Earlier this month, the governors of Oregon, Washington and California announced they are forming a partnership called the West Coast Health Alliance. The goal of this new partnership is aimed at preserving access to vaccines and will also develop its own immunization guidelines.
This comes after the the Trump administration fired the new director of the Centers for Disease Control and Prevention and several scientists resigned from the agency.
Now the group is sharing its guidelines recommending that everyone over 6 months of age should have access to the COVID-19 vaccine and that the vaccine should be accessible to “all who choose protection.”
Dean Sidelinger is the state epidemiologist for the Oregon Health Authority and joins us to share more on this new partnership and their recommendations.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. The governors of Oregon, Washington, California and Hawaii announced their own recommendations for who should get COVID-19 vaccines yesterday. These recommendations come as part of the newly formed Western States Health Alliance, which was created after state leaders at the U.S. Centers for Disease Control and Prevention had been compromised by politics. In recommending broad access to the COVID-19 vaccine for everyone over six months of age, these democratically controlled states, unlike the federal government, say that the shots should be available to all who choose protection.
Dean Sidelinger is the health officer and state epidemiologist for the Oregon Health Authority. He joins us now. Welcome back to the show.
Dean Sidelinger: Thanks, Dave. Good to be here.
Miller: I want to start with the recommendations themselves and the ways in which Oregon and its neighbors now differ from the federal government. It’s a little challenging to do this because we’re still waiting for the Advisory Committee on Immunization Practices – ACIP – at the CDC to put out its own recommendations. Those are expected tomorrow. But we do have the FDA’s august statements and a lot of information just in the last couple of months about RFK Jr’s approach to vaccines.
As I see it, there’s actually some real overlap between the federal government now and these states when it comes to people over the age of 65 and people with underlying health conditions. So let’s begin there, where there is a little bit of overlap. Do you see meaningful differences?
Sidelinger: I definitely see meaningful differences. And I think the reason that the governors directed the health departments in our four states to examine the evidence and to come out with independent recommendations was because we wanted to make sure it was based on the science. So even though there’s overlap with what the FDA said with those over 65 and those with underlying conditions, the changes that the FDA made in limiting the scope of vaccines on the label, didn’t have data behind it.
So they didn’t come out and say, OK, this is why we’re making these changes. We examined these data sources or these pieces of evidence, and we’re saying this. They just came out and said it. So we wanted to make sure that we could come out with some recommendations that say, OK, here are our recommendations, and here’s why we’re saying that, and here’s the information you need to make a choice for yourself and your family.
Miller: OK, so for the older age group or people who have underlying health conditions, even if the recommendations are, “yes, we recommend that you get vaccinated,” even if the recommendations are the same, you’re saying that what the states have now added is more evidence behind those. But there are bigger disagreements for other groups, for healthy adults and older kids – that’s where it gets more complicated. So what exactly are Oregon, Washington, California and Hawaii recommending right now for those groups?
Sidelinger: For COVID-19, as we go into the fall season, we’re still in a summer COVID wave right now with all of us probably knowing someone who’s sick or recovering ourselves. We know that it’s gonna come back this fall and winter. So, what we say is that everyone who wants a vaccine, who desires protection, [and are] 6 months and older should have access to it. People choose vaccination for various reasons. But we also say that there are certain people in certain groups who should get a vaccine because they’re at higher risk.
So let me start with one, again, where there’s agreement with what the FDA came out and said: individuals 65 and older. They have the highest rates of hospitalization, so the highest rates of more serious COVID of any other age group. So we recommend that they all get vaccinated to give them protection. But the second highest rate of hospitalization among age groups is kids under 2. So kids 6 months – which is when the vaccine is available – through 23 months, we recommend that they all get vaccinated because, again, they’re at high risk for severe disease. And about half the kids who are hospitalized don’t have an underlying condition in that age group, so we can’t parse it out and say just the young kids who have an underlying condition.
So, on the age group, that’s where we kind of bookend. Our youngest people in Oregon and our oldest folks in Oregon all should be vaccinated because they’re at high risk of hospitalization. In between, there are many things that put people at risk: immunocompromising conditions, so their body may not be able to fight off an infection as well. They should receive a dose and often extra doses in conversation with their provider, to provide the best protection.
