Researchers Question Why Sleep Apnea Patients Were Not a Priority for Early COVID-19 Vaccinations

By Admin

While the COVID-19 vaccination rollout will soon be including a majority of adult U.S. citizens, there have been many questions about who should have been vaccinated earlier as a priority. The COVID-19 pandemic is an unprecedented situation and a massive responsibility for the CDC and its local partners, but one question researchers have asked is why sleep apnea wasn’t included as a high-priority condition for early vaccinations. Despite existing evidence of sleep apnea’s role in progressive COVID-19 illness, the disorder was not included in the CDC’s list of conditions with increased risk for severe COVID-19 illness, while other sleep-related breathing conditions such as COPD and complications from smoking were included. Not only is there evidence that sleep apnea is a widespread condition affecting over 20 million Americans, but complications from sleep apnea and COVID-19 overlap have a high risk for hospitalization and death. Every life is a priority, and everyone who wants a vaccination will eventually be able to access this life-saving medicine, but when so many other conditions are included in a list of conditions with high risk for COVID complications, many believe that sleep apnea was overlooked. The following is an explanation of the CDC’s selection process for high-risk conditions and how risks associated with sleep apnea may have been underestimated.

Sleep Apnea and COVID-19

With over 20 million cases in the U.S. alone, sleep apnea is a major health concern during a pandemic. Luckily, many individuals with sleep apnea end up getting vaccinations early due to age, or due to common sleep apnea comorbidities included on the CDC list of high-risk conditions. Obesity, Type-2 diabetes, and heart conditions such as heart failure and coronary artery disease are all included as high-risk on the CDC guidelines, and each of these conditions is a common comorbid condition among patients with sleep apnea. Even conditions such as being overweight, defined by the CDC as having a body mass index (BMI) of less than 25 kg but over 30 kg per squared meter of height, is included in the CDC’s secondary list for conditions that “might” increase the risk for COVID-19 illness. While obesity (above 30 kg per squared meter of height) is linked to multiple life-threatening comorbidities and clearly meets the requirements of high risk for severe COVID-19 illness, the overweight criteria may not be as clearly linked to COVID-19 severity. Due to these discrepancies, it is understandable that some individuals feel left out of the process, and sleep apnea patients in particular, especially those who do not qualify for early vaccination due to age or other conditions, may have taken on risks that could have been avoided.

Sleep apnea, and especially obstructive sleep apnea (OSA), is a serious medical condition that can impair sleep and lower oxygen levels in the blood, often contributing to additional health problems associated with the heart, respiratory system, mental acuity, and metabolic health. A major obstacle in the treatment of sleep apnea is the need for more public awareness and education about the seriousness of its health effects. While complications from OSA and COVID-19 overlap have been well documented, the disorder’s omission from the CDC’s list of conditions with high risk for COVID-19 illness is an example of the continued need for outreach and public awareness campaigns to address the problem and improve access to treatment. According to Sleepapnea.org, around 80 percent of those living with sleep apnea are either untreated or undiagnosed, and during the current pandemic, this problem is exacerbated by the heightened risk of complications, as well as the increased need for proper treatment with CPAP.

The Selection Process for High-Priority Conditions

As stated on the CDC website, information is somewhat limited in regard to the impact of many health conditions on the risk for severe illness from COVID-19. As a result, the organization uses a set of summarized criteria to quantify risk levels. This includes the following:

“Strongest and most consistent evidence: Defined as consistent evidence from multiple small studies or a strong association from a large study,”
“Mixed evidence: Defined as multiple studies that reached different conclusions about risk associated with a condition,” or
“Limited evidence: Defined as consistent evidence from a small number of studies.”

To assess this set of criteria, the CDC uses a specific Advisory Committee on Immunization Practices (ACIP) that meets to discuss medical conditions and the criteria for immunization priority. According to the CDC website, the ACIP has met for ten public meetings since June of 2020 to review “evidence-based information pertaining to COVID-19 vaccines,” The ACIP has also established a COVID-19 Vaccines Work Group comprised of medical experts in a number of fields including vaccinology, infectious diseases, and public health. The COVID-19 VACCinES Work Group has held 28 private meetings to review data regarding vaccine candidates, and their conclusions have informed the policies of the CDC, including the list of conditions with high risk for severe COVID-19 illness. While this list represents the conditions with the most evidence for high risk, according to the CDC, it is also not exhaustive. State and local health departments are expected to use the CDC guidelines as a starting point to develop their own vaccination policies based on local data of high-priority populations.

