As Massachusetts and several other states prioritize vaccine distribution to residents with cancer, heart disease, obesity and other medical concerns, many are still trying to figure out if they qualify as criteria with these diseases remain unclear. Sean Levy, MD (Pulmonary Disease, BIDMC) noted some eligible risk factors like smoking are open to interpretation.

WBUR – February 18, 2021

Do I Qualify? Vaccine Confusion For Patients With Multiple Serious Medical Conditions

It’s clear that some health conditions increase risk for a serious case of COVID-19. So, in their vaccination plans, Massachusetts and several other states are prioritizing residents with cancer, heart disease, obesity and other medical concerns.

But, the criteria can be confusing. And the list of conditions for which the Centers for Disease Control says there’s confirmed evidence of increased danger — type 2 diabetes, for example — doesn’t match what some doctors say is common sense: type 1 diabetes isn’t included.

Now, as Massachusetts makes vaccines available for residents with two or more COVID risk conditions, many residents are trying to figure out if they qualify.

Take Suzy Dolan, a Cambridge resident diagnosed with type 1 diabetes. Dolan says the advice from her doctors has been clear since the beginning of the pandemic.

“ ‘If you get COVID, you will get really sick,’ is basically what they said,” she explains.

Dolan also has a second high-risk condition: asthma. At an appointment last week, she asked doctors who help manage her diabetes if she should be vaccinated. They talked about a state form that patients with at least two qualifying conditions will sign, a written way to swear that they are eligible.

“They instructed me to just put diabetes and not specify which type because, my doctors are like, ‘You have diabetes. If it doesn’t specify type 2, you should go for it,’ ” she says.

But, Dolan says she won’t lie and say she has type 2 diabetes to get the vaccine. This decision is left to the patient. Vaccine sites are not asking for medical records or a doctor’s note proving someone has a heart condition or kidney disease.

And the eligibility criteria within these diseases is not always clear. Take Dolan’s asthma. She says doctors have told her it’s a “moderate” case. That fits. The state’s list, adopted from the CDC, chose to also include “moderate to severe” asthma. But what’s moderate?

“I think when you get into the moderate category of asthma it becomes a little more ambiguous, both for patients, and to be honest, for providers,” says Dr. Sean Levy, a pulmonologist at Beth Israel Deaconess Medical Center.

He says “smoking” — another eligible risk factor — is also open to interpretation. The CDC list includes both current and former smokers. Levy says people who smoke now are definitely at risk, but those who’ve quit are a diverse group.

“I’m thinking, for example, about a person who is 55 who smoked for a year in college,” he explains. “Should that person have the same risk as somebody who is 55 and quit smoking last year after smoking two packs a day for the last 20 years?”

Probably not, says Levy, but evaluating individual risk is difficult because COVID is such a new disease. That’s true for patients with another qualifying medical condition: cancer.

“Certainly, having active cancer puts patients at a greater risk,” says Dr. Andrew Wagner, associate chief medical officer at the Dana Farber Cancer Institute. “But patients who are in remission at some point had active cancer, and what we don’t know is, where does that risk diminish?”

So again, patients will decide, perhaps in consultation with their doctor. Wagner says Dana Farber will prioritize patients coming in for chemotherapy and other treatments that compromise their immune systems. People with HIV, who may also have a weakened immune system, are on that list of conditions the CDC says might make COVID more dangerous but for which there’s not enough research yet. High blood pressure, liver disease and cystic fibrosis (CF) are also on that list. Doctors and patient advocacy groups say leaving some of these conditions off the vaccine eligibility list doesn’t make sense.

“If you have cystic fibrosis, and your lungs are literally filling with fluid,” says Colin Killick, executive director at Disability Policy Consortium, “of course, a disease that affects your respiratory system is going to put you at increased risk.”

Killick says many states are vaccinating people on that “maybe” list, including patients with CF.

“Massachusetts actually has a much more restrictive approach to comorbidities than most other states,” he says.

Killick says the Baker administration has agreed to consider adding other conditions to its current vaccine eligibility list.

“We stated from the very beginning of this process that if we had unlimited supply we would want to vaccinate everyone right away,” explains Dr. Paul Biddinger, chair of the state’s vaccine advisory group. “The really hard discussions stem from the fact that the supply is limited.”

Gov. Charlie Baker said it will take at least a month to vaccinate everyone who wants the shots among the group that became eligible Thursday, under the current state plan. But some providers have already expanded their vaccine eligibility criteria.

“I think we’re trying not to get too analytical,” says Cheryl Bartlett. She runs the Greater New Bedford Community Health Center and says type 1 diabetes, hypertension and some of the other possible risk conditions count now for her patients who want to be vaccinated.

“This strict categorization,” she says, “really has limited our public health progress, and I say, just keep moving.”

Bartlett says roughly half her patients have two or more chronic illnesses.

Dr. Cassandra Pierre, acting hospital epidemiologist at Boston Medical Center, says outreach to patients of color will be especially important in this phase of the vaccine roll-out because they have high rates of asthma, type 2 diabetes, sickle cell disease and some of the other COVID risk inflators.

BMC has already prioritized vaccines for patients 75 and older in Dorchester, Roxbury, Mattapan and East Boston where high coronavirus infection rates overlap with poverty, crowded housing and other health risks.

“This is a bigger group of people to reach,” Pierre says, “so we have to ensure that our resources are being used wisely.”