As states rapidly work to get COVID-19 vaccines into arms as quickly as possible as viral variants spread, state officials know vaccine rollout plans must focus on equitable distribution to communities of color, especially Black and Latinx communities that have experienced disproportionately high infection rates, hospitalizations, and deaths. However, early data suggests that these populations are receiving vaccines at lower rates than White Americans.
Pharmacies will be a critical venues for vaccine access, and this pharmacy distribution program is expected to build that capacity as the US Centers for Disease Control and Prevention (CDC) and state health directors work together to identity areas of need and ship vaccines to pharmacies in those areas, especially in the early days of the program when distribution is still curtailed by limited vaccine supplies. State officials told NASHP that the selection of pharmacies will be based on their ability to both reach the most vulnerable populations and also align with states’ current distribution phases and priority populations in their vaccination plans.
Tracking and Reporting Race and Ethnicity Data
One of the first steps to ensure equitable access to vaccines is having the data to determine where disparities exist. Forty-eight states and Washington, DC currently collect and share varying levels of vaccine data in publicly available data dashboards. Of these, 26 states and Washington, DC publicly display race and ethnicity data for individuals who have received their vaccines. States report the data slightly differently – which can result in different conclusions about their efforts. They are reporting either:
- Total number of individuals vaccinated by race and ethnicity (for example, Florida and Pennsylvania);
- Percentage of total individuals of each race or ethnicity in the state who have been vaccinated (North Dakota); or
- Percent of total doses that have gone to individuals by each race and ethnicity (Indiana and North Carolina).
While these state trackers provide some insight into who is getting vaccinated, there are limitations in their data – a large percentage of race and ethnicity data is either missing or not reported. Nationwide, race and ethnicity data is missing for nearly half of those vaccinated, compared to age and gender data, which is reported 99.9 and 97 percent of the time, respectively. Even in states that collect and publicly report this data, some report over 50 percent of doses with “unknown” race and ethnicity. Providers will report “unknown” in the race and ethnicity fields either because the providers do not ask for the data, or because the recipients do not provide it. It is unclear why individuals are declining to provide their race and ethnicity, but some experts believe that some concerns may stem from a fear that their demographic data could be misused. For example, immigrants are concerned that getting the vaccine – or providing their data – may negatively affect their immigration status. However, the CDC said that vaccine data cannot be used for immigration enforcement, and that getting the COVID-19 vaccine will not be considered as part of the public charge inadmissibility rule.
Many states are working to improve their data collection and reporting. Some, such as Alabama, are collecting race and ethnicity data but have not yet made it public because it is incomplete. These states are working to collect complete and accurate data before publishing it. Most states that are reporting race and ethnicity data publicly do not require providers to include that information, citing a lack of express permission from the patient or concern that requirements might prevent providers from reporting vaccine doses at all.
Other states are imposing requirements to improve data. In North Carolina, Department of Health and Human Services Secretary Mandy Cohen pushed to make race and ethnicity a required field in the state’s COVID-19 vaccine registry. According to state officials, North Carolina emphasizes equity as a core value and conducts outreach and training with providers to emphasize the importance of race and ethnicity data. The availability of the data has enabled outreach strategies, such as partnerships with faith leaders.
While requiring providers to upload race and ethnicity data can add to administrative and logistical challenges, collecting the data is critical to ensuring that vaccine outreach and administration are targeted to the communities most in need. If large percentages of race and ethnicity data are missing, ensuring equity in distribution becomes much more difficult.
Locating Clinics in High-Need Areas
Delivering vaccines to underserved communities is key and the new Federal Pharmacy Program helps address this goal. States and local health departments can use preliminary data to identify counties or jurisdictions with disparities and low rates of vaccination uptake to use to target their vaccination efforts.
Rick Palacio, the cochair of Colorado’s COVID-19 Vaccine Equity Taskforce, announced that one of the state’s goals is to hold pop-up vaccination clinics in half of the state’s top 50 census tracts containing low-density, low-income communities. Officials emphasized the importance of using data to determine under-vaccinated areas and tailor communication strategies to reach those residents. The state kicked off this plan by vaccinating more than 10,000 seniors at a mass vaccination event in Denver and plans to expand the initiative as it receives more doses.
Other examples of state efforts to identify and reach underserved areas include:
- Rhode Island is using its hospitalization, death, and case data to target vaccine distribution by geography. Vaccines will be available in community clinics, pharmacies, and housing sites in communities that have been identified as high risk.
- Illinois has had success by holding events scheduled by local health departments that reached out to discreet, hard-to-reach communities and invited them to register for a vaccine appointments.
- Connecticut is closely tracking vaccine rollout in localities that rank high on the social vulnerability index.
- After Washington, DC opened its vaccine registration portal to all individuals over the age of 65, data quickly showed that an outsized proportion of appointments was going to wealthier White residents. In response, health officials made more appointments available for residents in parts of the city that were currently securing the fewest vaccine appointments. The city also started making appointments for residents in these high-priority zip codes available a day before other eligible residents could register.
- North Carolina has partnered with faith leaders to ensure communities of color and underserved communities have access to vaccinations at the state’s mass vaccination clinics, including releasing appointments to Black and Latinx church attendees before opening up registration to the general public.
States can also reduce transportation barriers to increase vaccination uptake and ensure transportation will not be a barrier for targeted populations to access the vaccine. North Carolina’s mass vaccination clinic location was chosen for its proximity to public transportation.
The Tennessee Department of Health (TDH) is expanding access to the COVID-19 vaccine by focusing on increasing vaccinations in rural and underserved areas. TDH partnered with pharmacies and community health clinics to add over 100 vaccination sites across the state, focusing on “hard-to-reach” areas, as identified in the state’s vaccination plan. Tennessee’s state plan indicated that 5 percent of the state’s allocation of COVID-19 vaccines are earmarked for use in targeted areas with vulnerable populations.