State and Local Policies

While states are free to develop their own policies in regard to the vaccination rollout, most follow the CDC’s guidelines for vaccination phases, which are summarized as follows:

Phase 1a. healthcare personnel and care facility residents
Phase 1b. People aged 75 years and older and frontline essential workers (those who work directly with the public but are not included in phase 1a, for example, teachers or transportation employees)
Phase 1c. People aged 65–74 years, and people aged 16–64 years with high-risk medical conditions, as well as other essential workers (not included in phases 1a or 1b)
Phase 2. all people aged 16 years and older who are not included in previous vaccination phases

Among these phases, it is the issue of high-risk health conditions that has become one of the most controversial aspects of the rollout, leading to concerns that some patients, even those listed by the CDC as being high-risk, may not be included in every state.

An analysis conducted by the Kaiser Family Foundation (KFF) concluded that some states have set different COVID-19 vaccination priorities for people with high-risk conditions, but most have used the CDC’s top list of primary conditions as qualifiers. Only a few states, according to the analysis, have prioritized all the conditions in the CDC’s secondary list of conditions that “might” put people at an increased risk, though some have included a portion of them. Neither OSA nor sleep apnea in general were noted in the KFF analysis as being included at the state or local level. In addition, some states left out one or more conditions from the CDC’s primary list of high-risk conditions, especially problems from cigarette smoking, which only 16 states included as a priority. Surprisingly, according to the analysis, there were some states that did not include obesity (23 out of 52) as a priority, making it less likely that people with sleep apnea would be admitted for an early vaccination, since obesity is one of the most common comorbid conditions among patients with OSA.

On the more positive side, the KFF analysis also found that many states continue to rely on patient “self-attestation” that they have a priority condition, and this practice is supported by the CDC, which states on its website that “a conversation between the patient and the patient’s clinical team might assist with decisions” regarding vaccination and vaccination scheduling. This policy approach allows for anyone with a serious medical concern to seek vaccination guidance from a healthcare professional. The vaccination rollout is meant to reach every citizen in need, and no one should have to wait when there are immediate health concerns, and when supplies of the vaccine are available.

Quantifying Risk - A Challenge for Health Departments Everywhere

Estimating a health condition’s risk factors, either for the contraction of COVID-19 or the development more severe cases of the illness, is a challenge for many reasons, but it is especially challenging for disorders like sleep apnea, which are often treated in the home setting or not treated at all. In many cases, data used for this purpose is derived from cases in hospitals and intensive care units (ICU), rather than on less severe or outpatient cases. And those who treat their sleep apnea with CPAP may already be reducing symptoms outside of the clinical setting, which is very difficult to quantify. In addition, there are potential patients who may have chosen to avoid clinics and hospitals during the pandemic, in some cases leading to early mortality. As mentioned above, a majority of individuals with sleep apnea remain untreated, and the underestimation of health risks involved in sleep apnea conditions is a problem that predates the current pandemic and like COVID-19, remains a serious threat to public health in the U.S. and abroad.

The CDC estimates that under their current guidelines, there are over 100 million American adults with conditions that it recognizes as having a high risk for severe illness from COVID-19, and of those, 81 million do not meet other qualifications for early vaccinations. While vaccine supplies are still somewhat limited, there will be waiting periods even for those who qualify for early vaccinations, especially in areas with limited resources or high numbers of patients. Even so, the rollout is well on its way to increasing access throughout the country, and anyone still waiting for a vaccine should be able to get one in the coming months. If you have sleep apnea, have contracted COVID-19, or have other health conditions that concern you at this time, reach out to your health provider immediately. Whether or not a vaccine is immediately available, a health professional will be able to assess the situation and recommend the best course of action for your needs.

For more information on the CDC’s list of health conditions with high risk for severe COVID-19 illness, visit the CDC website at:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html