Local health departments say they lack the staff, money, and tools to distribute and administer millions of vaccines.
BY LIZ
SZABO
PUBLIC HEALTH DEPARTMENTS, which
have struggled for months to test and trace everyone exposed to the novel
coronavirus, are now being told to prepare to distribute Covid-19 vaccines as
early as November 1.
In
a four-page memo this summer, the
federal Centers for Disease Control and Prevention told health departments
across the country to draft vaccination plans by October 1 “to coincide with
the earliest possible release of Covid-19 vaccine.”
The
CDC’s director, Dr. Robert Redfield, also wrote to governors last week about
the urgent need to have vaccine distribution sites up and running by November
1, McClatchy first reported. Redfield asked
governors to expedite the process for setting up these facilities.
But health departments that have
been underfunded for decades say they
currently lack the staff, money and tools to educate people about vaccines and
then to distribute, administer, and track doses to some 330 million people. Nor
do they know when, or if, they’ll get federal aid to do that.
“There
is a tremendous amount of work to be done to be prepared for this vaccination
program and it will not be complete by November 1,” said Dr. Kelly Moore,
associate director of immunization education at the Immunization Action
Coalition, a national vaccine education and advocacy organization based in St.
Paul, Minnesota. “States will need more financial resources than they have
now.”
Dozens
of doctors, nurses, and health officials interviewed by KHN and The Associated
Press expressed concern about the country’s readiness to conduct mass
vaccinations, as well as frustration with months of inconsistent information
from the federal government.
The
gaps include figuring out how officials will keep track of who has gotten which
doses and how they’ll keep the workers who give the shots safe, with enough
protective gear and syringes to do their jobs.
With only about half of Americans saying they would get vaccinated, according to a poll from AP-NORC Center for Public Affairs Research, it also will be crucial to educate people about the benefits of vaccination, said Molly Howell, who manages the North Dakota Department of Health’s immunization program.
The
unprecedented pace of vaccine development has left many Americans skeptical
about the safety of Covid-19 immunizations; others simply don’t trust the
federal government.
“We’re
in a very deep-red state,” said Ann Lewis, CEO of CareSouth Carolina, a group
of community health centers that serve mostly low-income people in five rural
counties in South Carolina. “The message that is coming out is not a message of
trust and confidence in medical or scientific evidence.”
The
U.S. has committed more than $10 billion to develop new coronavirus vaccines but
hasn’t allocated money specifically for distributing and administering
vaccines.
And
while states, territories, and 154 large cities and counties received billions
in congressional emergency funding, that money can be used for a variety of
purposes, including testing and overtime pay.
An
ongoing investigation by KHN and the AP has detailed how state and local public
health departments across the U.S. have been starved for decades, leaving
them underfunded and without adequate resources to
confront the coronavirus pandemic. The investigation further found that federal
coronavirus funds have been slow to reach public health
departments, forcing some communities to cancel non-coronavirus vaccine clinics
and other essential services.
States are allowed to use some of the federal money they’ve already received to prepare for immunizations. But KHN and the AP found that many health departments are so overwhelmed with the current costs of the pandemic — such as testing and contact tracing — that they can’t reserve money for the vaccine work to come.
Health departments will need to hire people to administer the
vaccines and systems to track them, and pay for supplies such as protective
medical masks, gowns, and gloves, as well as warehouses and refrigerator space.
CareSouth
Carolina is collaborating with the state health department on testing and the
pandemic response. They used federal funding to purchase $140,000 retrofitted
vans for mobile testing that they plan to continue to use to keep vaccines cold
and deliver them to residents when the time comes, said Lewis.
But
most vaccine costs will be new.
Pima
County, Arizona, for example, is already at least $30 million short of what
health officials need to fight the pandemic, let alone plan for vaccines, said
Dr. Francisco Garcia, deputy county administrator and chief medical officer.
Some
federal funds will expire soon. The $150 billion that states and local
governments received from a fund in the CARES Act, for example, covers only
expenses made through the end of the year, said Gretchen
Musicant, health commissioner in Minneapolis. That’s a problem, given vaccine
distribution may not have even begun.
Although
public health officials say they need more money, Congress left Washington for
its summer recess without passing a new pandemic relief bill that would include
additional funding for vaccine distribution.
“States
are anxious to receive those funds as soon as possible, so they can do what
they need to be prepared,” Moore said. “We can’t assume they can take existing
funding and attempt the largest vaccination campaign in history.”
Then
there’s the basic question of scale. The federally funded Vaccines for Children
program immunizes 40 million children each year. In 2009 and
2010, the CDC scaled up to vaccinate 81 million people against pandemic
H1N1 influenza. And last winter, the country distributed 175 million vaccines
for seasonal influenza vaccine, according to
the CDC.
But
for the U.S. to reach herd immunity against the coronavirus, most experts say,
the nation would likely need to vaccinate roughly 70% of Americans, which translates
to 200 million people and — because the first vaccines will require two doses
to be effective — 400 million shots.
Although
the CDC has overseen immunization campaigns in the past, the Trump
administration created a new program, Operation Warp Speed, to facilitate
vaccine development and distribution. In August, the administration announced that McKesson Corp., which
distributed H1N1 vaccines during that pandemic, will also distribute Covid-19
vaccines to doctors’ offices and clinics.
