Vaccine Distribution to Frontline Healthcare Workers: Q&A with Tarquin Collis, MD with Kaiser Permanente Hawaii

COVID-19 vaccines are here in Hawai‘i, and distribution to frontline healthcare workers has already begun. Kaiser Permanente Hawaii is playing a leading role in COVID-19 care and vaccine distribution in our state. They received their first shipment of 975 doses of the vaccine last week Wednesday, and started administering shots the following day.

In September, we asked Tarquin Collis, MD, Chief of Infectious Diseases with Kaiser Permanente Hawaii, to share his frontline observations in providing care for patients with COVID-19. Today, the Hawai‘i Department of Health asked Dr. Collis for his insight on how hospitals prepared to administer its first COVID-19 vaccine.

With a limited supply expected to be available with the initial rollout of the vaccine, how are hospitals determining which healthcare workers are high-risk and should receive the vaccine?

Dr. Collis: I can’t speak for other hospitals or health care systems, but at Kaiser Permanente we’ve prioritized eligibility for the first wave of COVID-19 vaccinations for those whose jobs involve direct, high-risk patient care with COVID-19 patients—the bulk of those folks work in the hospital, as you’d expect, but certainly not all of them. I think most organizations our size have taken the same approach.  We’ve also prioritized those who are actually helping to give the COVID-19 vaccine shots, given the high-volume throughput in our vaccine clinics that they’ll be exposed to. Finally, we’ve developed a process by which those who are at higher risk of getting severe complications from COVID-19 because of their age or medical history can request being considered for earlier vaccination than their job-related priority might allow for, which I think is important to offer.

We’re trying to be very deliberative and fair about this, and we’re focused not only on doctors and nurses but other folks in our hospital and clinics whose jobs put them at real risk of contracting the virus because of the front-line nature of their work—phlebotomists, radiology technicians, lab workers handling SARS-CoV-2 specimens, patient transporters and lift team members, and others that might not occur to you right away.

We’ve really tried to make it a very thoughtful and democratic process, and a lot of good minds have leaned in to try and get this right. We brought ethicists into the decision-making framework early on to help make sure that the guiding principles behind the process of choosing groups for vaccination were sound.

And, of course, during all of this work, in the back of our minds we also recognize that almost without exception PPE works incredibly well in protecting health care workers. We’ve not had many COVID-19 infections in our hospital workers or clinic staff, thank goodness, and most of the ones we’ve seen have actually resulted from exposures in the home, community, or from travel, rather than at work—so, really, everyone’s at significant risk. But it still makes sense to focus the initial wave of vaccinations on those whose jobs put them at substantial risk of contracting COVID-19, and that’s how we’ve tried to approach this.

How did Kaiser Permanente Hawaii prepare for vaccine distribution?

Dr. Collis: We recognized very early on that having our own ultra-low-temperature freezer to store what was likely to be the first vaccine licensed—the Pfizer-BioNTech vaccine, which needs to be kept at remarkably low temperatures right up until you’re ready to administer it—would be crucial for us to able to distribute and work with this vaccine as flexibly and efficiently as we wanted to. So, we moved quickly and purchased a big, ultra-low-temperature freezer for Kaiser Permanente’s Moanalua Medical Center and had it installed and ready to go well before the first vaccine arrived in Hawai‘i. I’m glad we jumped on this early because these freezers are now in extremely high demand and hard to find.

Our freezer is really large, around 700 pounds, and can hold several hundred-thousand doses of Pfizer’s COVID-19 vaccine.  We named her Bertha, and she looks like a cross between a bank safe and a very high-tech ice machine.  I was so excited when Bertha was safely in our hospital that I hugged her. (She did not hug back.)  That photo made the rounds pretty quickly.  Anyhow, because of our freezer’s large capacity, we’ve volunteered to the state to help store extra doses for the community. And as other health care facilities have done, we’ve upgraded our security measures, knowing that these vaccines are in extremely high demand.

