The largest mass vaccination campaign ever attempted in the United States could begin as soon as this week, with the federal government turning over millions of doses to the states and territories.
Everything depends on them.
But days before the first COVID-19 vaccine is cleared for use, an exclusive USA TODAY Network survey of health officials in all 50 states revealed a patchwork of preparations and different distribution plans that may mean wide variations in what the rollout looks like as it expands across the nation.
Many states are struggling to prepare because information about what, when and how much vaccine is coming constantly changes, and extra funding to make the undertaking possible depends on Congress. Preparedness varies widely depending on how well a state’s health department is funded, how hard the pandemic has hit and how robust its immunization system was pre-pandemic.
Overall, state officials express confidence for this month’s launch. They’re meeting two and three times a week to prepare for the onslaught, hiring more people, beefing up computer systems, requisitioning or buying everything from all-terrain delivery vehicles for remote places to dry ice machines for keeping the precious vaccine at its required sub-zero temperature.
Most expect to be able to immunize the relatively small first round of health care workers and nursing home residents. The complexity, however, ratchets up considerably when the numbers go from uniform groups of tens of thousands per state to millions of essential workers, people 65 and older and those with multiple underlying illnesses.
As Hawaii’s planning document says, quoting boxer Mike Tyson, “Everyone has a plan until they get punched in the mouth.”
In states such as Arizona, private health care systems will do much of the distribution. There, Banner Health already is planning immunization sites at the state fairground in Phoenix. In Alaska, the tribal health system of 180 clinics will be integral to getting vaccine out.
The countdown begins Thursday, when a critical committee in the vaccine authorization process, the Vaccines and Related Biological Products Advisory Committee, meets. It will vote and send recommendations to the Food and Drug Administration that night. FDA could authorize Pfizer’s COVID-19 vaccine within hours.
States are on high alert waiting for the first shipments to go out. The White House has promised to get vaccine to all 50 states, the District of Columbia and five U.S. territories within 24 hours of the decision.
States say they’re bound and determined to get vaccine to their residents and end the pandemic as fast as possible.
“We are shoring up our logistics,” said Maine CDC Director Dr. Nirav Shah. “Our goal is to be able to vaccinate both with velocity and equity as soon as the vaccine is released.”
The USA TODAY Network survey found that while state plans have the same broad outlines, there are remarkable differences.
Some have only signed up a few providers into the U.S. Centers for Disease Control and Prevention’s vaccine ordering system, others have hundreds ready to go. Some are doing everything with their own staff, others have asked the National Guard to help – in one case, almost 1,000 Guardsmen. Some shroud where vaccine is being stored in secrecy, others publish lists and maps of every site on the web.
Two things stand out as the biggest stumbling blocks – constantly shifting information about when and how much vaccine will arrive at clinic loading docks and a grinding lack of funds to deal with it.
A state can be told to expect 60,000 doses in its first shipment, only to see the number drop to 20,000 a few weeks later. One month the CDC says states don’t need to invest in ultra-cold freezers to store the Pfizer vaccine, the next there’s a run on them by bigger states, no matter what CDC says.
For small public health staffs, trying to pull off the medical equivalent of D-Day is head-spinning.
Take something as simple as how much vaccine will arrive. The numbers they’re seeing are merely “notional,” said Stephen White, immunizations director at the South Carolina Department of Health and Environmental Control.
“This information has changed several times over the course of several weeks,” he said. He hopes to provide more public information “once we have the doses in hand.”
“A continuously changing planning environment” is a huge hurdle, said Buffy Heater, Oklahoma State Department of Health Assistant Deputy Commissioner. “The vaccine plan has to be very fluid, as there are many unknowns in what lies ahead.”
Pennsylvania Secretary of Health Dr. Rachel Levine said she simply didn’t know how many doses her state is expecting for its first distribution wave.
“We heard various numbers, but we don’t know exactly how many doses we’re going to be getting, which again is why all of our plans are drafts and will continue to evolve, because it will be different depending on the doses we get,” she said.
