Vaccine distribution at the state level

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 Update, health experts discuss the challenges with the COVID-19 vaccine distribution and administration at the state level, and what we can expect moving forward.

Learn more at the AMA COVID-19 resource center.

Speakers

• James Blumenstock, senior vice president, pandemic response and recovery, Association of State and Territorial Health Officials (ASTHO)
• Rebecca Coyle, executive director, American Immunization Registry Association
• Claire Hannan, MPH, executive director, Association of Immunization Managers

Unger: Hello. This is the American Medical Association's COVID-19 update. Today, we're talking about the challenges we've seen with vaccine distribution and administration at the state level. I'm joined today by James Blumenstock, senior vice president for pandemic response and recovery at the Association of State and Territorial Health Officials or ASTHO, in Brielle, New Jersey, Rebecca Coyle, executive director, American Immunization Registry Association in Washington D.C. and Claire Hannan, executive director, Association of Immunization Managers in Rockville, Maryland. I'm Todd Unger, AMA's chief experience officer in Chicago. Mr. Blumenstock, let's start with you. Welcome back to our program. When we last spoke in November, we talked about what you referred to as the last mile of the vaccine rollout or the administration piece. And we have been hearing that the roll out is going much more slowly than expected. In your view, why is this the case?

Blumenstock: Well, thanks, Todd, and it's great to be back with you again. I mean, certainly it's both understandable and unfortunate that the rollout has been disappointing to some, maybe many. And I think it's worth spending a few moments really trying to explain that, not to provide alibis or excuses, but really to put it in proper context going forward. First, we can't lose sight of the fact that even five and a half weeks into the campaign, we successfully administered over 12 million doses to the American public. That is an accomplishment. But that being said, we certainly need to do more. We continue to work through the start-up of this campaign. As many of your members know, the vaccine is a very complex issue. The vaccine has very specific and complex components for logistics and administration. It was a terrible time of year for the campaign to begin around the holiday season.

Not that everyone takes the season off to celebrate, but it was critically important that we didn't drain the health care sector from providing the services to the individuals in the hospitals and all the health care centers realizing that they may have been on skeletal crews, and also the lack of people really wanting to accept the vaccine during that time of year too. So that was another dynamic that really attributed to the sort of slow startup. The biggest point here is that it wasn't about speed and volume. It was about being very measured, very careful and very strategic on who should get the vaccine first, and that was the highest risk populations that we really carefully identified and designed this program for. So for all of those reasons, those first several weeks, again, the numbers weren't impressive to some, but again, it was successful.

It made an impression and I think a really good early start into this campaign. We're now in the process of making the adjustments. We've learned from the last four to five weeks, we are addressing some of the root causes of barriers. I know we'll talk about it in a few minutes as well. So I think our members of State and Territorial Health Officials in partnership with the health care community really are on a good glide path to improve the availability and uptake of this life-saving vaccine in the weeks and months ahead.

Unger: It is a Herculean effort and it's good to hear that. Ms. Hannan, Ms. Coyle, do you have anything to add from your vantage points?

Hannan: I mean, I would just say that one of the things we have done really well is built this infrastructure of private providers, getting providers enrolled, getting information to them about the vaccine, the storage, the handling. This as a new vaccine, a delicate vaccine, and working to really build that trust in the vaccine. So hopefully that pays off dividends as we move forward. That is really a monumental task to merge a government supplied vaccine in a state based public health system, in a private sector based health care delivery system. So that infrastructure being set up I think is huge and hopefully the efficiency of getting the vaccine out will be higher as we move out to larger populations.

Coyle: Yeah. And I think just to speak to what Claire had mentioned, I think we have decades of investment into these systems and really have been able to leverage that in the first phases of this rollout. All of our major health care systems have an electronic health record system and most of those are connected to an immunization registry. So this has really allowed us to take advantage of that existing infrastructure.

Unger: Ms. Hannan, what would you tell physicians to help them better understand how the COVID vaccine distribution planning process works at the state level?

Hannan: Well, the planning process at the state level really was looking to roll the vaccine out in phases, to enroll as many providers as possible. So if physicians are not enrolled at this point, they really should be. If they can participate as a provider, they should look to their state health agency, their jurisdiction to get enrolled. And I think we've seen that we've gone to perhaps larger populations more quickly than maybe we thought we would just to get vaccine into arms, and we're seeing states do that at a different level of urgency, I guess, or different pace to get vaccines into arms. But physicians should be doing everything they can to get the vaccine, to talk about getting the vaccine, to talk about how great the vaccine is, its effectiveness, its value, make sure they're enrolled as providers in the program.