Additionally, at a February US House Energy and Commerce Oversight and Investigations Subcommittee hearing, Louisiana state officials cited a plan to create community mobile strike teams that will travel to areas that rank high on the social vulnerability index to administer vaccines. The strike teams will be staffed by the National Guard and funded by the Federal Emergency Management Administration, which reimburses states for 100 percent of costs associated with the National Guard’s COVID-19 relief efforts. A state official in Michigan also noted at this hearing that the increase in doses from the federal government will help advance equity, because those extra doses can be distributed directly to underserved areas and minority populations.
Tailoring Communication Strategies to Address Vaccine Hesitancy
While reporting and tracking vaccination data and removing logistical barriers are important strategies for identifying pockets of need, they alone are not sufficient to reduce disparities. A history of racism in the health care system has led to distrust by communities of color. Though the share of adults planning to get the COVID-19 vaccine has increased over the year, according to recent surveys White adults (53 percent) remain more likely than Black (35 percent) and Latinx (42 percent) individuals to want to be vaccinated as soon as possible. A survey last fall found that less than 20 percent of Black Americans trusted vaccine safety and efficacy. The survey also indicated that the best messengers to support vaccination in these communities are those living in their own communities, or their health care providers.
State officials and several members of the federal Advisory Committee on Immunization Practices (ACIP) mentioned that the desire to vaccinate quickly must be balanced with the need to reach vulnerable communities. State officials note that balancing speed and equity is one of the biggest challenges they face. Community input builds trust and assists in building effective and acceptable strategies. For example, Tennessee has an African American Health Care Clinician Workgroup, with working members from the NAACP, the Black Nursing Society, and other Black organizations, who are disseminating messaging on the importance of vaccinations and will ultimately help vaccinate Black communities. The Colorado Department of Health and Environment has released commercials in English and Spanish featuring Colorado health care workers who are people of color, promoting the message that vaccines are safe. West Virginia is funding faith-based community members and people of color to administer COVID-19 vaccines directly to communities of color, ascribing to the principle that having trusted, local figures helping with distribution will improve those communities’ confidence in the vaccine.
Federal and state governments are working to vaccinate residents as quickly as possible, while also working to ensure doses are equitably distributed. In light of reports of disparities in vaccination rates and in vaccination access among people of color and in rural communities, the Biden Administration is acting on its promise to ensure an equitable distribution, including their new strategy to ship extra doses to pharmacies in hard to reach areas. While distribution strategies vary across states and are continually tweaked to improve efficacy and equity, the emerging best practices:
- Use data to track and identify under-vaccinated areas and populations;
- Set up additional clinics in underserved areas and provide additional doses to these clinics;
- Ensure transportation is available for patients to access the clinics; and
- Partner with local agencies and community organizations to promote vaccine confidence.
Each of these components is necessary to ensure underserved communities and communities of color are interested in receiving vaccines and are able to access them.
Faced with limited vaccine supplies, a slow rollout of federal funds, and new federal guidelines allowing vaccination of those 65 and older, states face distribution challenges as they quickly evaluate which mass immunization practices are most effective.
Every state is working to vaccinate populations identified in Phase 1A, including health care workers and nursing home residents. Below are challenges and emerging strategies state officials have identified to date in their efforts to vaccinate these populations.
Leveraging Relationships with Pharmacies
To reach residents and staff of long-term care facilities (including skilled nursing facilities that provide higher levels of medical care and assisted living facilities), the federal government partnered with large pharmacy chains, such as CVS and Walgreens, to manage all aspects of vaccine distribution – from storage to vaccine administration. Forty-nine states (all but West Virginia) and Washington, DC signed onto this federal partnership, but the program has proven challenging for states and vaccine roll-out has been slower than expected. While CVS and Walgreens have been able to provide first doses to most skilled nursing facilities participating in the partnership, CVS Health data shows that vaccination of assisted living and long-term care facilities has not yet begun in some states, including Alabama and Indiana. Pennsylvania just activated Part B of its Pharmacy Partnership plan on Jan. 14, 2021, which means pharmacies are only now beginning to vaccinate in long-term care facilities – Part A only provided vaccinations in nursing homes. In Mississippi, vaccination of some assisted living facilities through the federal partnership is not expecting to start until February.
State officials ascribe some of the inefficiency to big chains’ limited personnel capacity, the cumbersome process for getting written consent from residents, and the challenge of obtaining residents’ Medicare information for reimbursement. The federal pharmacy partnership only allows Walgreens and CVS staff to administer the vaccines, rather than partnering with long-term care facility (LTCF) staff. Despite both pharmacies onboarding additional staff to aid in the large-scale vaccination effort, some states, including Mississippi, found that Walgreens and CVS lack the personnel to vaccinate LTCFs quickly and efficiently, causing delays. Additionally, while federal law does not require nursing homes to get consent from residents or family members for vaccination, CVS and Walgreens do. Kaiser Health News (KHN) reports that these requirements have slowed down the vaccination process because they place an additional administrative burden on LTCF staff who must help obtain consent forms and provide patients’ insurance information. KHN noted that states and individual facilities that declined to partner with the federal pharmacy partnership are actually vaccinating at a faster pace.
Other states blame the lag on the structure of big pharmacy chain corporations that may not have had previous experience partnering with LTCFs in their communities. John Vincent, president of the Arkansas Pharmacist Association, explained that because the distribution plan was developed at the federal rather than local level, it does not work for every state or region. CVS and Walgreens, which contract directly with LTCFs under the partnership, have tried to adopt a one-size-fits-all approach to distribution at the federal level, rather than tailoring strategies to the unique needs of local communities.
Maine is also experiencing a lack of communication between the pharmacies and LTCFs, CVS and Walgreens are responsible for contacting facilities to schedule appointments, but without existing relationships, communication and coordination becomes more challenging. Recently, after confirming that Walgreens had unused doses on hand and had not yet scheduled appointments to administer them to LTCF residents, Maine asked the pharmacy to redistribute these doses to two hospitals in need.
