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.