People with underlying conditions, whether that be diabetes or lung disease, being obese or other pieces, put people at higher risk for being hospitalized and having serious complications, they should all be vaccinated. People who live in a congregate setting – think of a dorm for young adults, think of a skilled nursing facility, or an assisted living facility for many folks recovering from a disease, or older folks who have longer term stays. That puts them at higher risk because of the exposure. And people in those settings, including the individual patient, may have underlying conditions or may not permanently, but they’re at higher risk for exposure.
And then, people who work in a health care setting who are exposed to more people, or other occupational settings where they have increased exposure, should get protection. But that leaves open many other reasons people want to get protected. Living at home with a spouse who may be undergoing chemotherapy for cancer, and you want to get protected, not just for yourself but to help protect your spouse.
Living with an older adult who’s got chronic heart conditions, who may have heart failure, you may want to get protected, you may want to get protection to protect them. Knowing that you work in an office setting with people who are receiving therapy for rheumatological conditions, you may want to get protected for them. So we say that anyone who chooses that protection, for themselves or the people around them, should be able to choose it, but the people at highest risk really should be talking to their providers about getting vaccines ...
Miller: Oh, sorry to interrupt, but a lot of the categories you were just talking about there are about essentially getting vaccinated because you’re in close contact with people who are at higher risk if they themselves get infected. What do studies show about the likelihood that successive boosters prevent transmission?
Sidelinger: So what we know about our COVID vaccinations and the protection has really changed, as the disease has changed and as the immunology, as the number of people who’ve been vaccinated or recovered from illness has changed. So what we can say very definitively is the vaccine is very efficacious. It works very well at preventing serious disease. That includes hospitalization. It also works well at preventing long COVID for people who get it.
But in the short term, after you’re vaccinated, you also have protection from getting the disease at all. That protection isn’t as long lasting as the protection that keeps you out of the hospital, but your body’s response to the vaccine creates antibodies that help fight off an infection. So in those months following vaccination, [if] you’re exposed, you’re less likely to become ill.
Over the longer period, those antibodies that are circulating in our bloodstream kind of go away and we rely on the cells to produce more antibodies, and that takes some time. And so that may be why four, five or six months following your vaccination, you may get exposed to someone and you may get sick, but then those cells ramp up, they produce those antibodies and fight off the infection, and keep you out of the hospital. But early on, they really do fight off the infection and may keep you healthy.
Miller: So let’s talk about a particular potential patient: a healthy 40-year-old with no risk factors, who has already had a series of vaccine shots and boosters over the years, and got COVID. They come to you and they don’t say, “I want the booster.” They ask you, “Should I get the booster? Do you recommend that I get it?” How would you respond?
Sidelinger: I think that’s having a conversation. So, what does a booster mean? A booster for you might mean that if over the next several months, you’re exposed to people who have COVID, you may not get sick. And if you get sick, that may not put you in the hospital cause you’re relatively healthy, but you may be laid up and not able to work, not be able to participate in social activities you are looking forward to, and you may feel lousy. Like anyone who’s had COVID or the flu, just because you’re not in the hospital doesn’t mean you’re sitting at home enjoying yourself on the couch. You often feel very lousy. So a vaccine can offer you protection from that over the next several months and also lower your chances of getting long COVID if you do get sick.
And for you, the risks of the vaccine are very low. This vaccine is very safe and used tens of millions of times across the world. And we look for safety signals and just don’t see them. There’s a small, slight risk in adolescent males and young adult males of myocarditis or inflammation around the heart that seems to be short-lived, may not cause any symptoms and occurs at lower rates than it does with the disease itself. So given those facts, what do you think about getting vaccinated? That’s where I would leave it, that we would have that conversation after they learned the facts.
Miller: Let’s turn to the process here. How did these four states actually come up with this whole set of recommendations?
Sidelinger: Well, first, I want to [say] I’m very proud to live in Oregon and live in one of these states where the governors have come together and said, “Hey, we want our health department to continue to look at the data and science, and have that drive decisions.” So what we did is the state health officials, the health officers in those states came together, met and said, “OK, we need to look at the data that’s out there.”
Luckily, there have been a lot of data that had been compiled for previous ACIP work groups and that had been compiled based on last season that we could look at and say, OK, who’s still getting sick, who’s still getting hospitalized with COVID – where we spent more time on – and how well is the vaccine working? Do we see any new safety signals? So we kind of looked at that data.