But I’d say the majority of our efforts in preparing for the vaccine have actually been around educating our staff. In part because these vaccines were approved much quicker than anyone anticipated, there really hasn’t been a national education campaign yet to speak of from the federal government. There’s an amazing amount of disinformation out there about vaccines as well as about COVID-19 itself, and a lot of mistrust that needs to be overcome–even among some health care workers. So, we’ve held many town halls and department meetings and question-and-answer sessions with our physicians, providers, and employees to review the evidence behind these vaccines, what to expect, and about what we’re trying to accomplish. We’ve really tried to talk openly about what we know about the vaccines, what we don’t yet know, and how to think about vaccination relative to what we do know about COVID-19 itself—a particularly nasty and dangerous infection.

To me, it’s an easy decision to take this vaccine, but I understand and respect that it’s not a straightforward decision yet for a lot of people. I just want folks to have the facts, and to hear what’s known in a way that’s open and transparent so that they can make a decision about vaccination that respects who they are and the risks they face, but that also frames this issue in terms of our obligations as health care workers to our patients, co-workers, and to our community.

The education side of things has been a massive effort, and it’s an ongoing one. So much of public health is about thoughtful and honest education, and we’ve really tried to focus on that.

How widely can Pfizer’s vaccine be used, given its taxing storage requirements? With air travel slowed, can vaccines be distributed quickly?

Dr. Collis: Well, it’s a tricky dance, certainly. The cold storage requirements for the Pfizer vaccine are substantial, as we’ve talked about. Once you remove a vial of the vaccine from the deep freeze, you then have about 5 days at a normal refrigerator temperature to use it, and it can’t be refrozen. And once you thaw the vaccine to room temperature, you have just 6 hours to administer the shot.

Ultra-low-temperature freezers can preserve this vaccine for up to 6 months at an extremely chilly -94 degrees Fahrenheit—colder than your average winter day in Antarctica. Having one of these special freezers feels absolutely critical at this juncture; we’re very grateful for ours (Bertha!), as there aren’t many of these in the islands right now. A lot of dry ice is required for airline-related transport, and a ton of care needs to be taken to maintain the “cold-chain” of distribution from one place to another. So far this has worked really well, and the state and the national distribution networks have been very solid, but the logistics involved are pretty profound.

All of these issues make it essential that you have a very thoughtful and organized program to coordinate and administer mass vaccinations, and to avoid any waste of the vaccine—it’s such a crucial and precious resource. And yet at the same time, you also want to get as many shots in arms as quickly as you can in order to get folks protected promptly, especially given what we’re seeing on the mainland right now in terms of the virus’s spread. It’s all do-able, but it takes a ton of thought and careful planning and partnering.

The Moderna vaccine has to be frozen also, but at a much less daunting minus-4 degrees F—something closer to ice-cream temperatures. So, Moderna’s vaccine will be a good deal easier to work with in terms of storage and transportation, I think, and should be a lot easier for the neighbor islands and skilled nursing facilities to handle.

Despite all of these logistical headaches, we’re incredibly grateful to have these vaccines, and they appear to work remarkably well. Both of these vaccines represent hope, really, so we’ll happily take the logistical trickiness they carry with them, any day of the week.

Is COVID-19 vaccination voluntary for front-line workers? Will the vaccine be available for physicians, nurses and other staff who may not have daily direct contact with COVID patients?

Dr. Collis: COVID-19 vaccination is definitely voluntary at Kaiser Permanente Hawaii, though of course it’s highly recommended, and our hope is that almost everyone chooses to be vaccinated. As we’ve talked about, we’ve prioritized early receipt of the vaccine for our staff who have the highest-risk contact with COVID-19 patients, as well as for those administering the vaccines and handling infective specimens in the lab. But clearly, all health care workers are at some risk while at work, given the nature of what we do. So, all health care workers, even those not in the direct line of fire, are included in the CDC’s “Phase 1a” priority group and will be offered the vaccine. As more vaccine becomes available, we’ll expand outwards from the initial group of highest-risk folks to include those with lower on-the-job risks of contracting the virus.

How do healthcare workers, including yourself, feel about being the first the receive the new vaccine? Are there any worries about potential side effects?

Dr. Collis: The arrival of the Pfizer vaccine and its first few days of use at our hospital has been an emotionally intense process—there’s such a mix of feelings at play among the staff, it’s really been something to see. There’s so much hope, relief, happiness, and gratitude that the vaccine’s here, it’s very moving. And there was also some understandable nervousness in some folks too, as is common when you’re receiving any new vaccine or medication. But we administered the shot in a very safe environment, with a lot of experienced staff and all the right medicines ready in case anyone had a reaction to the vaccine—we do this with all vaccines, actually, but we’re especially careful with new ones—which I think helped put folks at ease.

