The US Food and Drug Administration’s (FDA) recent approval of the one-dose Johnson & Johnson (J&J) vaccine, which is easier to store and transport than others and reportedly causes fewer side effects, offers opportunities for states to improve vaccination outreach.
At a time when supply remains one of the largest barriers to vaccine administration, the new J&J vaccine helps boosts supply and allows more people to be vaccinated. However, efforts to distribute the newest vaccine have been complicated by mixed messaging around its efficacy. States, with federal guidance, are working to emphasize the benefits of the J&J vaccine and the importance of getting vaccinated as soon as any vaccine is available.
In clinical trials, the J&J vaccine had a 72 percent efficacy overall in the United States, with an 85 percent efficacy against severe COVID-19 infection. While there is some public concern that the J&J vaccine has a lower efficacy than Pfizer and Moderna’s, experts are stressing two facts:
- The (J&J) vaccine has a high efficacy against severe disease and is just as effective at preventing hospitalization and mortality as the older vaccines. Those who do get COVID-19 after J&J vaccination are likely to only experience only mild symptoms.
- Unlike the Moderna and Pfizer vaccines approved in December, J&J was tested in Brazil and South Africa in the presence of the new 1.351 variant. It proved to be highly effective at preventing infection and severe disease from these COVID-19 variants.
J&J Vaccine Advantages
In addition to its success against virus variants, the J&J vaccine has a number of different characteristics that make it easier to transport, store, and administer than the Moderna and Pfizer vaccines.
First and foremost, the vaccine requires one dose rather than two. State officials have shared that scheduling second doses, reminding patients to come in for their second dose, and following up when individuals miss their appointments have been significant challenges in their vaccine rollout. The one-dose J&J vaccine eliminates this issue.
Additionally, the J&J dose is easier to store and can be kept in a regular refrigerator for up to three months. This makes it possible that more and different types of health care providers, such as those working in rural health centers or with communities that have limited access to health care, can keep the vaccine in their facilities so their patients can receive the COVID-19 vaccine from providers whom they view as trusted sources.
Many J&J recipients also report fewer side effects from the vaccine, making the vaccine ideal for individuals who cannot afford to miss a day of work because of severe side effects, or who might not be connected to a health care professional who can help treat symptoms if needed.
Importance of Messaging
Throughout the pandemic, federal and state governments and public health leaders have struggled to find a balance between managing public expectations and encouraging measures that prevent the spread of COVID-19. The introduction of the J&J vaccine has again highlighted the importance of crafting messages for the public to counter any misinformation about its efficacy.
After concerns began arising about the efficacy of the J&J vaccine, the Centers for Disease Control and Prevention (CDC) recommended that jurisdictions use the following language when promoting the J&J vaccine, “All the available vaccines have been proven effective at preventing serious illness, hospitalization, and death from COVID-19 disease.” The CDC also encourages individuals to get the first vaccine available to them. States are beginning to craft their own messages to reach their residents.
Before opening up new vaccine appointments, the Washington, DC Department of Health sent an email using the CDC’s language to all residents who signed up for vaccine alerts. The email noted that individuals will be able to see which vaccine is being administered at each site before choosing an appointment, but emphasized that all vaccines are effective at preventing “serious illness, hospitalization, and death from COVID-19,” and that residents are “highly encouraged to take the first vaccine available to them.” All appointments were booked within minutes, suggesting that Washington, DC residents were willing to take whichever vaccine was available.
In Iowa, Gov. Kim Reynolds received the J&J vaccine during a news conference to help promote the vaccine and emphasized her trust in the vaccine before her constituents. She also addressed concerns about the J&J vaccine’s efficacy, noting, “This information is misleading, and quite frankly, it’s irresponsible to position any vaccine as a less desirable option when it’s undergone the same rigorous clinical trials to test the safety and efficacy and has received approval by the FDA and the CDC.”