It’s hard to get ready for the biggest single medical undertaking many states have ever undertaken with no exact timeline, clear amounts and a staff that must be ready “within days of when it’s approved,” said Joe Sullivan, senior health adviser with the Oregon Health Authority. “Normally, we would be more out front with communication about things.”
The other concern is a lack of funds. State public health systems are notoriously underfunded and now they’re being asked to mount an “all hands on deck” undertaking with an already exhausted staff.
“Health care workers are stretched managing the COVID cases and the ongoing outbreak. We will be tapping into the same workforce to vaccinate individuals,” said Michigan’s Lynn Sutfin, a spokesperson for the Michigan Department of Health and Human Services.
States had some money from the Coronavirus Aid, Relief and Economic Security Act, known as the CARES Act. And the CDC awarded $200 million to states for vaccine preparedness in September. But it won’t go far, say public health officials.
Asked how much of her staff’s time is being taken up with getting ready for COVID-19 vaccinations, Nevada Immunization Program Manager Shannon Bennett answered simply, “all of it.”
“A very large proportion of our staff time has gone into this,” she said. “Typically we have around 20 state full-time staffers. Right now we’re in the low 30s.”
Those people have to be paid, said Tiffany Tate, executive director of the Maryland Partnership for Prevention, a nonprofit that supports the state’s immunization coalitions.
And it’s not just finding the space and hiring extra people to give the injections, though that’s expensive enough, she said. It’s also buying the orange cones to mark out lanes for people waiting in their cars and outdoor tents.
The coordinator who spends days checking the credentials of everyone hired to give shots also must be paid, as well as the person organizing the schedule and the staffers answering hotline questions and billing insurance companies to get reimbursed for giving the shot.
Given Pfizer’s estimate that each immunization should take 10 minutes, it would take $136 million to simply pay for the staff time necessary for the state of Maryland to give everyone there the two-dose vaccine.
“We’re not ready for that,” Tate said.
The undertaking – to vaccinate American’s 328 million residents and end a pandemic killing thousands every day – is historic, said Dr. Thomas Tsai, a health policy researcher at Harvard T.H. Chan School of Public Health
“This is just a breathtaking scientific and public health effort,” he said.
The work falls on the backs of chronically underfunded public health systems, said Dr. Nicole Lurie, assistant health and human services secretary for preparedness and response in the Obama administration.
The United States has a highly decentralized medical system. The government effort to create vaccines, Operation Warp Speed, is very centralized. Once those vaccines are distributed, they hit a system of health departments and emergency management programs at the state level each with its own rules, requirements and infrastructure.
Despite the challenges, public health staff will make it work because the field attracts people who are selfless and dedicated to saving lives, Lurie said. “They will move heaven and earth to make this happen,” she said.
How much vaccine each state will get at the beginning is theoretically based on simple math. The first amount is 6.4 million doses divided by state population, said Health and Human Services Secretary Alex Azar.
Even so, confusion reigns. Over the past week governors have been naming various figures but it’s not always clear whether they’re based on how much vaccine they’ll get in December, or on the first day and if it’s based on two doses for each person or one.
Mississippi said it was getting 3,000 doses, which is about right for its 1% of the U.S. population. Texas Gov. Greg Abbott said on Thursday his state had been allotted 1.4 million doses for the month of December but didn’t say how many would come in the first shipment. Wisconsin on Wednesday offered a very specific first dose shipment of 49,725 doses.
Who will get vaccine first is pretty set, generally front-line healthcare workers and people in long-term care facilities. But because there won’t be enough vaccine to go around at the beginning, states are divvying up within those groups differently.
In Kentucky, two-thirds of its vaccine allotment will to go to residents and workers in long-term care centers while one-third will go to people working in hospital COVID-19 units. Gov. Andy Beshear said he is focusing on long-term care because that accounts for about 65% of all COVID-19 related deaths in Kentucky.