However, states that partnered with local, independent pharmacies to distribute and administer vaccines have had more success. For example, West Virginia used a network of over 250 independent pharmacies to distribute the vaccine to nursing homes, LTCFs, and rural areas of the state. These pharmacies already had existing relationships with LTCFs – many of them provide medications, routine vaccines, and more recently, COVID-19 testing services to residents – and therefore already had patient data in their systems. This helped accelerate the distribution process because LTCF facilities did not need to take the extra administrative step of filling out burdensome forms related to consent and Medicare information.
Additionally, West Virginia pharmacies could schedule vaccination clinics at these facilities immediately and on their own schedule, as opposed to CVS, Walgreens, and other large pharmacy chains participating in the pharmacy partnership program. Under the federal program, the large pharmacies scheduled three separate visits to each facility:
- The first two visits are for most residents and staff to get the two doses of the vaccine, and
- The third visit was designed to vaccinate people who missed the first two visits.
But despite this three-visit plan, not all residents and staff were able to get vaccinated, and the limited supply has caused frustrations.
By leveraging existing partnerships and working directly with the facilities, West Virginia was able to identify residents, schedule those vaccine appointments, and secure any required consent forms, all before the state received any of its allotted doses.
Similarly, in Arkansas, 35 of the state’s 350 nursing homes that selected a local pharmacy to distribute the vaccine received doses within 72 hours. In comparison, only 15 percent of the doses that CVS and Walgreens received earmarked for Arkansas nursing homes have been delivered so far. In Washington State, a facility opted out of the federal partnership with CVS after learning the company’s first doses weren’t expected until Jan. 9, 2021. Subsequently, residents were able to receive the vaccine from a smaller pharmacy nearly two weeks early. In Maine, one independent pharmacy, which has been collaborating with LTCFs since 2018 to supply prescription drugs directly to residents, credits its success in reaching and vaccinating residents to the strength of its pre-existing relationship with the facilities.
In Montana, one small independent pharmacy was able to administer about 1,000 doses to LTCF residents in one week, equivalent to the number CVS and Walgreens jointly were able to vaccinate statewide in the same time period.
Collaboration between States, Hospitals, and Health Systems
Most health care workers have received the vaccine through their work venues, such as hospitals, public health offices, federally qualified health centers (FQHCs), and tribal health clinics. Doses are shipped directly from the Pfizer and Moderna distribution plants to larger hospitals, which have more storage capacity, and often these hospitals are then tasked with further distributing the vaccine to smaller, more remote facilities. Montana officials cite their close relationship between the state health department and hospital administrators, which includes weekly or twice weekly calls between the two parties, as helpful in rolling out a collaborative vaccine strategy. Montana has administered close to 50 percent of doses received.
Similarly, in Connecticut, where 52 percent of doses distributed have been administered, the state began holding weekly calls with hospitals and state agencies at the beginning of the pandemic to discuss current concerns and future plans, and troubleshoot any emerging problems. State officials believe the constant communication and coordination between state and local partners have helped their vaccine distribution process.
Despite this success, there are concerns that health care workers’ status and facility size and location are impeding their access to the vaccine. Reports indicate that in cities like New York and Boston, more affluent individuals who are affiliated with large hospital systems – but not currently eligible for the vaccine – have been able to obtain doses early. In Delaware, those working in private practices voiced frustration that they have not been able to get doses as quickly as those working at larger facilities. The minutia of distribution is not determined at the state level. As states expand access to the vaccine, it will be important to make sure that socioeconomic status and location are not barriers to vaccination.
Immunization Information Systems (IIS) – immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients and the Vaccine Administration Management System (VAMS), a CDC system established to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments, are critical to states’ vaccine distribution pans. All states are currently using, or plan to use during later phases, their IIS or VAMS to:
- Identify individuals in need of a first or second dose;
- Track which vaccine and dose each person gets;
- Notify individuals when they are eligible for the vaccine;
- Invite them to schedule an appointment; and
- Send a reminder about second dose appointments.
Many immunization registries also collect patient demographics, such as race, ethnicity, and age, which are useful for tracking vaccination trends and identifying health inequities. States are identifying challenges and solutions for data tracking and reporting.
Streamlining processes for informed consent: Obtaining consent from patients to have their data entered into immunization information systems (IIS) or the Vaccine Administration Management System (VAMS) is an additional challenge. State IIS have varying patient consent policies, reporting mandates, and data-sharing policies. Some states use a opt-in process, meaning that individuals’ data will not be shared in the information system unless the patient or guardian signs a form indicating consent, while other states use an opt-out process, meaning that individuals’ data will automatically be included in the information system unless they, or their guardian, signs a form indicating they choose not to participate in the data sharing program.
Generally, states with opt-out policies have higher vaccination rates and more comprehensive data; state officials have concerns about comprehensive data, especially when using an opt-in consent process. To eliminate these concerns, some states are temporarily changing consent requirements for their immunization registries. In New Jersey, Gov. Phil Murphy issued an executive order changing the state’s IIS system from opt-in to opt-out, and will automatically enroll patients choosing to receive the COVID-19 vaccine into IIS. Patients can disenroll from the registry 30 days after the public health emergency ends. New York waived consent requirements for reporting adult doses into IIS, a step they also took during the H1N1 pandemic.
Ensuring timely and transparent reporting of vaccination progress: With states vaccinating thousands weekly, they are striving to be transparent about how many doses have been administered and who is being vaccinated. Additionally, consistent and timely reporting is critical to determining which areas may be lagging behind in distribution, and which are more successful. Currently, many places are experiencing delays in data reporting to IIS and VAMS, while others are seeing doses under-reported. Providers and pharmacists, already working at capacity, are inputting all of their immunization data into the systems – sometimes by hand – within 24 hours of vaccination.