And if they're having any kind of trouble finding the vaccine, really looking to their state medical association or their state health agency for more information about where to get it.

Unger: And a big shout out to all those AMA members out there, all those physicians that have been posting their pictures of them getting their first and their second shots. Thanks for speaking up and showing the way. Ms. Coyle, in your role, you oversee the implementation of the immunization information systems. Why is this so important and what challenges have your members faced?

Coyle: That's a great question. I should probably clarify. So I don't actually take responsibility for anyone implementing the systems. What we do is we work with all of the state and jurisdictions that operate these systems to implement them and in very consistent manner. So what role have they been playing in this? So I think it's important to recognize what an immunization information system is or an immunization registry. You can think about it as an electronic immunization card. So those paper records that we got as kids, that yellow vaccine card, this is the digital version of that. And so this digital version is now going to be keeping track of which COVID vaccine you got, the date you got it, and then also has an added feature where it can actually forecast for the next immunizations that a person ought to receive based upon what they've already received to date.

So we're pretty excited to be able to see this. From our perspective, you have to think about a COVID vaccine is very much like any other vaccine out there. That's the rule of these systems, it's to capture those documented and provide a record for providers and then also for the public.

Unger: Well, it's good to hear that because I have been seeing a lot of the pictures of the actual kind of paper card that people are holding up in their photos, but behind that is something far more sophisticated. Ms. Hannan, it seems that millions of doses are being distributed, but a smaller percentage are making it into people's arms, which some say that's the biggest challenge. Did we focus too heavily on getting vaccine from point A to point B and not enough of the logistics of the administration for what is a delicate vaccine?

Hannan: I think that's a really good point. And we always say that vaccines don't save lives, vaccinations do, and how important it is to focus on that last mile. And I think it's just really hard to predict. This is an unprecedented campaign and focusing on getting the vaccine out in phases, really trying to reduce the effort for health care workers to get the vaccine, to vaccinate in their sites where they work, also really focusing on the delicacy and the storage and handling of the vaccine. We did all of that. And yeah, now we're seeing we've got to make some adjustments, right? In getting the vaccine into arms. And Jim talked about that a little bit, but I think looking to scale up perhaps how we vaccinate, so holding larger scale clinics that go maybe around the clock so the vaccine actually is getting into arms.

But again, I think that we did well in setting up the infrastructure and getting the vaccine to hospitals. It may be going into arms more slowly than we would like, but it is going into arms and it is going into the right arms and we wanted to prioritize health care workers. So now we're moving on to larger groups, we're seeing a real high demand, we're adjusting, and I think you'll see that the doses administered hopefully will catch up as we move forward. And a big piece of that too is the long-term care facilities. Really difficult to get into long-term care facilities and vaccinate, and we're seeing those challenges play out. CVS and Walgreens are working with the federal government and going into states and doing that, but it is on a rolling basis so they can't do them all at one time.

But I think we're getting vaccines into arms and we are getting more efficient and we are adjusting. So it's just hard. This is an unprecedented campaign so we'll continue to get better as we move along.

Unger: So on the other end of this is the arena of supply. And we recently learned that supply is a problem and that a reserve that we thought we'd had for second doses that was going to be released didn't exist. So what have state officials been told about this and how is it going to affect plans going forward? Mr. Blumenstock, can you start?

Blumenstock: Sure. Well, thanks, Todd. It came as much of a surprise to us as it did to the viewing audience when that was revealed last week. So there really isn't much more insight or wisdom I could share other than the fact that we still lack clarity on exactly what was the fate of the reserve and what are the numbers available today. That being said, I mean, looking towards the future, I think the key here as the new administration takes over tomorrow is the critical importance of having a reliable, predictable and ample supply of vaccine, which in my opinion is really the number one rate controlling factor to accomplish this objective. So increasing transparency, communication, giving the state and local health officials better insights into sort of the forecasting of available vaccine over time is critical for successful planning going forward.

It will relieve anxiety and confusion on the part of the public and it will make them as government agencies more effective and more efficient in their mission.

Unger: Well said. We spoke before about prioritization. Equitable distribution of vaccine has been a key goal and there's been a lot discussed. Have prioritization efforts work so far or are they creating additional challenges for state allocation and distribution beyond the supply shortages? And what can we be doing better? Ms. Hannan?

Hannan: Well, anytime that you prioritize a specific group, I think you're sacrificing some efficiency. So the larger the group that you're trying to get the vaccine to, the better that you can get it out without delay. So the equity challenge is a very real challenge because you want to make sure that you are providing equity and you are getting the vaccine to as many accessible places as possible in every community and it's just very hard to do that with the lack of supply. And now as you're prioritizing or targeting, again, it's not as efficient. So in interest of efficiency, we're seeing opening it up to larger populations. But I think that state and local health departments are getting resources. They're coming this week. They're really working with communities trying to have that engagement, build that confidence in the vaccine. It's difficult when supplies are limited to ensure equity, but there's definitely an attention to that.