I was given the shot on the first day that we offered it in our hospital—I received the vaccine early in the rollout, both because I do a lot of direct care for patients with COVID-19 as an infectious disease doctor, but also because I wanted to model for my colleagues that getting the vaccine was the safe and the smart way to go. I know the research behind these vaccines very well—I’ve done a ton of learning about them as part of my job, and I also trained at the University of Pennsylvania where a lot of the seminal work on mRNA vaccines was done in the 1990s and early 2000s. These mRNA vaccines may be new in terms of their approval for broad use but the research around them in the U.S. dates back 30 years or so, and for the last decade they’ve been extensively studied, developed, and trialed. From everything we see, it’s an extremely safe and effective technology. Being very familiar with the science, I wasn’t frightened at all getting it myself, and the shot itself was easy. I’ll have my second shot in about three weeks, and I can’t wait.

In terms of vaccine side effects, the two big clinical trials of mRNA vaccines—one from Pfizer, and the other from Moderna and the National Institutes of Health (NIH)—have shown them to be extremely safe in different ages of folks and in different populations, which is really reassuring. All vaccines cause some side effects; they’re designed to stimulate your immune system, and it’s natural to feel something as part of that process. Especially after the second shot, it was pretty common in these trials to feel some headache, fatigue, arm soreness, and muscle aches—that’s the feeling of your immune system ramping up, which is actually pretty cool when you think about it. Neither of these vaccines can give you COVID-19 itself, and it’s really important to understand that—there’s no live virus involved in either vaccine, and you won’t spread anything to others if you do have vaccine side effects. These post-vaccine symptoms don’t last long from what the clinical trials show us, maybe a day or two, and then you’re done. And all of that is much, much better than catching COVID-19 itself.

Anytime a new vaccine rolls out, you learn some things. Allergic reactions to any drug or vaccine are possible, and we’re seeing some of that now here and there, but I think that will prove very manageable if we’re careful about giving the shots carefully and educating folks about what to expect. It takes a while to fully understand any newly available vaccine or drug, but we’re learning quickly as a health care community because this vaccine has now been approved in a number of countries, and information is shared so quickly nowadays.

So, we don’t yet know all there is to know about the side effects of the vaccine, but we’re getting there. The trick here, of course, is that if you choose to wait to receive the vaccine until we know everything there is to know about them, you might easily catch COVID-19 itself while you’re waiting. This can be a very deadly infection, and even if you’re never hospitalized with COVID it can make your life pretty miserable for months, as I’m seeing in a lot of my outpatients now. So, in the end, deciding on whether or not to receive a COVID-19 vaccination is really about weighing what we don’t yet know about these vaccines—longer-term efficacy data, especially, and a complete safety profile—against what we DO know about COVID-19 itself, which is an infection that can really turn your life upside-down, and which you can also easily spread to others who might die as a result. For me, that’s an easy choice.

I’ll also add this last thought, which is important to me. I hope the great majority of health care workers choose to receive a COVID-19 vaccine when it’s available to them, because look who’s next up to bat. The most vulnerable component of the wider public is going to be offered these vaccines soon–nursing facility residents, essential workers, the elderly, and the immunocompromised. I think that as health care workers we have a duty to lead, because patients and the community as a whole look to us to get their cues as to what’s safe and smart in terms of health care. What’s the chance of you, as a patient, choosing to take a vaccine that your doctor or nurse or physical therapist tells you that they’ve decided not to take themselves? Close to zero. We’re looked at by a lot of the community as heroes. Heroes should lead the way.

What can we expect to see change once the vaccine is distributed to healthcare workers? Will PPE continue to be worn? Will healthcare workers be able to take precautions with their household members?