Gov. Jay Inslee of Washington State also issued a statement about the J&J vaccine in a recent interview, where he acknowledged the lower efficacy rates in clinical trials, but also praised the advantages of this vaccine compared to others. “It’s going to save your life, which we think is a pretty high value. It has a downside of slightly lower efficacy to prevent you from getting a headache — but you only have to have one shot instead of two,” he explained.
Federal and state governments are also navigating the tension between the value of setting aside allocations of the J&J vaccine for individuals who face more barriers to getting two doses, and the danger of targeting a vaccine that some constituencies believe is less valuable to more vulnerable and historically marginalized populations.
Supply remains a key concern in state and federal vaccination efforts. However, President Biden’s announcement that the United States will have enough supply to vaccinate the entire adult population by May, in part due to J&J’s partnership with Merck to ramp up manufacturing, creates even more pressure to ensure that public health messaging effectively promotes the benefits of all vaccines equally.
In the meantime, the J&J vaccine arrives as many states are broadening their vaccine eligibility guidelines. According to National Academy for State Health Policy analysis, 35 states are now vaccinating individuals age 65 and older and 43 states are vaccinating teachers and/or childcare providers. During the first week of March, 11 states began vaccinating teachers, and four states expanded eligibility to individuals age 50 and older. This new vaccine can help ensure that newly eligible individuals can be vaccinated promptly, bringing the nation closer to herd immunity.
Acknowledgements: This blog 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 $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author 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: February 2021.
Individuals experiencing homelessness often face more barriers to obtaining a COVID-19 vaccination than others. As more vaccines become available and supplies increase, new and emerging best practices for vaccinating individuals in homeless shelters may help states more efficiently vaccinate other hard-to-reach or medically vulnerable populations, such as those living in rural areas or congregate settings.
The Centers for Disease Control and Prevention (CDC) classifies individuals experiencing homelessness as a high-risk population. Homeless shelters are congregate settings, which can facilitate the rapid spread of COVID-19 infection, and many individuals who are homeless also suffer from other medical conditions that put them at high risk of COVID-19-related complications. While some states group all individuals residing in congregate settings into one vaccination priority category, others specifically identify individuals in homeless shelters as a priority population. As a result, these individuals’ vaccination eligibility differs between states.
According to a recent analysis by the National Academy for State Health Policy (NASHP), 34 states explicitly include residents of homeless shelters as a priority population. A few states, including Wyoming and Washington, DC, explicitly prioritize “individuals experiencing homelessness.” Washington State lists “people experiencing homelessness that access services or live in congregate settings (e.g., shelters, temporary housing)” in its latest vaccine prioritization plan.
Every state has changed its eligibility criteria and prioritization guidelines as the CDC and the Department of Health and Human Services (HHS) have issued new recommendations based on the constantly changing vaccine rollout picture. Some states have identified these individuals in their plans and moved this population up in priority, while others have instead reprioritized other populations. For example, Wyoming recently moved individuals experiencing homelessness up in their prioritization. Arizona elevated individuals with high-risk medical conditions living in shelters as well all adults in congregate settings. Wisconsin added individuals in homeless shelters and in transitional housing to a priority phase of the state plan after previously not prioritizing this population. As of March 1, 2021, 15 states were vaccinating individuals experiencing homelessness.
In addition to the general vaccine distribution challenges states are facing – such as limited vaccine supplies, tracking data on doses administered, personnel shortages, and vaccine hesitancy – vaccinating individuals experiencing homelessness has its own difficulties:
- Conflicting priorities: On top of concerns about vaccine safety and mistrust of the health care system, many individuals experiencing homelessness are hesitant to receive the vaccine because they see other challenges – such as housing status, food insecurity, and financial instability – as more immediate concerns.
- Transportation barriers: Many individuals experiencing homelessness face transportation barriers that prevent them from traveling to mass vaccination clinics.
- Tracking second doses: For those who receive the Moderna or Pfizer vaccines, the state must figure out how to track where individuals are to ensure they receive their second dose and are fully immunized. It is particularly challenging for states to track second doses for individuals who are only in a shelter temporarily, or primarily live on the street.