That data, much of it, and including new data, anything that’s been published recently, was compiled by a group at the University of Minnesota called the Vaccine Integrity Project, who reviewed all of the data that’s out there, compiled that into a report, posted it publicly, had a public presentation of that data and allowed experts to ask questions. That compiled information and, again, all the data about who’s still getting sick was reviewed by many of the professional medical societies.
I think first and foremost are the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The American Academy of Pediatrics, the pediatricians, have had a vaccine recommendation schedule long before the CDC did. And the American College of Obstetricians and Gynecologists has been making recommendations about protection of people planning to be pregnant, people who are pregnant or people who’ve recently delivered. And so they reviewed the evidence and came up with recommendations for their specific populations. So we looked at those – independent folks who looked at the latest data and made recommendations to best protect patients.
Taking all of that together, looking at the data on who’s getting sick in adults and underlying conditions in their interplay, the health officials amongst the four states with our immunization experts at the states compiled these recommendations, and looked at our flu and our RSV recommendations. Flu recommendations remain universal. Everyone 6 months and above can benefit from a flu shot. Flu is still a great killer across the United States every year.
And for RSV, well, we’ve only had immunization products for two years, for older individuals, pregnant people and infants. The infants and the older folks are the folks most impacted. They have made a tremendous impact. We’ve seen a huge decrease in hospitalization amongst infants. So those recommendations haven’t changed from previous years, with the exception of some updates to a new product that’s available for infants, but otherwise they stay the same. So we discussed those, came up with a consensus and that’s what we announced yesterday.
Miller: How much difficulty was there, or was there not, in coming up to that consensus? I’m wondering if there were edge cases, if there were groups of people or specific pieces of the recommendations where there was real debate even among the health officials from these four states before you released these recommendations publicly?
Sidelinger: Certainly, I think we had a very robust debate. I will say, taking some of the age pieces, that was easy. Looking at hospitalization rates, oldest individuals, youngest individuals, highest and second highest hospitalization rates – those are fairly easy. Kind of looking at and embracing, endorsing the recommendations that the American Academy of Pediatrics made for kids was relatively easy. Their process was very transparent, how they reviewed the data. Same thing with the American College of Obstetricians and Gynecologists. It was very transparent, independent folks reviewing this data and making recommendations. So those, again, were fairly easy.
When it came to healthy adults, we didn’t have as much weigh-in from our professional societies. So we continued to look at the data and say, what does it show? And again, it shows that amongst adults under 65, certainly 50 and up, there’s a slightly higher hospitalization rate, but not as much as the change we see at 65. So we stayed with the 65 cut off. And certainly, most adults under 65 [who] were hospitalized had an underlying condition. So it didn’t make sense, similar to the conclusion that the American Academy of Pediatrics came up with kids and maybe necessarily continue to universally recommend a COVID vaccine for everyone.
But again, going back to people choose to be vaccinated, choose protection for different reasons, we didn’t want them not to have access. The people who choose protection are certainly a group we recommend the provider vaccinates, but that was probably our most robust discussion was around the adults without underlying medical conditions.
Miller: Does the release of these recommendations for Oregon mean that if Oregonians … let’s say for the category, the healthy adults, if they want the vaccine, it’s recommended that they get it. Does it mean that they will be able to have access to it and get it for free?
Sidelinger: I would say mostly yes. So for here, I’ll give a little background and context. Let’s go back a year [to the] last respiratory season. The actions taken at the federal government, reviewing the latest data, making recommendations by the Advisory Committee on Immunization Practices that were then accepted by the CDC, that starts a cascade of events that vaccines for children on Medicaid programs across the country are covered for free. That private insurers are required under federal law to cover all those recommendations for free. That process broke down this year. The federal government, the science wasn’t followed. They hadn’t even made a recommendation yet on COVID, so that process fell down.
It’s hard to recreate that at the state level, but each state is working within their kind of rules and regulations to make it happen. So in Oregon, a few important things happened yesterday in addition to the schedule. Because the Advisory Committee on Immunization Practices doesn’t have a recommendation yet on the updated COVID vaccine, pharmacists couldn’t give it by protocol in Oregon. They relied on a prescription from a provider.
