Missing from state plans to distribute the COVID-19 vaccine: money to do it

With the prospect that a coronavirus vaccine will become available for emergency use as soon as next month, states and cities are warning that distributing the shots to an anxious public could be hindered by inadequate technology, severe funding shortfalls and a lack of trained personnel.

While the Trump administration has showered billions of dollars on the companies developing the vaccines, it has left the logistics of inoculating and tracking as many as 20 million people by year’s end — and many tens of millions more next year — largely to local governments without providing enough money, officials in several localities and public health experts involved in the preparations said in interviews.


Public health departments, already strained by a pandemic that has overrun hospitals and drained budgets, are racing to expand online systems to track and share information about who has been vaccinated; to recruit and train hundreds of thousands of doctors, nurses and pharmacists to give people the shot and collect data about everyone who gets it; to find safe locations for mass vaccination events; and to convince the public of the importance of getting immunized.

The federal Centers for Disease Control and Prevention have sent $200 million to the states for the effort, with another $140 million promised in December, but state and local officials said that was billions of dollars short of what would be needed to carry out their complex plans.


“We absolutely do not have enough to pull this off successfully,” said Dr. Thomas E. Dobbs III, the state health officer of Mississippi. “This is going to be a phenomenal logistical feat, to vaccinate everybody in the country. We absolutely have zero margin for failure. We really have to get this right.”

Health departments have asked Congress for at least $8.4 billion more for “a timely, comprehensive, and equitable vaccine distribution campaign”; the CDC director, Dr. Robert Redfield, has said that at least $6 billion is needed. But negotiations for further funding are caught up in the stalemate between House Democrats and the Trump administration over the coronavirus stimulus bill.

“There’s a lot of anxiety,” said Rebecca Coyle, executive director of the American Immunization Registry Association, which has been helping states prepare. “I don’t think we are ready today.”

Congress has allocated $10 billion to Operation Warp Speed, the federal effort subsidizing vaccine companies' clinical trials and manufacturing costs. Dr. Mandy Cohen, the secretary of health and human services in North Carolina, said her state had received just $6 million for distributing and promoting the shot. She expects $3 million more by the end of the year and called the money “a down payment” for what is likely to be $30 million worth of work over the first year of vaccine distribution.

Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, said that more than anything, insufficient funding would slow the rate of vaccination, particularly among disadvantaged populations that are harder to reach.

“The speed at which we vaccinate the population in Maine is directly dependent on the funding,” he said. “We will still get the job done, but it will take longer if I can’t train the people to give it.”

An undated photo provided by the German pharmaceutical company BioNTech shows a vial of BNT162, the COVID-19 vaccine candidate developed with Pfizer.

There are myriad other costs too — including, Shah noted, paying for secure convoys to transport the vaccine once it gets to states.

“We can’t just throw it into Bob’s pickup truck and drive it down the road,” he said.


One official working on distribution plans at the CDC, who did not have authorization to speak publicly, said the slow drip of money had made it difficult for states to carry out plans and to hire for vaccine-related jobs.

“It’s unfortunate and inefficient to do it this way,” the official said.

Preliminary plans that almost every state has shared with the CDC offer a glimpse of urgent preparations for a mass vaccination campaign larger than the United States has never seen. Although the vaccine will be available to only a very small slice of Americans at first, probably starting with health care workers, access could expand rapidly over the first half of 2021.

Michigan is enlisting pharmacies to tell their customers with chronic conditions — like diabetes, asthma and high blood pressure — about the vaccine, as they will be prioritized to get it. Tennessee is recruiting more than 1,000 volunteer doctors and nurses to help administer the vaccine initially. Nebraska is making plans to promote it on gas station video screens and in robocalls. New Hampshire — the only state without an online immunization registry — is scrambling to build one to track which residents have received the shot and to report the information to the CDC.

The first vaccine that is likely to be authorized by the Food and Drug Administration, made by Pfizer, comes with especially daunting logistical challenges, including the fact that every recipient will need a booster shot three weeks after the initial dose. Keeping track of which people need the follow-up dose, and getting them to return for it, are among the steepest hurdles that public health officials face. So is a requirement that providers report, for every dose administered, demographic and other data to their state within 24 hours; states, in turn, will quickly report it to the CDC.