- Limited technology: Many people living on the street or in shelters do not have internet access, and therefore cannot sign up for vaccine appointments through state websites.
- Connection to health care providers: Individuals experiencing homelessness are less likely to be connected to health care providers or health care systems, making it more difficult to get an appointment or find out when they are eligible.
- Vaccine Storage: In order to reach individuals living on the street, providers need to be able to transport doses to encampments and other areas where individuals frequently live. However, the vaccines’ refrigerated storage requirements make bringing doses directly to individuals on the street difficult.
States are working diligently to determine strategies and best practices for vaccinating individuals experiencing homelessness. As supply increases and becomes less of a barrier to vaccine administration, it is critical to address access-related barriers that may prevent some individuals from receiving the vaccine and exacerbate existing health disparities.
As with most decisions related to vaccine distribution, eligibility criteria for priority populations has been left to states. Of the limited states already vaccinating individuals experiencing homelessness, many have turned to private organizations to aid in vaccinating individuals experiencing homelessness. In these cases, the state distributes doses to nonprofit organizations that work to address homelessness or provide health care to the homeless, and these organizations take the lead in organizing clinics and administering doses.
Since early February 2021, the Washington, DC Department of Human Services has partnered with Unity Health Care, the District’s largest network of federally qualified heath centers, to hold vaccination clinics at homeless shelters. Unity Health Care is also trying to vaccinate individuals living on the street when possible through case managers and outreach teams. Washington, DC is eliminating certain barriers to vaccination for individuals experiencing homelessness, including waiving the requirement to provide an ID at appointments, giving individuals waterproof wallets in which to keep their vaccination cards, and providing free transportation to clinics located at some homeless shelters.
In Connecticut, the state and local health departments are coordinating vaccination efforts in congregate facilities – including homeless shelters – affiliated with the state, and partnering with private nonprofits to actually administer the doses. Some hospitals and cities in Connecticut are also using mobile vaccination clinics to reach individuals in congregate settings.
In Massachusetts, the nonprofit Boston Health Care for the Homeless Program (BHCHP) is playing a crucial role in vaccinating individuals experiencing homelessness in the Boston area. BHCHP is leveraging the City of Boston’s Homeless Management Information System (HMIS) – which connects to their electronic health records system Epic – in conjunction with the state’s Immunization Information System (IIS) to track first doses administered and to send out second dose text reminders. Shelter can access these reminders and provide outreach to patients to make sure they get their second doses. BHCHP is also using their grant funding and their own funding to incentivize vaccinations among the populations they serve, including providing gift cards, clothing, and snacks and combatting vaccine hesitancy by training individuals experiencing homelessness to provide peer counseling. To date, the nonprofit reports it has been successful at ensuring individuals return for their second doses. BHCHP also announced plans to start vaccinating individuals living on the street. They hope to use a van to store doses while they drive to areas where individuals on the street often live.
As states try to simultaneously provide information about vaccination clinic locations, recruit and train personnel to administer vaccines, monitor individuals after vaccination, and plan mass clinics, nonprofits are a valuable resource for reaching specific populations. Many private organizations, especially those already working to address homelessness and housing insecurity, have existing relationships with individuals experiencing homelessness and are already trusted service providers. They have been providing outreach to these communities throughout the pandemic and are poised to take on some of the work of vaccinating individuals experiencing homelessness.
Because demand for the vaccine still exceeds supply, states are challenged to prioritize their populations. States have to make tough decisions that promote health equity, decrease infection rates, promote vaccine efficiency, and prevent deaths. States that have not yet started vaccinating individuals experiencing homelessness can learn from others that are already vaccinating this population so that they can more effectively reach those living in shelters and on the street.
As states – and their partnering nonprofits – pilot strategies like mobile vaccine clinics and offer incentive payments and peer counseling in order to reach individuals experiencing homelessness and encourage vaccinations, these and similar initiatives can inform efforts to vaccinate other hard-to-reach populations.
Acknowledgements: This blog 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 $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author 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: February 2021.
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.