Some states have begun to address reporting challenges. For example, the Oregon Health Authority is providing technical assistance to vaccine sites to improve the timeliness of data entry into their IIS. In order to improve data collection and reporting, states could consider bringing in additional personnel – either volunteers or hired staff through additional federal funding – with the sole job of inputting data in vaccine databases.
Many states have also developed public-facing COVID-19 vaccine tracking dashboards detailing the status of vaccine rollouts. All dashboards include the number of doses administered, and almost all include counts of how many individuals received the full two-dose series. Many also include demographic information, including county, age, gender, race, and ethnicity. Pennsylvania developed a designated tracker for the type and location of facilities that have received a vaccine shipment. Similarly, Minnesota is publicizing number of doses administered by provider type. North Dakota’s dashboard shows the number of vaccine enrolled provider sites by county.
These dashboards are not only a valuable tool for residents to track progress in their state, but they can also offer insight into current vaccination priorities. For example, Minnesota’s tracker shows that as of Jan. 14, 2021, the majority of vaccines were shipped directly to providers in hospitals, pharmacies, and local public health offices, with several primary care and tribal health sites receiving doses as well. This is in addition to the doses sent directly to LTCFs through the pharmacy partnership.
Prioritizing equity in distribution: Given the disproportionate impact of COVID-19 on people of color, states have emphasized equitable vaccine distribution in their plans. However, if states do not invest upfront in strategies such as targeted outreach, hosting clinics in areas and at times accessible to populations of color, onboarding of Black and Latinx vaccine providers, and addressing vaccine hesitancy concerns, officials fear racial disparities in COVID-19 infection and vaccine rates will only increase.
While vaccination rates across states vary very little, and numbers are still low, trends are emerging, including racial disparities. North Carolina’s, early data from its dashboard indicates that, compared to the state’s overall distribution numbers, disproportionately more White and non-Latinx individuals have been vaccinated than Black and Latinix individuals. Additionally, after opening vaccine appointment sign-ups to individuals 65 and older, Washington, DC found that far more people in affluent areas with low COVID-19 infection rates had signed up (2,465 people, in one ward) than individuals in less affluent, majority-Black areas of the city (94 in the ward with the highest death toll had signed up for the vaccine). In response, the district is opening up additional appointments in the neighborhoods with low sign-up rates.
Effective Communication of Vaccine Distribution Information
With vaccination plans rapidly evolving, and public confusion rampant, it has become critically important for state governments to get messages out to providers and the general public quickly and clearly. States are identifying challenges and solutions for effective communication.
Establishing effective ongoing communication with health care facilities and providers: One challenge for states is to make sure that providers are up to date on the latest guidance, especially in identifying which populations are eligible to be vaccinated and when facilities will receive additional doses. In Texas, providers noted the challenge of having a lack of advance notice about vaccine shipment arrivals. In some cases, they had only a few hours advance notice about the first vaccine shipment and cited concerns about not having the necessary staff to set up separate vaccination sites on such short notice. As previously noted, Montana and Connecticut have seen success in distribution due to established and effective communication between the states and their local partners.
Responding quickly to changing needs: Because prioritization guidance from federal and state governments is changing rapidly as the result of the slow vaccination rollout process, some states have opted to use executive orders to quickly communicate new eligibility criteria to localities. In Arizona, Gov. Doug Ducey issued an executive order directing the Arizona Department of Health Services to reallocate vaccines when necessary in order to ensure statewide coverage and rapid administration.
He also ordered counties to publicize the priority population they are currently vaccinating and the location of vaccination sites on their websites.
In Utah, Gov. Spencer Cox used an executive order to extend vaccine eligibility criteria to teachers and individuals ages 70 and older. In the event that providers do not follow these guidelines, the state reserved the right to redistribute the vaccine or reduce supplies during future allocations. For states struggling to get information out to providers and localities quickly, executive orders may be a way to convey new guidelines to a large audience publicly and quickly.
Establishing and enforcing eligibility criteria: Currently, demand for the vaccine is far outpacing the supply. State and local health departments need a system in place connected to IIS to have a waiting list of people ready to receive the vaccine so they can be rapidly deployed. Stories abound about individuals who believed they were eligible for the vaccine and tried to book appointments, but could not. State and local health departments must have systems in place for rapid deployment and need to communicate effectively about how they work, while implementing their carefully considered phased approach. Otherwise, expedience may preempt prioritization, with individuals who have time or access able to jump the line ahead of the most vulnerable.
Many states (including Alaska, Mississippi, New Jersey, New Mexico, and Virginia) and several counties and local health departments have websites that allow individuals to check eligibility and sign up for vaccine appointments or get placed on a wait list. Some individual health care systems have also employed various text message programs. However, some health systems sign-up websites have crashed with overuse, and appointments booked up rapidly. Recognizing that not everyone has access to internet or computers, states have also set up phone lines for booking appointments.
Some states have also had technical difficulties when vaccine tracking systems incorrectly identified individuals for vaccination. For example, in Connecticut, teachers at one school received a notification that they were eligible for the vaccine and made appointments to get vaccinated, when in fact they were not yet eligible under the state’s plan. Those who already were vaccinated before the mistake was corrected will be able to get their second dose, and the Department of Public Health reported that they are putting safeguards in place to make sure this does not happen again.
Colorado also recently changed its priority list to vaccinate those over 70 before essential workers. But, some essential workers, including teachers at a charter school, had already signed up. The state health department encouraged those with existing appointments to keep their appointments, with the assurance that they would be able to receive their second doses.
Vaccine Administration Strategies
As states move to vaccinate new populations, lessons for ensuring sufficient staff and accessible venues will help guide efficient and complete administration.
