The Disparity in COVID Vaccine Prioritization: Asthma vs. COPD
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Introduction
Over a year after the first COVID-19 case in the United States, many survivors continue to experience significant lung damage, even those who were asymptomatic. On January 4, Texas trauma surgeon Dr. Brittany Bankhead-Kendall shared alarming findings on social media, stating that patients’ chest X-rays displayed damage comparable to severe smoker’s lungs. This extensive lung damage was observed regardless of whether patients reported any breathing difficulties. Dr. Bankhead-Kendall emphasized that even in the absence of symptoms, the presence of scarring on X-rays could indicate potential future health issues, as she explained to CBS Dallas-Fort Worth.
Impact of COVID-19 on Chronic Lung Diseases
For individuals suffering from chronic lung conditions, the known effects of COVID-19 on lung function are particularly concerning. Fortunately, initiatives to ensure equitable vaccine distribution to vulnerable populations are in motion, with various states aiming to prioritize high-risk groups with preexisting medical conditions. The CDC has recognized the need to vaccinate individuals with chronic obstructive pulmonary disease (COPD) early in the rollout, but has not extended this prioritization to those with asthma.
Section 2.1: The Medical Confusion
This exclusion raises questions, as asthma and COPD often present similar symptoms. Asthma, a manageable yet incurable lung inflammation, affects around 23.4 million adults in the U.S., while COPD, which includes chronic bronchitis and emphysema, leads to irreversible lung function decline and affects approximately 17.4 million. Both conditions can worsen with acute respiratory infections like influenza or COVID-19. The primary distinction is that asthma can develop at any age, while COPD predominantly affects older adults with a smoking history.
Section 2.2: Misleading CDC Guidelines
The CDC's decision to prioritize COPD over asthma lacks clarity, especially given the accumulating evidence regarding COVID-19's effects on lung health. Studies referenced by the CDC to support their guidelines do not sufficiently differentiate between asthma and COPD. One study indicated that both conditions are associated with worse outcomes for COVID-19 patients, yet it failed to specify which diseases were analyzed.
Certain studies seem selectively interpreted. For example, a study indicating that asthma is prevalent but not strongly linked to intensive care admissions focused on a pediatric cohort, which is generally not eligible for available vaccines. The CDC also acknowledges asthma’s significance in disease severity through a large cohort study that identified preexisting asthma as a factor predicting longer intubation periods in COVID-19 patients, particularly those under 65.
Section 2.3: Racial Disparities in Diagnosis
The inconsistent interpretations of data raise alarms about equity in vaccine distribution. The prioritization of COPD over asthma is particularly troubling, as research suggests that an individual's diagnosis may be influenced more by their racial background than their actual health conditions.
Asthma is disproportionately diagnosed in communities of color. The American Lung Association reports that Black Americans and American Indian/Alaska Natives have higher lifetime asthma diagnosis rates compared to the general population (16.1% and 18.1% vs. 13%). The asthma mortality rate for Black Americans was found to be 2.8 times greater than that of their white counterparts in 2016.
Conversely, a greater percentage of white individuals are diagnosed with COPD. According to 2018 CDC data, the prevalence of emphysema was 1.9% among whites and 1% among Black Americans, while 4.1% of white Americans reported being diagnosed with chronic bronchitis, compared to 3.7% of Black Americans.
However, these figures may not accurately portray the true state of COPD in the U.S. Research by Dr. A. James Mamary and Dr. Jeffery I. Stewart indicates that up to 13 million individuals with impaired lung function may be unaware they have COPD. While the diagnosed population skews white, there are compelling reasons to believe the underdiagnosed individuals are more diverse.
Section 2.4: Asthma Diagnosis as a Barrier
In a study on genetic factors influencing COPD, researchers assessed the lung function of 9,000 long-term smokers, both Black and non-Hispanic white. Their findings revealed a concerning narrative of medical racism: 44% of Black participants without a prior COPD diagnosis met the clinical criteria for the disease, compared to only 29% of undiagnosed white participants. Alarmingly, Black individuals were found to be more likely to remain undiagnosed at every stage of lung disease progression.
Crucially, the study revealed that many Black participants had previously received an asthma diagnosis instead of a COPD diagnosis. A significant portion of Black participants with undiagnosed COPD had been diagnosed with asthma, at a rate higher than their white counterparts.
Conclusion: A Call for Equitable Health Policies
As efforts to distribute vaccines continue across the country, states are beginning to include individuals with underlying health conditions. While all states have included COPD in their priority lists, only Virginia has opted to include asthma, defying CDC guidelines.
The CDC's guidelines are subject to change, but state officials must reflect on the implications of these recommendations for health equity and justice. Prioritizing asthma as a high-risk condition during vaccine distribution is a necessary step to address existing injustices. The pandemic has highlighted systemic racial inequities in public health, and addressing these disparities is vital for improving health outcomes for marginalized communities.
Update: As of February 8, New York has announced plans to vaccinate residents with underlying conditions, including moderate-to-severe asthma, starting February 15.