To date, there have been more than 2 million COVID-19 infections in US children and 8,000 pediatric hospitalizations. As states begin vaccinating those age 16 and older, many are drafting plans and applying lessons learned from their existing vaccination initiatives for the day when a vaccine is authorized for younger children.
As the Biden Administration rolls out its comprehensive plan to vaccinate 100 million American adults in the next 100 days and reopen schools in 100 days, states are already taking actions to include children in their vaccine distribution plans and tackling issues, such as:
- Should schools require students to get the COVID-19 vaccine, similar to other immunization requirements?
- How should they prioritize children with medical conditions or living in congregate settings that put them at higher risk of infection?
Children are at lower risk of illness from COVID-19 than adults, yet this population can still develop symptoms and spread the virus to others. Though children have experienced fewer severe physical illness than adults, the pandemic has significantly impacted their emotional and social development. Children and their families have been stressed by social distancing, disruptions in schooling, unemployment, and loss of family members due to COVID-19.
Last October, states submitted COVID-19 vaccine distribution plans to the Centers for Disease Control and Prevention (CDC) that outlined their approaches, including how they will collaborate with stakeholders, enroll providers, and track vaccinations. The federal Advisory Committee on Immunization Practices (ACIP) has recommended vaccinations first for health care personnel and long-term care facility residents, people 65 and older, essential workers, and those with high-risk medial conditions. States are using these recommendations to guide their approaches to prioritizing populations for vaccine distribution.
ACIP is currently discussing vaccine trials in pediatric populations and has indicated it may update its recommendations once a vaccine is authorized for children under age 16. Meanwhile, several states have already identified a distribution phase for children in their current plans.
Youth age 12 and older have just begun enrolling in vaccine trials. If the vaccine is authorized for this age group, it will next be tested in a younger pediatric population. While there have been barriers to clinical trials for the vaccine in this population and the timeline is unclear, it will be months before any children under age 16 are eligible for vaccination. As states grapple with challenges in distributing the vaccine to currently eligible populations, they may be able to leverage the lessons they are now learning to improve distribution for younger children in the future.
Additionally, there are already systems in place to deliver vaccines to children, and many states plan to use the Vaccines for Children (VFC) infrastructure for enrolling and verifying providers, distributing, and tracking COVID-19 vaccine administration for all populations, including adults. States may find that these established protocols will facilitate vaccinating children.
States differ in how they have – or have not yet – included children in their vaccine distribution plans while the vaccine undergoes pediatric clinical trials. State approaches include:
- Incorporating child health agency representatives in COVID-19 vaccination planning teams;
- Designating roles for child health programs and providers to facilitate distribution; and
- Prioritizing children or subpopulations of children for when the vaccine is authorized.
Several states have indicated their pediatric vaccination plans may be updated once the vaccine is authorized for children. (See the table for a list of states that have included pediatric-specific approaches in their vaccine distribution plans.)
Including Child Health Stakeholders in Vaccination Planning
States have developed organizational structures that include internal and external agency representation to facilitate COVID-19 vaccination planning. At least 31 states have included child health stakeholders on their vaccine planning teams and advisory councils. These stakeholders include state chapters of the American Academy of Pediatrics (AAP) and other provider groups, children’s hospitals, other pediatric providers, state education agencies, local school districts, and others. Including these representatives in vaccine distribution planning early offers an important perspective for distributing the vaccine when it is authorized for children.
- Washington, DC’s vaccine planning team includes representatives from the District’s chapter of the American Academy of Pediatrics, pediatric providers, public schools, Families USA, and March of Dimes.
- Ohio’s vaccine planning team includes representatives from Ohio Children’s Hospital Association, Ohio Department of Education, and select local school districts.
Designating Roles for Child Health Programs and Providers
Beyond their vaccine planning teams, states have identified and partnered with child health programs and providers to support implementation of their distribution plans. These partners include pediatric practices, local school districts, and state public health agencies, including Title V Maternal and Child Health programs. Forming partnerships with these entities early in the planning process can facilitate rapid vaccine deployment once it is authorized. The specific roles designated to these partners include promoting the vaccine, facilitating communication with children and their families, identifying eligible children, and administering the vaccine.