Dr. Collis: Even after receiving the COVID-19 vaccine, health care workers will definitely continue their current PPE practices at work and will continue to need to be careful about their exposures in the community. There are two big reasons for this: 1) even the best vaccines aren’t perfect in their protection, and neither of these vaccines has been around long enough to know exactly how long you’re protected from COVID-19 after getting them. There’s a lot of good evidence and some very encouraging early signals that suggest that mRNA vaccines will produce durable protection, but it’s going to take a few years to really understand this completely; also, very importantly, 2) we still need to understand better how much these vaccines protect you not just from getting sick from SARS-CoV-2 (they do an excellent job of that from everything we’re seeing), but also how well they keep you from spreading the infection to others, which is data we’re eagerly awaiting. Could it be that some folks who get the vaccine can still catch the virus, not feel at all sick because of the protection the vaccine gives them, and still spread it to others? Theoretically, yes, though I suspect the vaccines will help cut down on this as well.

But until all of that is known—the duration of immunity, and also whether the vaccine prevents people from asymptomatic infection and spreading the infection to others– nothing will really change in terms of masking and physical distancing recommendations in the folks who are vaccinated, no matter what you do for a living. It seems counter-intuitive until you think about it—you’ll still need to mask up and limit your exposures after getting the vaccine, even if a lot of that may turn out to be for the benefit of others. It’s really not going to be until the pandemic itself is clearly under good control in the community as a whole that the masking and distancing aspects of our lives will ease up. Herd immunity is the name of the game. We’re some distance from that yet, I’m afraid. And widespread vaccination is clearly going to be the best way for us to get to that point.

As Hawai‘i anticipates more vaccine supply, what is most important for the public to know about the vaccine and about what this upcoming year may hold?

Dr. Collis: Well, I really look at these new COVID-19 vaccines as a remarkable gift for all of us, and I try and stress that to others. It’s something close to a miracle that we have them at all—a testament both to the power of science on the one hand, and to blind luck on the other. I’ve spent a lot of my career fighting hepatitis C and HIV, two viruses discovered over 30 years ago, neither of which has a “soft target” for vaccines. We’re still nowhere close to an HIV or hep C vaccine despite decades of brilliant people trying their hardest. We just can’t seem to find a chink in their armor to exploit. But SARS-Co-V-2 has a soft underbelly, the spike protein, and in less than a year we’ve both figured that out and designed elegant vaccines to target it. And it looks like this will work remarkably well. I think it’s important that the public understand this—the gift and the incredible stroke of fortune that these vaccines represent.  We need to grab that gift with both hands; it’s our chance to end a pandemic that has caused immeasurable isolation and suffering.

Something else I think is really critical for people to understand—vaccines only work to end pandemics if a large swath of the public chooses to receive them. That’s what herd immunity is really about—until most of the herd is immune, the whole herd remains vulnerable. Your getting the vaccine yourself won’t bring your life back to normal or protect you indefinitely unless most other folks make the decision to take it also. Like a lot of the choices we make that feel entirely personal, choosing to receive a COVID-19 vaccine actually affects your community as well, profoundly so. It’s like driving on a busy freeway—it’s not all about personal freedom, there are a lot of folks tight around you whose health is directly affected by your choices. Freeways aren’t safe unless nearly everyone chooses to drive carefully. Vaccines work in much the same way, really, because we’re much more interconnected than we understand. Long before technology made that clear, infectious diseases have taught us that.

So, it’s really important to think outside of yourself when considering vaccination. At a purely personal level, I think it’s the smart choice to be vaccinated—trust me, COVID-19 is worth avoiding, especially as we’re now starting to understand that you can definitely catch COVID-19 twice! But I also think that taking the vaccine also helps bring those around you to safety and helps get our community to a better place and our lives collectively back to normal. If we want 2021 to be a good year—and I think it can be a great one, a really historic year—the great majority of us will need to choose to take a vaccine against COVID-19. It’s a little leap of faith, I know. But it’s an incredibly important one to take.

 

About Dr. Tarquin Collis

Dr. Collis grew up in Kailua and majored in English, studying creative writing and Shakespeare at Cornell University and at Oxford University in England, but ultimately decided to become a physician. He received his medical degree from Cornell University Medical College in New York. He and his wife, also a physician, completed their residencies at the Hospital of the University of Pennsylvania. Dr. Collis then completed a three-year fellowship in infectious disease at the University of Washington, obtaining a master’s degree in epidemiology at UW’s School of Public Health during his fellowship. He joined Kaiser Permanente Hawaii in 2001.