Q&A: Dealing with COVID-19 vaccine allocation, distribution

Issues and questions surrounding COVID-19 vaccines have evolved significantly between a first forum on promoting vaccination and a recent third forum hosted by ACP and Annals of Internal Medicine.

“There's been great progress since our October and December programs. Two vaccines have emergency use approval in the U.S., and as of January 19, nearly 36 million doses of these vaccines have been distributed to state and local governments,” said Christine Laine, MD, MPH, FACP, ACP Senior Vice President and Editor-in-Chief of Annals, in her introduction to the Jan. 22 online event, which is available online for replay with an accompanying Annals article.

The new availability of vaccines has highlighted the challenges of allocation and distribution, which were the focus of the third forum. These were addressed in a Q&A format by moderator Jason Goldman, MD, FACP, and speakers Amanda Cohn, MD, David G. Fairchild, MD, MPH, FACP, Wayne J. Riley, MD, MPH, MBA, MACP, and Mark A. Levine, MD, MACP. Following are some excerpts.

On the pace of vaccination

Dr. Cohn, chief medical officer of the National Center for Immunizations and Respiratory Diseases and executive secretary of the Advisory Committee on Immunization Practices (ACIP): Our initial doses went to a limited number of providers until we had more doses to get into the system, and so it took us some time to have an expansive number of providers. And frankly, we still need a lot more providers, and we still need a lot more doses of vaccine. … We have vaccinated over a million people a day over the last several days. Unfortunately, that's just Monday through Friday, so we need to get there on Saturdays and Sundays as well.

Dr. Riley, president of SUNY Downstate Health Sciences University and ACP President Emeritus: Our institution is large. I am responsible for over 4,000 employees, over 2,000 students. ... We basically shut down the seating part of our hospital cafeteria and set that up as our vaccine administration hub. We ran it 24 hours a day for the last three weeks. We wanted to make sure it was convenient for hospital staff who clock in at 7 a.m. in the morning or clock out at 11 p.m. at night—that they could get it before or after their shift. … We did not take it for granted that people would just show up because we had vaccine available. ... We had town hall meetings, and we explained the science behind the two mRNA vaccines, Moderna and Pfizer. We answered questions. And I think we've made progress.

On the possibility of vaccine mandates

Dr. Riley: It's going to become a more pressing question in about six months. … You cannot, as an employer, compel employees to have the vaccine until both of those vaccines have received full FDA approval. Once they receive full FDA approval, which I suspect will be late spring, early summer, it is then legally possible, for particularly private employers, to compel their health care workers to get the COVID vaccine ... less likely on the public sector side because of the collective bargaining. …There are some private hospitals and medical centers that can compel it, particularly in my former state of Texas. ... If you are a nurse or a physician or a respiratory therapist who refuses a flu vaccine, you can be terminated.

On vaccination prioritization

Dr. Cohn: I have heard countless stories about frontline health care workers having a challenging time finding vaccine, and then health care administrators or people who are able to work from home being able to get vaccinated, and it is such a local institutional, local county problem. … When the ACIP had these discussions, they said paid, unpaid, anyone who interacted with a person in the health care setting. It was a very broad definition. But the intent was those individuals who take care of people in a setting where they could be exposed to COVID.

Dr. Goldman, ACP Regent and practicing internist in Coral Springs, Fla.: Dr. Riley, will your institution and others vaccinate health care workers without a formal affiliation to your institution? And if so, how will that be accomplished?

Dr. Riley: This is one we're wrestling with now. ... We're going to run out of vaccine tomorrow here, and as much as we would like to broaden our “catchment area” to catch other unaffiliated health care colleagues, it's going to be difficult until we get enough supply of vaccine. I would rather take the heat for vaccinating a secretary who doesn't have any patient care contact, as opposed to having reports of vaccine going wasted.

Dr. Cohn: I think that should actually be a key guiding principle: Get doses in arms, don't throw them away.

Dr. Levine, Commissioner of Health for the state of Vermont: We've been very successful in Vermont with having our hospital systems play a major role. Admittedly, like Dr. Riley said, they are vaccinating their own first, but we made them quickly start incorporating aspects of the health care system that were not employed within their walls.

On the role of primary care

Dr. Levine: Because the state barely receives enough vaccine to inoculate them as primary care internists, never mind all the rest of the health care workforce, … there will not be a lot of vaccine going to the primary care office setting or any ambulatory office setting at this level of allocation. That doesn't mean the grand vision isn't for the primary care workforce to play as much of a role as needed.

Dr. Cohn: Even if you're not providing the vaccine to those you serve, we really need health care providers to support the decision to vaccinate when vaccine is available to your patients. And I know that varies by jurisdiction right now. And I know that there's a lot of confusing information about both where to get vaccine and who's eligible for vaccine. I'm really hopeful that in the next couple of weeks, we can start to solve some of these problems.

Dr. Fairchild, chief medical officer at MinuteClinic, the clinical arm of CVS Health: CVS did a small survey a few months ago to look at vaccine hesitancy, and as expected, particularly among communities of color, vaccine hesitancy was quite high. And then we asked, “Who are the influencers that would be helpful to making you feel more comfortable?” And of course, having Dr. Tony Fauci talk to you and endorse the vaccine is important. But who do you suppose is more influential than Dr. Fauci? It's your primary care physician.

On later phases of vaccination

Dr. Levine: We are, of course, starting with the oldest age group, age 75 and older, who are often stereotyped anyway as not being as internet savvy, or as comfortable with registering on an online system. So we've taken great pains to try to make that a smooth process for them. We also have videos to guide them through the process. But ultimately, we are backing it up with a phone system. ... Having navigators, having interpretive services, having good partnerships with advocacy groups in the communities where these people live has been critical to our success in other endeavors and will only be built upon to help us succeed in the area of vaccination.

Dr. Riley: It's very important that we get folks [to sign up for vaccination] through whatever state mechanism there is. New York's mechanism is different than Vermont's, Vermont is different than Michigan's, Michigan's is different than Pennsylvania's. So for all our colleagues out there, please make sure that you avail yourself of the information about your particular state or territory in terms of how they would wish folks to get registered for vaccines.

Dr. Cohn: We're hoping in the next couple of weeks, we'll have more of a national way to connect people with either resources in their states or directly to their state systems to register. … We need a different way to reach different populations. So I am hopeful with expanding funding that states should be seeing soon that was recently approved by Congress, some of these resources will be put to use in that way. … Getting vaccine to communities as close to people as possible, including people with disabilities, people who are homebound [will be important].

On the role of the federal government

Dr. Levine: With the new administration, there's been a real articulation of the fact that states are going to need more help for this, and so I see that coming, and I see that as a very positive development. ... But the reality is, it's a scarce resource right now… Distribution and administration are clearly state responsibilities.

Dr. Cohn: The federal government can help reach communities or places that jurisdictions may have a hard time reaching. … I see this as an all-of-government approach and all-of-society approach and, frankly, all of our health care community approach. We've got a lot of work to do, but it's the only way we're going to get it done.