Charting A Path To Deliver The COVID-19 Vaccine

JOHN DANKOSKY: This is Science Friday. I’m John Dankosky. Last week, the United Kingdom approved a COVID-19 vaccine developed by Pfizer through an emergency authorization, and vaccinations began this week. The first person to get the vaccine in the UK was a 90-year-old woman who was a retired shopkeeper. Here in the US, there’s still not an approved vaccine. According to Operation Warp Speed, the federal government’s COVID-19 vaccine unit, the goal is to produce and deliver 300 million doses by the end of January 20, 2021.

So how are states and health departments preparing for all this? And how might we distribute the vaccine to the general public? My guests are here to talk about that today. Maryn McKenna is a science writer and columnist at WIRED. Maryn, welcome back to the show.

MARYN MCKENNA: Thanks for having me.

JOHN DANKOSKY: And Dr. Uché Blackstock is a physician and founder of Advancing Health Equity. She’s also a Yahoo News medical contributor, and she’s based in Brooklyn, New York. Welcome back to the show, Dr. Blackstock.

UCHE BLACKSTOCK: Thank you so much for having me.

JOHN DANKOSKY: So Maryn, let’s get started here. Once there is finally an approval of this Pfizer vaccine– this Moderna vaccine, each state will get an allotment. How exactly does this work? How many doses does each state get?

MARYN MCKENNA: So this is turning out to be complicated. We know that there are going to be tranches of vaccine rolling out from the manufacturers. Not all of those doses are going to land at once. And for quite a while, the states have been confused about what they’re going to get. And it’s important to say that it’s up to the states for the most part to distribute this because public health is a function of the states.

So back in November, Operation Warp Speed, the federal effort said to the states that they were going to assign those first trenches, divide them up and assign them to states on the basis of population. And this, on the one hand, was an answer that the states have been waiting for a while. But on the other hand, it caused a lot of alarm, because if you do a cut just on the basis of a certain percentage of population, not every state is going to have that same percentage of people who are highly at risk.

There might be a ferocious outbreak in one state and not in another, though, that seems unlikely because we have ferocious outbreaks everywhere right now. Or there might be more elderly people or more long-term care homes in one state than another. So that sense of just based on population has been causing some distress.

JOHN DANKOSKY: So Dr. Blackstock, what are you hearing about vaccines and vaccine distribution right now?

UCHE BLACKSTOCK: I think we’re hearing a lot of the confusion at both the state and local level. I currently work for an urgent care organization. And we’ve been told that we are definitely getting vaccines within a few weeks but that details are to come. And I want to say that I think given the work that I do around health equity, some of the issues in terms of vaccine distribution going specifically to hospitals, academic medical centers, and pharmacies focusing more on sort of the private sector at being distribution sites for the vaccination are of deep concern to me.

There are many people who don’t feel comfortable even walking into a hospital facility. And so I think that we’re going to have to really work on a public health campaign, an expansive one, that will address some of the concerns that the public has around the vaccine.

JOHN DANKOSKY: So there’s that distress, but and maybe we’ll get back to that because we need to talk about who exactly is going to be prioritized in each state. But Maryn, maybe you can walk us through just the real nitty gritty here. When you talk about a big load of vaccines going to the state, like, what happens? Does a pallet get dropped off at the state Capitol? Like, how exactly are these being delivered to the various states?

MARYN MCKENNA: So I think the states are asking those questions and working through the answers now themselves. There are complexities to these vaccines so that the two vaccines that we’re going to get first are the one from Pfizer and the one from Moderna. Pfizer could be approved by the FDA’s committee within days and Moderna next week. And the trucks could be rolling on those days.

In fact, it’s possible that some doses are prepositioned at the academic medical centers that were vaccine testing sites. At any rate, so vaccine gets delivered into a state. That Pfizer vaccine has to be held at a temperature that’s referred to as ultra cold– something like I think minus-80 degrees Celsius, which you can only do in the kind of freezer that you have.

For instance, at an academic medical center or in the special packaging that Pfizer’s had designed for them but that Moderna’s temperatures are a little less challenging– a little bit below the level of a home freezer. But still, it has to be frozen and still with special packaging.

The problem is that both of those vaccines come in what’s called a minimum order– a certain minimum number of doses that have to arrive at a location. So then the states have to ask themselves, when those doses get there, can they get enough people to match the number of doses they have? Or do they have to figure out to what degree they can disaggregate those shipments and send them further out down the chain and keep them viable while they do that? And that’s particularly going to be challenging.

JOHN DANKOSKY: We spoke with Dr. Nirav Shah who’s the director of the Main Center for Disease Control and Prevention about how the state of Maine is preparing and some of his concerns there.