A new federal platform, called the Immunization Gateway, aims to connect state vaccine registries so they can share information with one another — for example, if someone gets an initial coronavirus vaccine in New York and then goes to Florida for the winter, a doctor there can look up that person’s first dose information in order to give the correct second dose. But most registries have not yet connected to the platform. Between that and another new federal platform to track vaccines, public health officials are haunted by the spectacular crash of, the federal online insurance marketplace set up under the Affordable Care Act, when it went live in 2013 after being finished in a rush.


“A month before the vaccine is about to become available is not the time to think about making systems across 3,000 health departments in 50 states interoperable,” said Lori Freeman, chief executive of the National Association of County and City Health Officials. “It just doesn’t work.”

Addressing Americans' wariness toward the vaccine — recent polls show that between a third and half of Americans would be reluctant to get it — is also hard, some state officials said, given that none has been approved yet and comprehensive safety data from the ongoing clinical trials has not been released.

“We don’t really have the safety studies available to quote from,” said Dr. Jennifer Dillaha, the medical director for immunizations with the Arkansas Department of Health. “What we’re trying to do is develop relationships with people and organizations that can help us with messaging when the time comes.”

Other unknowns include how many doses of vaccine each state will initially receive, which groups will the CDC will recommend to get it first and even whether states need to worry about building the ultracold storage capacity needed for the Pfizer vaccine.

The CDC has told states and localities not to buy ultracold freezers for now, since the Pfizer vaccine will be shipped in coolers with dry ice that can keep it viable for up to 15 days with re-icing; it can then last five additional days in a conventional freezer. But many academic medical centers and other hospitals that can afford it are acquiring colder freezers anyway, setting up a have and have-not scenario.

Record-keeping requirements will also be an overwhelming task, officials said. The CDC wants to track, in real time, the age, sex, race and ethnicity of everyone who is vaccinated — states usually provide such data quarterly, at best — so it can analyze how well the vaccination campaign is going among different demographic groups day by day and make adjustments if certain populations or regions have low vaccination rates.


The CDC, which holds frequent planning calls with state and local health officials, is also still working on persuading states to hand over the personal data of their citizens. In its data use agreement with the states, the agency has requested each vaccine recipient’s name, date of birth, address, race, ethnicity and certain medical history.

“States have never had to report that to the federal government,” said J.T. Lane, the chief population health and innovation officer of the Association of State and Territorial Health Officials, adding that his organization was seeking clarity on exactly how the information would be used.

In particular, the organization’s members worry that the information could be used by Immigrations and Customs Enforcement to track undocumented immigrants.

As soon as the FDA approves a vaccine, the CDC’s Advisory Committee on Immunization Practices will meet to issue recommendations, already in the works, on how it should be distributed. It will almost certainly say that health care workers should be the group with the highest priority for vaccination, followed by essential service workers, people with high-risk medical conditions and those older than 65.

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But states will be allowed flexibility within those guidelines; Maryland, for example, plans to include its prison and jail populations in its “Phase 1” priority group. State officials also have to figure out whom to focus on within priority populations if they get less vaccine than they need.

During the CDC advisory committee’s meeting last month, some members said they wanted to ensure that information about any safety problems would be made public quickly. The Department of Health and Human Services has said its goal is to start shipping a vaccine within a day of FDA authorization. Until now, the FDA and the CDC have maintained one data system for patients or providers to report bad reactions to vaccines. They plan to supplement that system with a smartphone-based tool that checks in with individuals who have been vaccinated to see whether they have had any health problems.


The CDC advisory group has also stressed the importance of a campaign to persuade the public to take the vaccine, noting that messages were likely to be more effective if they came from community leaders than from the federal government. North Carolina says its campaign will use “photos, video, and personal testimony of celebrities, leaders of historically marginalized populations, and other trusted messengers receiving vaccine as early adopters.”

To ease the burden on health departments, the federal government is contracting with CVS and Walgreens pharmacies to vaccinate residents of nursing homes and other long-term-care centers around the country. But it could be difficult to reach those in isolated regions, and some might opt out of the program. Last week, the administration announced it would contract with pharmacies across the nation to provide the vaccine generally, as they do with flu shots, once supplies of it increase next year.

Christine Finley, the immunization program manager at the Vermont Department of Health, said her focus right now was enrolling hospitals to provide the first doses to health care workers and preparing a communications strategy. She hopes enthusiasm for the vaccine will grow once it gets through the approval process.

“A doctor the other day told me he thinks people may be much more hesitant about a theoretical vaccine than when we begin to see safety and efficacy data on a real one,” she said. “There are so many questions we’ve received, and so much interest, with the disease rate soaring — people saying, ‘We need a vaccine, now.’”

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