Authorize a wide range of health care staff to administer the vaccine: The delays in administering the COVID-19 vaccine highlights a nationwide shortage of health care workers. HHS issued guidance in September 2020 to allow licensed and registered pharmacists to order and administer the COVID-19 vaccine to individuals age 3 and older, providing relief from scope of practice laws. Pharmacists have been involved in the Pharmacy Partnership for Long-Term Care Program, administering vaccines in LTCFs and will be instrumental once states begin vaccinating the general public. In other regions, dentists and dental assistants have been licensed to administer the vaccines.
Since March 2020, states have used a variety of policy levers to expand and relax scope-of-practice laws for health care providers in order to overcome personnel shortages. Similarly, given the enormous capacity demands of states’ COVID-19 vaccine distribution plans, many states and the federal government have begun allowing more providers and non-traditional vaccinators to administer vaccines. A December 2020 report by the National Governors Association and the Duke-Margolis Center for Health Policy found that 20 states had included plans to onboard non-traditional providers, such as dentists and emergency medical technicians (EMTs) in their vaccine distribution plans.
In December 2020, an Oregon provider became the first dentist in the United States to give a COVID-19 vaccine, and in early January 2021, California approved a public health emergency waiver authorizing dentists to vaccinate against COVID-19. In South Carolina, some ambulance agencies are training paramedics to administer the vaccine, and expect that they may eventually go directly to people’s homes to vaccinate them , and in Illinois, the director of the Department of Public Health modified EMT’s scope of practice to allow advanced and intermediate EMTs to vaccinate.
State officials hope that expanding providers’ capacity to administer vaccines might help reach more individuals faster, especially as states expand priority phases to include more people. According to Claire Hannan, executive director of the Association of Immunization Managers, staffing is one of states’ greatest needs. Expanding scope-of-practice laws is one way to increase staffing, but Hannan suggests that states might also consider using new federal money to onboard more staff — both those who can physically administer the vaccine and those who can help with data entry, provider enrollment, and vaccine ordering.
Establishing accessible vaccination venues: As states move into new distribution phases, processes will change, shifting from closed to open points of distribution. Many states are planning to open mass vaccination clinics to help distribute the vaccine more rapidly to residents. Over 50,000 people in Pennsylvania have already registered for the vaccine, and one Pennsylvania clinic reported having 2,600 doses and plans to inoculate three to seven people every five minutes. New Jersey announced the sites of six mass vaccination clinics across the state, which include two malls, two convention centers, a stadium, and one college facility; and as of Jan. 18, 2021, some of them had begun vaccinating people in eligible phases.
In Oregon, four health systems are joining forces by pooling their COVID-19 vaccines and staff to run a clinic at the Oregon Convention Center to serve eligible residents starting Jan. 23, 2021, which will include people over age 65 and teachers. Montana plans to use federal money from the new stimulus package to finance mass vaccination clinics run by community health centers and local health departments. To staff these clinics, many states are using the National Guard and local health care workers, with some also tapping EMTs for the job.
So far, states that have already started operating mass clinics have found them to be effective at vaccinating large numbers of individuals in a small amount of time. Arizona began vaccinating people at State Farm Stadium, which has been so successful that the state announced they are opening additional sites beginning Feb. 1, 2021, with appointment registration beginning this week. Additionally, a vaccination clinic operating at the Mercedes-Benz Stadium in Atlanta was able to vaccinate over 4,000 people in its first week of distribution.
States and counties running these mass clinics are using different mechanisms to track vaccine administration and monitor individuals for any adverse reactions immediately after vaccination. In Oregon, members of the National Guard are helping run the clinics, including assisting with traffic control, processing electronic medical records data, monitoring individuals after vaccination, and even administering vaccines. Clark County, Wisconsin officials asked that anyone coming to their drive-through vaccination clinic complete a COVID-19 Vaccine Administration Record beforehand, which includes demographic and medical history information that is then shared with the Wisconsin Immunization Registry. Clark County also has EMTs on site to help monitor individuals after vaccination.
The New Jersey Convention Center, which will be the site of up to 2,400 doses per day, has 100 staffers on site – including health care workers and National Guard members – to provide registration and security services, administer the vaccine, and monitor individuals post-vaccination.
Mass vaccination clinics are promising. Questions remain, such as how to operate them efficiently and:
- Avoid reported long lines and staffing issues, while also following COVID-19 safety and distancing protocols;
- Ensure equal access for everyone who wants to get vaccinated; and
- Address concerns of those who may feel more comfortable getting vaccinated in familiar, community settings with trusted providers who can answer any of their questions and ease anxiety about the process.
Deploying leftover doses: Due to the short shelf life of the vaccine and the number of people choosing to delay getting it, vaccine administrators are often faced with the challenging situation of finding individuals to vaccinate before the doses expire. States are working to ensure that leftover doses are not wasted. New York health care providers now must use their total vaccine allocation within a week or face a penalty. Florida also announced hospitals would face fines for not using their total allotment of vaccines, and the state deployed an additional 1,000 nurses to aid in administering vaccines and help keep clinics open seven days a week to ensure doses do not go unadministered. Other states, including Connecticut, have released guidance policies to prevent wasted vaccinations. According to the Connecticut Department of Health guidance, vaccine providers should keep a wait list of people to call in case they have extra doses.
These state tactics show that having an enforceable plan is critical to ensure doses are provided to priority patients and not wasted.
Through previous CARES Act funding, HHS distributed $200 million across 64 states and jurisdictions for vaccine planning and preparedness. Though originally earmarked to be spent by Dec. 31, 2020, HR 133 extended the deadline for states to spend down their CARES Act funding for an additional year, sunsetting at the same time as HR 133. State officials had noted that this funding was insufficient for adequate vaccine planning and distribution.