NIRAV SHAH: It is a massive, massive project to build out that infrastructure. In order for there to be mass vaccination, you have to have a massive force of vaccinators. So we’ve had to recruit a number of different health care providers to serve as vaccinators as we go into community vaccination.

The first phase as a vaccine will be largely administered in the hospital setting. So hospitals themselves have had to tap their own staff to vaccinate their own staff. And then, of course, all of this has got to be tracked in a way so that we know where folks are getting vaccinated so we can remind them of when to come back for their second dose, so on and so forth. That all requires massive IT infrastructure.

The IT infrastructure in many states is decades old. Thankfully, Maine’s is quite recent and modern. What I’ve told my staff is every day, I want to know how many people we vaccinated. And then the related and equally important question, the equity question– did we vaccinate the right people? So those are the two questions I want to know every day.

How many people did we vaccinate yesterday in Maine? And did we vaccinate the right people? If we don’t have an IT system that can track who got vaccinated and what category they fell into? If we don’t know the answers to either of those things, how do states know if they’re doing a good job?

The bottom line here is that states like Maine will get the job done. That’s what we do. It’s what we do every single day. We tackle problems that are seemingly impossible and get it done. But additional assistance from the federal government would help me reach my goal of vaccinating with velocity and equity in Maine.

JOHN DANKOSKY: That’s Dr. Nirav Shah who’s the director of the Maine Center for Disease Control and Prevention. And he said the bottom line to all this is funding.

NIRAV SHAH: On a fiscal perspective, we’ve received approximately $800,000 thus far and have been informed that there will be additional funding forthcoming. But even there, it’s on the order of just a couple of extra $100,000. At the national level, my colleagues and I across the 50 states and to 14 territories have come together. And we project that just as an initial down payment, states and territories would require at least $8.4 billion just initially to get all of these systems set up. Additional resources are almost certainly going to be required so that across the country, a vaccine can be delivered efficiently.

MARYN MCKENNA: The state and local health departments have been waiting for the stimulus funds that are held up in Congress in order to literally get the money to hire IT professionals in order to build this infrastructure. That money has not yet arrived, and they are running out of time.

JOHN DANKOSKY: So Maryn, let’s get back to these rollout phases. As we talk about phase one, health care workers, people on the front lines and nursing home residents, by and large, are set to get the first vaccines. Is that pretty much happening across the board in all the states?

MARYN MCKENNA: So that’s the CDC’s recommendation. Let’s go over a couple of numbers because I think it’s worth talking about the number of people that need to be vaccinated. So in the United States– and these are CDC numbers– there are 21 million health care workers, 53 million people over the age of 65 who presumably are at more risk, 3 million people living in long-term care centers.

There’s more than 100 million people who have some kind of high risk or chronic medical condition that puts them at greater risk of infection and death. And there are essential workers. And we can talk about who those are. They add up to 87 million people. Now, we’re only going to get 6.4 million doses in this first delivery in December. So how do you figure out among all of those people who seem at risk and in need? Who gets it first?

So in the meeting of the CDC’s Advisory Committee on Immunization Practices, the ACIP just a week ago, the decision was made that people should be ranked 1, 2, 3, 4. And then there are subdivisions within one– 1A, 1B, 1C. And the ACIP affirmed that 1A should be health care workers and long-term care residents. But, again, that’s 24 million people. And that’s many more people than there are doses arriving in this first month.

JOHN DANKOSKY: So Dr. Blackstock, what do you think about these recommendations? Are we prioritizing the right people to get the vaccine first?

UCHE BLACKSTOCK: Well, I will definitely say with that first group, the 1A group consisting of health care workers and residents of long-term care facilities that we definitely got that right. But the goals of the prioritization scheme are to protect those at highest risk from severe disease, so the people in the long-term care facilities, but also to reduce the spread of virus, as well, as among health care workers.

And so I don’t think anyone’s going to argue that the 1A group isn’t where most people do agree. I think the more complicated conversation is going to be around the 1B group– essential workers. Do we target essential workers who have essentially really faced the brunt of the pandemic because of the public-facing nature of their jobs? Or are we going to give it to the elderly, who because of their age are at risk of severe disease?

And so I think those conversations at a state level are going to look different depending on the state and depending on the population in the state. Just another concern that I had about the essential workers was I think that was at the Advisory Committee on Immunization Practices’ way of incorporating race.

We know that in black and Latinx workers are overrepresented among essential workers. And because of anti-discrimination laws, they could not explicitly put race into the guidelines. And so I do think that was one way they tried to use essential workers as a surrogate of race because we know black and Latinx communities have been disproportionately impacted in this pandemic.

