COVID-19 vaccine distribution — challenges and perhaps opportunities

Recent guidance from Operation Warp Speed and the Centers for Disease Control and Prevention (CDC) provided details to state and local health departments who will be delivering and administering the COVID-19 vaccines. 

They are being asked to complete a Herculean task without enough resources. Engaging effectively in public-private partnerships could be helpful in achieving the goal while leading to long-term innovation for public health. 

States need to plan for a scenario where a very limited vaccine is initially available (for example, enough for less than 5 percent of the country in the beginning). The first problem to solve is getting information to the public effectively and management of expectations. During the H1N1 response, when a small amount of vaccine was delivered initially, the lack of information on where vaccine was available led to panic and stress on communities and providers. This frustration may have led to decreased demand for the vaccine. 

States should invest now or partner to improve information systems. For COVID-19 tests, for example, some states deployed a tool from Microsoft that allowed a user to screen themselves for COVID-19 and schedule a test if they needed one. A similar tool could screen for vaccine priority and recommend where to obtain a vaccine if appropriate.  

A second problem that states need to be aware of is how to reach priority populations effectively with the limited vaccine. One of the hardest target populations to locate is people with conditions that put them the most at risk for deaths, such as multiple health comorbidities, who are not living in a nursing home. For the H1N1 vaccine, we found that distributing through pharmacy chains, community clinics and similar broad access locations was effective at reaching high risk individuals. This also seemed to be more effective than sending vaccines to specialty physicians, perhaps because visits to a pharmacy can occur more frequently, at different times of the day or week and with short drives or walks. Currently pharmacies are called out for phase two of the distribution, but with effective partnerships on vaccine priorities they could serve a crucial role in phase one also if they can help be gatekeepers to ensure priority populations get the vaccine first. Partners like Facebook could be useful in identifying individuals at higher risk through their advanced algorithms.

A third challenge is to reach populations as quickly as possible. For H1N1, vaccines were often sitting in distribution centers waiting to be ordered by providers, where the delays involved the process states used to collect orders from providers and submit them to the CDC. During the critical early days, that time was days or weeks for some states, and we found that those states had lower vaccine uptake in the overall population and in priority groups. When states design the process for the COVID-19 vaccine distribution, they could ensure speedy operations by requesting orders from providers in advance of vaccine availability, submitting orders hourly or daily instead of weekly, emphasizing a smaller number of consolidated distribution points over many individual, small providers in the beginning phase, or allocating to regional distribution centers immediately while taking orders for secondary distribution while the vaccine is being shipped. 

A fourth challenge includes setting up the infrastructure needed to distribute vaccines, especially when there is ample supply for the population. One or more vaccines are likely to require ultra-low cold storage, which is expensive and not typically available in physician offices. Administering vaccines in mass-vaccination clinics can deliver a large number of doses efficiently, although locations need to be planned in advance and resources reserved that can be stood up quickly when a vaccine is shipped. Drive-through testing has been one innovation during COVID-19 that could be one solution to administer vaccines while reducing disease transmission. Other ideas may need to be modified from existing emergency preparedness plans, with an emphasis on delivering quickly and safely. Strong partnerships with commercial pharmacies and retail clinics could help reduce the logistical burden on health departments who have neither the people nor the money to perform the additional logistics needed for a vaccine that expires when out of the specialty freezer for five days. 

A fifth challenge is to ensure that the entire population is reached equitably. We have already seen that COVID-19 has had a greater infection rate and fatality rate among African Americans, Native Americans and Latino populations. Health care resources tend to be more available in urban areas than rural, in high income than low income and in white communities than in communities of color. The demand may also differ across communities, which means education may need to be increased to ensure equitable outcomes. During H1N1, the allocation process clearly emphasized fairness by population size (“pro rata” allocation to states) and fairness by need (priority populations defined) while allowing states to have additional sub priorities. During this pandemic, there have been questions around allocation of personal protective equipment and remdesivir treatments and allocation processes have not been fully defined for a vaccine. The public should ask for transparency in decisions, so defining allocation processes clearly can reduce anxiety and backlash. States should engage with stakeholder groups now, establish distribution plans for areas with fewer healthcare resources and plan for education. Targeted messaging can be developed for at-risk communities, and partners like Facebook can help in targeting the public service announcement to those who need it the most.  

Disruption breeds innovation. Companies, researchers and new market models can lead to approaches that may not have even been dreamed of before distributing COVID-19 vaccine. If states engage with partners of various types now, the seeds for effective innovation can be planted and nurtured, thereby ensuring the COVID-19 vaccines can be distributed efficiently, effectively, and equitably. Partners should also be ready to listen to the public health teams on the priorities and concerns and develop their solutions with the public health perspective. I hope we learn from our “H1N1 pandemic test” and do things even better this time when the mortality rate, infection rate and susceptible population are all higher. 

Julie Swann is an Allison Distinguished professor at North Carolina State University. She is also the co-founder of the Center for Health and Humanitarian Systems at Georgia Tech. Swann is a very active member of the Institute for Operations Research and the Management Sciences (INFORMS) and a former senior science advisor at the CDC during the H1N1 pandemic response.