The omnibus bill (HR 133) signed into law on Dec. 27, 2020, includes $8.75 billion in funding for states’ vaccine distribution with a spending deadline of Dec. 31, 2021. These funds will be distributed to federal, state, local, territorial, and tribal public health agencies to “administer, monitor, and track coronavirus vaccinations to ensure broad-based distribution, access, and vaccine coverage.” In this fund, $300 million has been earmarked for distribution and administration of vaccines in high-risk and underserved populations, including populations of color and rural populations. The new funds will be available to states within 21 days, but many are concerned that it is too late to fully support the staffing required in the roll out.
An additional $3 billion is available to states through the Coronavirus Response and Relief Supplemental Appropriations Act to support state’s COVID-19 vaccination activities through an existing CDC Immunization cooperative agreement. States are identifying what the money will be used for specifically.
Last week, President-Elect Joseph Biden announced a $20 billion national program to establish community vaccination centers across the country, including mobile units in more rural and remote communities and mass vaccination clinics. This plan must be approved by Congress, but demonstrates his priorities of comprehensive coverage and equitable distribution. As states await action on Biden’s proposal, their efforts to launch mass vaccination clinics can inform federal policy and establish an infrastructure for speedy deployment as more vaccine becomes available. Similarly, states can report on the challenges experienced with the chain store program and how they were remedied in order to ensure the problems are not repeated.
*As of 8 p.m. Jan. 18, 2020.
This analysis is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $200,000 with 100 percent funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: January 2021.
As COVID-19 infections, hospitalizations and deaths soar and federal guidance evolves, states are finetuning their vaccine distribution plans as the US Food and Drug Administration (FDA) appears poised to approve a vaccine later this week. The timely, safe, and equitable distribution of the vaccines falls squarely on states and their providers, who are already stretched thin in dealing with the pandemic and need billions of federal funds to distribute the vaccines successfully in the months ahead.
Fueled by the challenges that confronted the distribution of testing supplies and personal protective equipment (PPE) earlier this year, and the knowledge that vaccine demand vastly exceeds current supply, states are developing distribution plans that will target high priority populations without clearly scheduled deliveries.
Supported by $200 million from the Coronavirus Aid, Relief, and Economic Security (CARES) Act for vaccination preparedness, state plans that addressed ordering, storage, handling, and distribution priorities were submitted to the Centers for Disease Control and Prevention (CDC) in October. Each state’s plan takes federal recommendations into consideration but are unique and reflect their workforce and population priorities.
CDC’s Advisory Committee for Immunization Practices (ACIP), which states historically rely on for vaccine guidance, will hold an emergency meeting to vote on their prioritization and vaccine recommendations after FDA votes to approve the vaccine later this week. However, if distribution begins 24 hours after FDA approval as planned, many states may receive the vaccine before ACIP issues recommendations.
Not all states reported on all populations. Of the states that provided detailed information about how distribution would be prioritized within phases, NASHP found:
- Forty-two states included HCW in Phase 1A of distribution.
- Nineteen states included residents of LTCF in Phase 1A, and 21 states included LTCF residents in Phase 1B, six states designated that population in Phase 2 and one state designated for Phase 3.
- Six states (Delaware, Michigan, Mississippi, New Mexico, Pennsylvania, and Utah) further sub-prioritized distribution to HCW, by specifying paid and unpaid employees who are at highest risk of coming into contact with someone with COVID-19 to receive the vaccine first in Phase 1A, followed by other essential HCWs critical to maintaining the health care system, including administrative and janitorial staff, in Phase 1B.
- Ten states do not yet specify sub-prioritization of Phase 1 in their plans.
What is the initial vaccine distribution strategy?
Of those states that have issued guidance on how to sub-prioritize HCW, they have done so in three ways:
- Based their distribution on population. Allocation within the state will be proportional to the number of health care workers in the area.
- Designed distribution based on COVID-19 prevalence. Hospitals and facilities that have more cases of COVID-19 will get more doses of vaccine. In Utah, priority distribution will go to the top four hospitals treating the most COVID-19 patients, and in New York, HCW in areas with high COVID-19 prevalence are anticipated to receive the vaccine before HCW in areas with lower case rates.
- Use job responsibility. Certain HCWs will be prioritized over others. In Pennsylvania, the first doses will go to providers working in emergency departments, on inpatient floors, and in intensive care units.
In Kentucky, according to Gov. Andy Beshear, the first doses of the vaccines will be shipped to 11 hospitals. Kentucky is expecting to receive 38,025 doses of the Pfizer vaccine, and 76,700 doses of the Moderna vaccine. The Pfizer vaccine doses will be used to vaccinate 26,000 of the state’s nursing home residents and staff, and 12,000 more of the Pfizer doses will go to the frontline HCWs at greatest risk of exposure. California Gov. Gavin Newsom announced the state expects to receive 327,000 initial doses in mid-December, but the state is home to 2.4 million HCWs, with 1 million working in acute care hospitals and around 150,000 working in nursing homes. Tennessee anticipates receiving 56,550 doses of the Pfizer vaccine in the first immediate phase and the state plans to reserve one tray of 975 doses in case any vaccine spoils when shipped to facilities. Tennessee also plans to set aside 5 percent of its first shipment of the Moderna vaccine in case of spoilage (about 5,000 doses), with the rest of the doses going to each county health department.
Additionally, states will have to decide whether to save some of their initial doses for a second round of immunization for the first priority groups, or use their entire supply of vaccine and hope they are able to receive a second shipment in time to give HCWs their second dose within the required timeframe. Current guidance, as reflected in some state plans like Washington’s and Tennessee’s, suggest that the federal government plans to hold back doses and send a second shipment at a later date that is intended for second doses for these first individuals. The states do not know when to expect the next shipment of doses, or how many they will get in the follow up shipments.
How are states prioritizing other key populations?
State plans vary in specificity of phases for vaccinating other specific critical populations and are dynamic documents that are constantly updated. For states that did delineate, NASHP noted these trends:
- Teachers are a high-priority population. Twenty-two states plan to vaccinate teachers at some point during their Phase 1 distribution and 12 states list teachers in Phase 2.