JOHN DANKOSKY: So, Maryn, with 50 different plans, as you get through the 1A, the 1B and into the general public, are you going to see a lot of variation between how all the states are prioritizing who gets the vaccine when?

MARYN MCKENNA: Absolutely. Now, some of that is due to the population of the state and what goes on in the state, right? If your state includes a nuclear power plant, you might want to vaccinate those people so that the new plant keeps running. If your state has a major deepwater port, you might consider port workers to be among the essential people, as well as people who work in 7-Eleven’s and the cashiers in supermarkets and teachers and so forth. There are a lot of conversations still going on about who those people are.

But also, states have it within their purview to decide to deliver the vaccine in different ways. So one state might say we have a county fairgrounds where we have a rodeo every fall. So let’s just put everyone in their cars and have them drive through the county fairground and hang one arm out the window. But another state might say, no, really, we have a number of small towns, and they have pharmacies. And we’ll empower the pharmacists to give the shot instead.

And the last time we had a major vaccination campaign– not as big as this– was the 2009, 2010 H1N1 flu. And there were situations in that campaign in which people living close to the borders of states could literally look over into the next state and say those people are getting vaccine differently than I am. And they may be getting it before I am. And that caused a lot of confusion.

JOHN DANKOSKY: I’m John Dankosky and this is Science Friday from WNYC Studios. I’m talking with Maryn McKenna, a science writer and columnist at WIRED and Dr. Uché Blackstock, a physician and founder of Advancing Health Equity. Dr. Blackstock, maybe you can pick up on that because you have expressed concerns about using pharmacies or maybe some of the traditional medical facilities that people don’t feel so comfortable going into. How would you design a system whether or not it’s driving through the rodeo fairgrounds or anything else that gets people where they actually are and where they want to get the vaccine?

UCHE BLACKSTOCK: Right, I think that it’s going to be key for Department of Public Health to partner with community-based organizations, faith-based organizations, churches, community centers, schools. I think that what we wanted for testing should happen for vaccine distribution. We wanted it to be free– wanted it to be accessible.

So I wish that people would be able to access vaccines at every street corner. There should be mobile vaccine distribution units driving and neighborhoods. And I know that because of the coaching issues that’s going to be a problem, especially with the Pfizer and Moderna vaccines– less so with some of the other vaccines if they are approved.

I did just want to also mention about the states. There are about 18 states that are going to be using the CDC’s structural vulnerability index. That is essentially the calculation based on census track to figure out which areas are most socially vulnerable. So ACIP did not include this in their guidelines, but the National Academy of Science, Engineering, and Medicine did include it in their framework for equitable allocation of the vaccine.

And I think that is also a great way. It incorporates housing, vehicle access, poverty– not race explicitly, but minority status. And so I think there are some states that are going to do this distribution process a little bit differently but using the numbers that really matter in terms of determining which populations are more vulnerable.

JOHN DANKOSKY: But that does raise a question, of course. As Maryn said, you might be able to look across the border and see your neighbor doing something that in your mind might make a lot more sense than what’s happening in your state.

UCHE BLACKSTOCK: Yeah, I think we’re going to see that a lot. Oh, because you live in New Jersey, things are a certain way. But in New York, we don’t do it that way. And unfortunately, I think this rollout is going to be more challenging than we had hoped it would be.

JOHN DANKOSKY: Dr. Blackstock, what’s another big barrier that you see here? I mean, are people going to be willing to take this vaccine? What sort of public information campaign do we need to make sure that people are willing to get in line and do this?

UCHE BLACKSTOCK: Right, I think just as we need funding for IT and for storage for the vaccines, we also need funding for a public health campaign and rather expensive one that again, [INAUDIBLE] engages trusted leaders in the community, but also is using social media and other sort of innovative ways to connect with different communities in a culturally responsive way, because what’s the sense in having a safe and effective vaccine if no one will take it?

We already have the data that especially among black Americans, less than 50% said they would be willing to take the vaccine– a little more so among Latino and white Americans. But I think vaccine acceptance is going to be another challenge that we’ll have to address over the next few months to a year.

JOHN DANKOSKY: We’ve run out of time here, and there’s so much more to talk about. We’ll have to continue this conversation in the weeks to come. Maryn McKenna’s a science writer and columnist at WIRED. Dr. Uché Blackstock is a physician and founder of Advancing Health Equity. She’s also a Yahoo News medical contributor. She’s based out of Brooklyn, New York. Thank you both for joining me today. I really appreciate it.

UCHE BLACKSTOCK: A pleasure to be here.

MARYN MCKENNA: Thank you, John.

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