your own immune system encountering the vaccine and mounting a potent response that will provide long-lasting immunity.

No. The vaccines from Moderna and Pfizer use a genetic molecule to prime the immune system. That molecule, known as mRNA, is eventually destroyed by the body. The mRNA is packaged in an oily bubble that can fuse to a cell, allowing the molecule to slip in. The cell uses the mRNA to make proteins from the coronavirus, which can stimulate the immune system. At any moment, each of our cells may contain hundreds of thousands of mRNA molecules, which they produce in order to make proteins of their own. Once those proteins are made, our cells then shred the mRNA with special enzymes. The mRNA molecules our cells make can only survive a matter of minutes. The mRNA in vaccines is engineered to withstand the cell’s enzymes a bit longer, so that the cells can make extra virus proteins and prompt a stronger immune response. But the mRNA can only last for a few days at most before they are destroyed.

“Without question there will be people who will die over the next three or four months because they didn’t get this vaccine,” Dr. Offit said. “It’s tragic.”

Dr. Grace Lee, a pediatrician at Stanford University and member of the expert committee that came up with the C.D.C.’s recommendations for prioritizing the vaccine, said she was eager to see far more people get vaccinated but concerned that some vulnerable groups could get lost in the shuffle.

“We should make sure we keep to outcomes in mind at the national level: efficiency and equity,” Dr. Lee said.


The health secretary, Alex M. Azar II, said the federal government would release all available doses of the vaccine instead of holding about half in reserve for second doses.
Credit…Pool photo by Patrick Semansky

Nearly 380,000 people have died from Covid-19 in the United States since the start of the pandemic. In recent days, the number of daily deaths in the country has topped 4,000.

As of Monday, about nine million people have received at least one dose of a Covid-19 vaccine, the C.D.C. said, far short of what the federal government initially promised. At least 151,000 people in the United States had been fully vaccinated as of Jan. 8, according to a New York Times survey of all 50 states. But Mr. Azar said that the country was “on track” to reach the rate of one million vaccinations a day in a week or so. He said the perceived delay in using up doses is at least partly because of slow data collection.

Even before Tuesday’s order, health experts and state officials have faced difficult choices as they decided which groups would be prioritized in the vaccine rollout. While older Americans have died of the virus at the highest rates, essential workers have borne the greatest risk of infection, and the category includes many poor people and people of color, who have suffered disproportionately high rates of infection and death.

Despite his state’s bumpy rollout, Gov. Ron DeSantis of Florida, who prioritized people 65 and older from the start, said he believed making all older people eligible was always the right thing to do.

The initial guidelines “would have allowed a 20-year-old healthy worker to get a vaccine before a 74-year-old grandmother,” Mr. DeSantis said on Tuesday at a news conference in the sprawling retirement community called the Villages. “That does not recognize how this virus has affected elderly people.”

In New York, which began vaccinating people 75 and older and more essential workers this week, Gov. Andrew M. Cuomo said that the state would accept the new federal guidance to prioritize those 65 and older, though he emphasized the state would not have nearly enough vaccine in the short term to reach the newly targeted populations.

The new guidance will make more than seven million New Yorkers eligible for the vaccine, Mr. Cuomo said, though the state currently receives only 300,000 doses a week.

New Yorkers 65 and older are immediately able to schedule appointments on the state’s website, according to Melissa DeRosa, a top Cuomo aide, who added that the state was working with the C.D.C. on who is considered to have compromised immune systems.


Credit…Alex Welsh for The New York Times

New guidelines released on Monday by the C.D.C. now note that while people should get their second shots “as close to the recommended three-week or one-month interval as possible,” there is “no maximum interval between the first and second doses for either vaccine.”

The update perplexed experts, who said that while other, previously licensed vaccines that involve multiple doses could be administered months or even years apart, no evidence yet exists to clearly support this strategy for Covid-19. “They will need to back this up with data,” said Marion Pepper, an immunologist at the University of Washington.

Health officials in Britain are now allowing intervals of up to 12 weeks between the first and second doses of Pfizer’s vaccines. Last week, the World Health Organization said the injections could be given up to six weeks apart.

In response to queries about dose delays, representatives from Pfizer and Moderna have repeatedly pointed to the company’s clinical trials, which tested dosing regimens of two shots, separated by 21 days for Pfizer and 28 days for Moderna.

“Two doses of the vaccine are required to provide the maximum protection against the disease, a vaccine efficacy of 95 percent,” Steven Danehy, a spokesman for Pfizer, said this month.

On Tuesday afternoon, Kristen Nordlund, a spokeswoman for the C.D.C., said the agency’s guidance would allow “flexibility” as the vaccine rollout continued.

But, she added, “We are not trying to promote delays of the second dose as a strategy to get more people vaccinated with the first dose.”

Reporting was contributed by Katie Thomas from Chicago, Roni Caryn Rabin, Katherine J. Wu and Amanda Rosa from New York and Patricia Mazzei from Miami.

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