- Incarcerated populations and correctional officers are usually in Phase 1 or 2. Nine states plan to vaccinate incarcerated people at some point in phase 1, 27 states plan to vaccine incarcerated people in Phase 2, and two states plan to vaccinate them in Phase 3. In contrast, 10 states plan to vaccinate correctional officers in Phase 1, and 13 states have plans to do so in Phase 2.
- Most states include individuals living in homeless shelters in phase 3. Eight states plan to vaccinate individuals living in homeless shelters at some point in Phase 1, 22 states plan to do so in Phase 2, and three states plan to do so in Phase 3.
What support do states need for successful distribution?
States have been planning for vaccine distribution for months, but acknowledge that their plans are working documents, and will need to be refined as more federal guidance and more information about the number of doses states can expect to receive become available. Key considerations include:
- ACIP’s upcoming vote following emergency use approval by the FDA regarding who should receive the vaccines and in what order, and then continued guidance as the situation evolves. As more data from the vaccines’ Phase 3 clinical trials become available, more changes might be made in distribution recommendations.
- Federal leadership and potential new funding to strengthen state and local distribution infrastructure as CARES Act funding expires on Dec. 31, 2020. States need to procure more personal protective equipment , set up socially distanced mass-vaccination sites, provide public information to encourage immunization and complete the logistics of delivering and tracking to priority populations.
- Other vaccines in the pipeline which may affect the timeline of the phases for each state, and equitable distribution of the vaccine.
While the vaccine will ultimately be available to everyone, states must make important policy decisions to ensure timely, ethical, and equitable distribution of the vaccine during initial phases when supply is limited
As states continue determining their priority populations and phased approaches, they anxiously await a stimulus package from Congress that includes much needed support for vaccine distribution. As the vaccine becomes available and states begin to roll out administration, NASHP will continue to track all aspects of the COVID-19 vaccine distribution process and engage with states to address challenges.
Support for this work was provided by Centers for Disease Control and Prevention.
As development of a COVID-19 vaccine continues, states are racing to develop vaccine distribution plans and are eager to ensure that the administrative challenges of testing and personal protective equipment distribution are not repeated. They must orchestrate vaccine storage and administration, data tracking, and capacity issues while questions about who will ultimately pay for the massive vaccine deployment, how it will be equitably distributed, and effective vaccine messaging require a uniform federal response for best results.
State leaders also raised concerns about a variety of challenges they face in distributing the COVID-19 vaccine, such as a lack of clarity on federal funding for vaccine administration, refrigeration and storage, and availability of state funding.
According to the CDC playbook, the federal government will procure and distribute the vaccine and any associated supplies (including needles, syringes, and limited masks and face shields) at no cost to providers. Typically, insurance reimbursement to providers includes the cost of the vaccine itself and some of the associated administrative cost. The National Academies of Sciences, Engineering, and Medicine (NASEM) recommended in its framework for equitable vaccine allocation that vaccines be made available at no cost and that administration of the vaccine be adequately reimbursed. However, it is unclear how administrative expenses will be covered and by whom.
Other complications to state planning efforts include:
- What and how many vaccines will be rolled out, and over what time periods; and
- What refrigeration temperature requirements will be.
For example, given the storage and temperature requirements of one COVID-19 vaccine currently in clinical trial, states are concerned about additional costs of storing, freezing, delivering, and administering vaccines. CDC, meanwhile, has instructed states not to invest in ulta-cold freezers yet.
Vaccine administration can also be prohibitively expensive for facilities. Because there are still so many unknowns about which vaccines will be available and how they will be transported, details about who will ultimately finance these costs are still being finalized. State officials expressed concern that as they face budget crises and limited federal information and regulations, they are being set up to fail.
Who will be the first to be vaccinated?
The CDC recommends that states establish COVID-19 vaccination program implementation committees with representatives from every sector and from communities. The NASEM framework highlights the need for equal regard, maximization of benefits, evidence-based actions, and transparency in decision-making. NASEM and the Advisory Committee on Immunization Practices (ACIP) have been discussing how to prioritize the distribution of the COVID-19 vaccine to critical populations, but delayed making a final decision until a vaccine has been approved by the US Food and Drug Administration for clinical use.
Source: CDC COVID-19 vaccine implementation presentation, July 29, 2020.
The CDC playbook highlights a phased approach to distributing the vaccine and delineates three phases of distribution. However, during Phase 1, which has a limited supply of COVID-19 vaccine doses available, states are encouraged, but not required, to focus their initial efforts on reaching critical populations, including:
- Health care personnel who are likely to be exposed while treating people with COVID-19;
- Those at increased risk for severe illness, including those with underlying medical conditions and people age 65 years and older; and
- Other essential workers.
These phases align closely but differ slightly from NASEM’s equitable distribution framework for Phase 1.
Most state officials noted they intend to follow this guidance for prioritizing an equitable vaccine distribution. But, some states also noted concerns regarding using their immunization systems to identify and distribute the vaccine to these populations, especially to those who live in large, sparse, rural, and frontier areas with smaller public health administrative capacity. Others raised concerns about whether individual providers will be able and willing to administer the vaccine, and if they can do so in a way that follows the equitable allocation framework. Their concerns are tied to cost and reimbursement levels, as well as physical capacity to store and refrigerate the vaccines. Additional federal guidance and funds could alleviate these issues.
Who will pay for the vaccine and associated costs?
The NASEM framework recommends that the COVID-19 vaccine be provided and administered with no out-of-pocket costs. Paul Mango, HHS deputy chief of staff for policy, said the agency’s goal is for the COVID-19 vaccine to be free for all Americans. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, similarly noted, “… The vaccine itself has already been bought by the federal government… A person who gets a vaccine will not pay for the vaccine.” However, Fauci did note that patients could be charged for costs related to the vaccine’s administration. Confusion remains about how these decisions will be made and it remains unclear how administrative expenses will be covered and by whom. For example, in the VFC Program, a provider who administers a qualified pediatric vaccine to an eligible child may not impose a charge for the cost of the vaccine, but can charge a fee for its administration as long as the fee does not exceed the costs of the administration.