So the Board of Pharmacy, working with OHA and other state agencies and the governor’s office, passed a couple of rules yesterday to remove COVID, RSV and flu from the standard protocol process relying on our federal partners, and then created new protocols for each of those diseases referencing the Western states or the West Coast Health Alliance recommendations. And those were adopted by the board yesterday, went into effect yesterday, so that people can once again go to a pharmacy and get a vaccine without a prescription.
I just want to say it may take some time for you to be able to walk in and get it, but that access point is being restored here in Oregon. And just a little more about access, cost is another piece. So actions we could take at the state where we could work with a bulletin to our Medicaid providers – Oregon Health Plan – and say that nothing has changed, you will continue to cover these vaccines for your patients without a cost. For private insurers that are regulated by the state, they are required, at least for COVID, to cover those vaccines without a cost.
We still have ACIP recommendations for flu and RSV so that that wasn’t in danger right now, but the bulletin was issued to private insurers that they must continue that. There’s some insurers that aren’t regulated by the state, they are only regulated at the federal level or outside of the state. We are having conversations and encouraging continued coverage, but that’s why we advise people to check with their HR or insurer about coverage before they go. But for many Oregonians, coverage hasn’t changed. It’ll be without copay and the state has taken actions to ensure that.
Miller: The Advisory Committee on Immunization Practices, ACIP, is talking right now about the hepatitis B and MMR vaccines. If they make changes to these – which is, at this point, the smart watchers think that’s likely – will the West Coast Health Alliance again make its own recommendations?
Sidelinger: Yeah, I think we are committed in Oregon and across our four West Coast Health Alliance states to look at not just the information that comes out of the Advisory Committee on Immunization Practices, what the recommendations are, but how did they come to that? Was there new data brought to the table? What was the rationale behind it, so that we can say this makes sense or doesn’t?
I can say I personally don’t hold out a lot of hope that there’s going to be an evidence-based, data-driven process driving these recommendations. So we will be coming out with a statement, examining that and seeing if we need to make our own recommendations for those particular vaccines.
Miller: I totally understand the arguments you’re making and the grave concern about the politicization of the CDC, and frankly, the staffing at the highest levels of the federal health apparatus of people who are bringing many unscientific views about vaccines or vaccine safety, and they’re now running the federal health apparatus.
So that’s the background here. But this is an alliance, these four states, of states led by Democrats, which seems like it could run the risk of just deepening the politicization of vaccines. So I’m wondering what the long-term public health strategy is for gaining bipartisan trust, not just in vaccines, but in the whole idea of public health as opposed to a bifurcated, even more politicized system?
Sidelinger: Yeah, and I worry about that as well. I think it is painful for me as a public health professional who’s based my career and what I do on data and science, and trying to encourage people to make healthy choices and to support those healthy choices. And to see that undermined by my federal colleagues … and let me just say that there are thousands of CDC and FDA employees right now that are continuing to try and follow the science and do the right thing. The politicization and the direction is coming from the top. So I don’t want to cast aspersions on my federal colleagues. They’re trying to do some amazing work.
But yeah, certainly there is a partisan divide. But I think we need to continue to have a conversation and some of the things I say, you wouldn’t think that I am a health official in a blue state. The actions that we took yesterday are preserving choice for people. This is a preserving choice for anyone in Oregon who’s choosing protection from COVID-19 with a safe and effective vaccine for their child or for themselves.
And that is extremely important, not just here in Portland, but I think in rural Oregon. And we heard from Doctor Liz Powers from Wallowa County yesterday about how important it is for her patients, in a fairly red part of the state, to have access to vaccines and to be able to choose that protection if they want it. Because again, these vaccines work. They keep people out of the hospital. They make sure that if we need a hospital bed, if I need a hospital bed or you do, for a car accident, a heart attack, COVID, whatever, that we’re going to be more likely to have it because people have chosen protection.
So I think having that conversation, focusing on what we know and focusing on giving people the information to make healthy choices is where we need to go. But it is going to take a long time to recover from this polarization and politicization of what was an extremely well respected system for public health under the CDC and the ACIP that really has been dismantled.
Miller: Dean Sidelinger, thanks very much.
Sidelinger: Thanks.
Miller: Dean Sidelinger is the health officer and state epidemiologist for the Oregon Health Authority.
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