“With
few exceptions, our commercial distribution partners will be responsible for
handling all the vaccines,” Operation Warp Speed’s Paul Mango said in an email.
“We’re
not going to have 300 million doses all at once,” said Mango, deputy chief of
staff for policy at the Health and Human Services Department, despite earlier
government pledges to have that many doses ready by the new year. “We believe
we are maximizing our probability of success of having tens of millions of doses of vaccines
by January 2021, which is our goal.”
Amesh
Adalja, a senior scholar at the Johns Hopkins Center for Health Security, said
it will take time for the vaccines to be widespread enough for life to return
to what’s considered normal. “We have to be prepared to deal with this virus in
the absence of significant vaccine-induced immunity for a period of maybe a
year or longer,” Adalja said in August.
In preliminary guidance for state vaccine
managers, the CDC said doses will be distributed free of charge from a central
location. Health departments’ local vaccination plans may be reviewed by both
the CDC and Operation Warp Speed.
The CDC spent two days working with vaccine planners in five locations — North Dakota, Florida, California, Minnesota, and Philadelphia — to discuss potential obstacles and solutions.
No actual vaccines were distributed during the
planning sessions, which focused on how to get vaccines to people in places as
different as urban Philadelphia, where pharmacies abound, and rural North
Dakota, which has few chain drugstores but many clinics run by the federal
Indian Health Service, said Kris Ehresmann, who directs infectious disease control
at the Minnesota Department of Health.
Those
planning sessions have made Ehresmann feel more confident about who’s in charge
of distributing vaccines. “We are getting more specific guidance from CDC on
planning now,” she said. “We feel better about the process, though there are
still a lot of unknowns.”
Still,
many public health departments will struggle to adequately track who has been
vaccinated and when, because a lack of funding in recent decades has left them
in the technological dark ages, said Dr. Marcus Plescia, chief medical officer
at the Association of State and Territorial Health Officials.
In
Mississippi, for example, health officials still rely on faxes, said the
state’s health officer, Dr. Thomas Dobbs. “You can’t manually handle 1,200
faxes a day and expect anything efficient to happen,” he said.
When
Covid-19 vaccines become available, health providers will need to track where
and when patients receive their vaccines, said Moore, the medical director of
Tennessee’s immunization plan during the H1N1 influenza pandemic in 2009 and
2010. And with many different shots in the works, they will need to know
exactly which one each patient got, she said.
People
will need to receive their second Covid-19 dose 21 or 28 days after the first,
so health providers will need to remind patients to receive their second shot,
Moore said, and ensure that the second dose is the same brand as the first.
The
CDC will require vaccinators to provide “dose-level accounting and reporting”
for immunizations, so that the agency knows where every dose of Covid-19
vaccine is “at any point in time,” Moore said. Although “the sophistication of
these systems has improved dramatically” in the past decade, she said, “many
states will still face major challenges meeting data tracking and reporting
expectations.”
The
CDC is developing an app called the Vaccine Administration Monitoring System
for health departments whose data systems don’t meet standards for Covid-19
response, said Claire Hannan, executive director of the Association of
Immunization Managers, a nonprofit based in Rockville, Maryland.
“Those
standards haven’t been released,” Hannan said, “so health departments are
waiting to invest in necessary IT enhancements.” The CDC needs to release
standards and data expectations as quickly as possible, she added.
Meanwhile,
health departments are dealing with what Minnesota’s Ehresmann described as
“legacy” vaccine registries, sometimes dating to the late 1980s.
Overwhelmed public health teams are
already working long hours to test patients and trace their contacts, a
time-consuming process that will need to continue even after vaccines become
available.
When
vaccines are ready, health departments will need more staffers to identify
people at high risk for Covid-19, who should get the vaccine first, Moore said.
Public health staff also will be needed to educate the public about the
importance of vaccines and to administer shots, she said, as well as monitor
patients and report serious side effects.
At
an August meeting about vaccine distribution,
Dr. Ngozi Ezike, director of Illinois’ health department, said her state will
need to recruit additional health professionals to administer the shots,
including nursing students, medical students, dentists, dental hygienists, and
even veterinarians. Such vaccinators will need medical-grade masks, gowns, and
gloves to keep those workers safe as they handle needles amid the contagious
coronavirus.
Many
health officials say they feel burned by the country’s struggle to provide
hospitals with ventilators last spring, when states found themselves bidding against one another for a
limited supply. Those concerns are amplified by the country’s continuing
difficulties providing enough testing kits; supplying
health workers with personal protective equipment; allocating
drugs such as remdesivir; and recruiting contact tracers — who track down
everyone with whom people diagnosed with Covid-19 have been in contact.
Although
Ehresmann said she’s concerned Minnesota could run out of syringes, she said
the CDC has assured her they will provide them.
Given
that vaccines are far more complex than personal protective equipment and other
medical supplies — one vaccine candidate must be stored at minus 94 degrees Fahrenheit — Plescia
said people should be prepared for shortages, delays, and mix-ups.
“It’s
probably going to be even worse than the problems with testing and PPE,”
Plescia said.
Liz
Szabo reports for Kaiser Health News. Associated Press writer Michelle R. Smith
and KHN Midwest correspondent Lauren Weber contributed to this report.
This
story is a collaboration between The Associated Press and KHN.
This
article was originally published by Kaiser Health News and
is republished here under a Creative Commons license.