And I think hopefully the strategies that states are planning on and their communications campaign that they've planned on, when the resources come, these strategies will come to bear.

Unger: Ms. Coyle, anything to add to that?

Coyle: Yeah. I think in terms of leveraging an immunization information system, when you're looking at large scale populations, it's a great tool for looking to see who has been vaccinated. It's not necessarily going to tell you who hasn't been vaccinated given that we're really sort of extending this into the adult population. And as a whole, we have about 60% of the adult population in an immunization registry today, but that's not all. So using this in conjunction with other tools, our local and state health departments are the ones who know their audience. They know their constituents, they know what their population looks like. So this is just another tool that can be of assistance in that planning and evaluation process.

Unger: Mr. Blumenstock, the last time we spoke, which was back in November, you were very specific about the need for more funding for this effort. I think the number that you gave me was just shy of about $9 billion. And at that point, I think only about 200 million had been approved. Now the Biden administration has announced that they will invest $20 billion in a national vaccine program. And Biden himself said that he will, quote, move heaven and earth to get more people vaccinated. How do you see this making a difference in the vaccine rollout going forward, I guess, starting tomorrow?

Blumenstock: Sure. I mean, we're still optimistic that it will make a significant difference. I mean, we're very excited because President-elect Biden's rescue plan certainly captures a vast majority of what the public health community feels is really necessary to protect the health and safety of our citizens. And the vaccination plan just basically embraces all the key common sense planning elements of ensuring that we have enough space, staff and stuff to be successful in this mission. And again, this mission is not measured in weeks, not even in single digit months. So it's a long term campaign and I think with the resources and the federal leadership that will soon be in place, we're optimistic that it will bring us to the next generation of our response going forward.

Unger: Excellent. Well, last question. You can imagine now the phone's ringing off the hook at pretty much every physician office across America with everyone, including myself saying, how do I get a vaccine? So there are a lot of people wondering when it will be their turn if they're not in this initial priority group. And what should physicians be telling their patients right now who want to get this vaccine? Mr. Blumenstock, will you start?

Blumenstock: Oh, thanks. Number one, be patient. Things will continue to improve as the systems mature and the vaccine supply becomes available. So don't lose hope, don't think any less of the life saving value of a vaccine. Be patient, be calm and stay close to your local and state health departments. Their websites probably are the best resource available to give an individual sort of the official set of guidance on how best to put yourself in place for scheduling. So that would be your go-to, your state health department's website.

Unger: Ms. Coyle?

Coyle: I would say from the perspective of the data and the systems that are being leveraged, particularly for providers that maybe use an EHR, but have no idea about these things called immunization registries, you're checking with the health IT folks at the office, is the system already connected? Is information flowing? Is there a way to check that immunization registry before you administer that second dose? These vaccines are very precious, they're in limited quantities right now. We want to ensure that everyone is getting the right dose at the right time and we certainly don't want to be wasting vaccine. We want to ensure that folks are getting the same vaccine for the second dose that they got for their first dose. So familiarizing yourselves with the systems that are out there. And then if you have questions, the state health department, the local health department are great resources to help answer some of these basic questions.

Unger: Ms. Hannan?

Hannan: Yeah. I mean, I would just add that I know there's a lot of anxiety right now in the population about when are we going to get the vaccine. My day job, I'm really focusing on the rollout of states and then my night job is trying to find the vaccine for my 95-year-old dad and sort of keep him off the ledge that he's going to get vaccinated. And I think that's the kind of reassurance that the patients need and physicians can provide. We can't vaccinate everyone all at once. So like Jim said, you have to have some patients and no one's going to be left behind. The vaccine is coming. Every week, we're getting new vaccine candidates. We do anticipate production at some point ramping up. So there's just really a lot of good news out in front. So physicians can be very reassuring to their patients.

We're not at a point now where we can spread vaccine across all the physicians that want to give it to their patients, but I think just reassuring people the vaccine is coming and you want to get it as soon as you can, but you're not going to be left behind.

Unger: Well, excellent. I just can't tell you how much more optimistic it makes me feel to listen to the three of you and how we appreciate the work that you're doing to make sure that these vaccines do indeed get in people's arms. Thanks for joining us today, Mr. Blumenstock, Ms. Coyle and Ms. Hannan, we really appreciate it. We'll be back soon with another COVID-19 update. For more resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. Take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.