- Connecticut has identified vaccine administration locations that will specifically serve children. These include school-based health centers and pediatric medical practices.
- North Carolina plans to partner with schools to help identify children for vaccination once it is authorized. The state is also engaged with the state’s AAP and the Pediatric Society to support education and communication about the vaccine.
Children at higher risk of illness due to COVID-19: While the distribution phase differs, most states have categorized people with chronic conditions that increase their risk for illness due to COVID-19 as a priority group for vaccine receipt. Because most states do not specify the age range for this prioritized group in their distribution plans, some of these states may implicitly plan to include children, including children and youth with special health care needs (CYSHCN) who are at increased risk of COVID-19 illness, within this group when the vaccine is authorized for pediatric populations. However, five states (HI, KY, ME, NY, and OK) have specifically included children at higher risk as a prioritized population.
- Oklahoma has prioritized students including those in K-12 schools, childcare facilities, and early childhood facilities for Phase 3 of their vaccination distribution. Within their distribution plans, they specify that students at higher risk due to comorbid conditions will be prioritized among all students.
- Maine’s distribution plan specifies that “people of all ages” with conditions that put them at higher risk will be prioritized for earlier phases of vaccination. Anyone with a condition that puts them at significantly higher risk will be prioritized for Phase 1b, and those with conditions that put them at moderately high risk will be prioritized for Phase 2.
As the vaccine is tested for safety in the pediatric population, states are considering how they will further incorporate children into their distribution plans if it is authorized.
- Including child health stakeholders in planning for the vaccine for children. Many states have leveraged the existing VFC infrastructure and partnered with child health agencies to support planning and implementation for distribution of the currently available vaccine. This important perspective will be increasingly critical if the vaccine is authorized for use in children. States can consider collaborating with additional stakeholders that represent the broad range of child health services to effectively support vaccine administration for the pediatric population.
- Leveraging lessons learned from distribution of the adult vaccine. States have faced various challenges in distributing the vaccine to those who are currently eligible. Given that children under age 16 will not be eligible for the vaccine for at least several months, states may be able to draw from their experiences to improve their strategies for distributing the vaccine to children while also considering the challenges and opportunities that are unique to the pediatric population.
- Prioritizing caregivers of children with underlying conditions. Many CYSHCN who may have underlying conditions that increase their susceptibility to COVID-19 symptoms are cared for by family members. To reduce the risk for CYSHCN, states can prioritize vaccinating these family members by classifying them as health care workers.
- Prioritizing sub-populations of children. Children who are at higher risk of COVID-19 due to underlying medical conditions and/or those in congregate facilities are important populations for states to consider for prioritization. Additionally, states can consider how to distribute the vaccine to minimize learning losses due to school closures. CYSHCN may face unique challenges in accessing virtual learning compared to other children, whether or not they are at greater risk of COVID-19 illness. This is particularly true for children of color, those with high socioeconomic needs, and those with limited access to technology. Prioritizing children with greater virtual learning challenges could more equitably facilitate a safe return to in-person learning.
- Determining whether the vaccine will be a school requirement. Several state vaccine distribution plans include language about their state statutes that currently require certain vaccines for children to enter schools. While these plans do not specify that the COVID-19 vaccine is a school requirement, this will be an important consideration for states if the vaccine is authorized for use in pediatric populations.
- Distributing the vaccine across pediatric age groups. Vaccination authorization in children will likely be authorized in stages, with current trials for those ages 12 and older, and subsequent trials for younger age groups. This may impact states’ decisions governing how they prioritize vaccine distribution, when and which schools reopen for in-person instruction, and who, if anyone, is required to have received the vaccine to attend school in person.
The National Academy for State Health Policy will continue to monitor states’ COVID-19 vaccine distribution plans, and how states’ plans change once the vaccine is authorized for children under age 16.
Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials co-operative agreement. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA/HHS, or the US government.
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.
The National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.
Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.
Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.
Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.
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.