ACIP has not yet issued a recommendation on state coverage of a COVID-19 vaccine, but Section 2713 of the Public Health Service Act requires mandatory coverage of all ACIP- recommended vaccines for state Medicaid expansion programs and most commercial health plans (state-based exchanges). ACIP-recommended vaccines are considered preventive and therefore are not subject to cost-sharing by patients. In March, Congress added a COVID-19 vaccine to the list of vaccines commercial health plans are required to cover. Usually insurers have up to a year after a vaccine is recommended by ACIP to implement coverage, but the CARES Act drastically speeds up this timeline by requiring plans to cover a COVID-19 vaccine within 15 days of its approval. The Coronavirus Preparedness and Response Supplemental Act specified that a vaccine should be priced “fairly and reasonably.” And, US officials noted over the summer that they expect insurance companies will not charge copays for COVID-19 vaccinations.
The cost of the vaccine for Medicaid enrollees is expected to vary by state. While Medicaid expansion states require complete coverage of ACIP-recommended vaccines without cost sharing, vaccine coverage is optional in non-Medicaid expansion states and remains up to the state’s discretion. However, through the Families First Coronavirus Response Act, all states are eligible for a temporary (through the end of the public health emergency) 6.2 percent increase to their Federal Medical Assistance Percentage (FMAP). One condition for states to receive this money is that the state plans must cover, without cost sharing, COVID-19 vaccinations.
For Medicare enrollees, vaccines are typically covered under Medicare Part D, which allows for cost sharing. The Centers for Medicare & Medicaid Services (CMS) can opt to cover the COVID-19 vaccine under Medicare Part B (which already covers the influenza vaccine and the pneumococcal pneumonia vaccine), a move that would prohibit cost sharing. As of mid-September, officials were still working with Medicare to figure out the cost to beneficiaries, but noted that the cost would likely not exceed $3.50 out of pocket per individual.
How will states monitor vaccine distribution?
The CDC is developing a Vaccine Administration Management System (VAMS) to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments. The system, funded by an almost $16 million sole-source contract, is designed to share data with existing Immunization Information Systems or immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients. As of Oct. 7, 2020, however, VAMS has not yet announced plans, leaving state leaders confused about how to plan for vaccine tracking. Concerns have been raised that VAMS might bypass state systems, leaving states unsure whether they will need to use the new system or be able to enhance their existing immunization registry systems in time.
Immunization registries – either VAMS, IIS or a combination of both – will be needed to record vaccination information, identify individuals in need of a first or second dose of a vaccine, remind individuals to get vaccinated, and track follow-up. One critical concern is whether immunization registries have the capacity to ensure that people receive a second dose of the vaccine within an acceptable timeframe and that they receive the same type of vaccine for both doses.
Historical underinvestment in IIS has resulted in wide variation across states’ IIS policies, size, and scope. They have different patient consent policies, reporting mandates, and data-sharing policies. In some states, provider participation in the IIS is mandated by law, and in other states participation is voluntary. As a result, only 55 percent of immunization programs have 95 percent or more of individuals in their jurisdictions registered in their IIS. There is also inconsistent communication between systems. Many electronic health record (EHR) systems are not connected to immunization registries, leaving individuals who receive vaccines at different locations with incomplete immunization records. Although some states receive matching funds available through the Health Information Technology for Economic and Clinical Health Act (HITECH) to enhance interoperability of electronic data exchange between EHR and immunization registries, many rely on the CDC, private foundations, and health care providers and insurers to fund their systems.
Because multiple COVID-19 vaccine doses are forecast to be required, strong data-sharing capabilities between registries also is critical. State IIS need to be able to talk to other health records systems and other states’ immunization registries in order to ensure that individuals receive the correct second dose at a different facility, and even in a different state if necessary. However, in 2018, only 10 percent of immunization registries had conducted at least one query of an IIS in another jurisdiction. While the need for better systems to distribute and monitor the COVID-19 vaccine is clear, because VAMS has not yet released plans, states are left to figure out whether and how to:
- Upgrade existing systems, which requires time and resources;
- Rely on a new system that will be unfamiliar to providers and clinics; or
- Use a combination of both.
How are states promoting public trust in the vaccine?
Vaccine hesitancy will also be a critical issue. According to a recent Pew Study, the number of adults who say they will get a COVID-19 vaccine has fallen from 72 percent in May 2020 to 51 percent in September. Another study found that 35 percent of Americans would not get a vaccine, even if it were free. Mistrust of health care is especially prevalent among Black communities, who are skeptical of the medical system because of current and past discrimination against people of color. This distrust continues as Black Americans are hit hardest by COVID-19, making it even more critical that the government finds ways to boost confidence in COVID-19 vaccine safety.
The need for standardized public health messaging during this pandemic is also clear. In fact, state officials noted that currently, clear and consistent vaccination messaging is one of the biggest issues that states need the federal government to address. Typically, states use a variety of mechanisms for disseminating vaccine information, such as partnering with community organizations, hospitals, and other state agencies to disseminate information to their constituents, sending out clinician letters to providers and pharmacists, and using IIS to send vaccine reminders to patients. These strategies will continue to be important when states market the importance of getting the COVID-19 vaccination.
At the same time that state officials are concerned about gaining and developing public trust in the vaccine, they also need to manage expectations about vaccine availability and efficacy. As noted, the CDC playbook asks jurisdictions to plan for three phases of distribution:
- During Phase 1, critical populations such as essential workers and high-risk individuals are prioritized;
- In Phase 2, limited doses will be available to the public; and
- In Phase 3, there will be sufficient vaccine supply for the entire population.