In Indiana, hospital chaplains will be included among the first to get the vaccine, while in Tennessee health care workers 65 and older will go to the front of the line.
All states have spent the past few months surveying their health care systems and medical personnel to have as accurate a count as possible of those in each of the CDC’s recommended vaccine rollout phases.
Imagine trying to give shots when it’s so cold hand sanitizer freezes.
In Maryland, Tate said medical staff are dealing with such winter weather issues at outdoor testing sites. The logistics of vaccination clinics are an order of magnitude harder.
“You’ve got to have people spaced 6 feet apart. You have to worry about outdoor clinics and inclement weather and tents and outdoor heaters,” she said.
Her staff sets up testing sites at 6 a.m. to accommodate people who have to get to work. “It’s 32 degrees. Last week when they used hand sanitizer, it was freezing on their hands,” she said. “How do you give a shot when your hands are freezing?”
Winter issues are a big part of the planning for all but the most southern states. Vaccinations will launch just before Christmas, with the bulk of health care workers getting at least their first shot within three weeks, according to Dr. Nancy Messionier, director of CDC’s National Center for Immunization and Respiratory Diseases.
That puts the largest and most difficult portion of the rollout smack in the middle of the coldest months. The most vulnerable will be lining up, including essential workers who may only be able to come nights and weekends, people with one or more severe illnesses that put them at high risk for severe COVID-19 disease and those 65 and older, including many in their 70s and 80s who are at absolute highest risk of dying from COVID-19.
Nevada is a state of mountains and desert, with two major population areas, Reno and Las Vegas, a seven-hour drive apart. The state health department is preparing for snow in the mountains and hundreds of miles of driving to get vaccine out to rural areas.
State immunization program manager Shannon Bennett has commandeered 4-wheel drive SUVs from the state motor pool and has them parked outside her building. “We don’t want to have to wait for them,” she said, “we have three available right now.”
Each state is making different choices about who will administer and distribute vaccine based on local circumstances.
In Florida, the first round of vaccine will go to five designated hospitals in Orlando, Miami, Tampa, Jacksonville and Hollywood. Immunizations will be provided for health care workers at those hospitals and for those who work elsewhere.
Illinois will receive the first shipments of vaccine centrally and then redistribute it to local health departments, to ensure it’s equitably allocated to all jurisdictions, said Melaney Arnold, with the Illinois Public Health Department.
Utah is prioritizing health care workers in its five largest hospitals as they’re treating the largest proportion of COVID-19 patients. As more vaccine becomes available, it will expand to other hospitals and clinic settings, said Tom Hudachko, director of communications with the Utah Department of Health.
In Alaska 80% of communities are only accessible by air or water and most vaccine must be distributed by plane. It has a centralized vaccine depot in Anchorage.
Oklahoma is going for a hub and spoke model. Strategically located sites with ultra-cold storage capability will get the first shipments and vaccine will be redistributed from those locations through county health departments. For security purposes, the state won’t say where the pre-positioned vaccine will be stored.
In contrast, a day’s drive to the east, Ohio has designated 10 hospitals in the state to serve as pre-positioning sites, all helpfully listed on the state Department of Health’s website, along with a map.
Having enough people to give the shots will become a problem as distribution moves beyond the first phase of front-line health care workers and nursing home residents to the more general public. Doctors, nurses, pharmacists – and those in training to become them – are all expected to take part. Dentists are clamoring to help. Some have suggested allowing veterinarians to give immunize people, though no state so far has set up a program to allow it.
Maine plans to use its robust system of volunteer firefighters to aid the effort. EMS clinicians will work together with local fire departments and volunteer fire and rescue agencies to host pop up vaccination sites.
When it comes time to vaccinating the general public, having enough providers in the hardest-hit areas is one of Arizona health director Dr. Cara Christ’s biggest worries.
We’re “really trying to get out to those populations that really desperately need the vaccine,” she said.
The first vaccine expected to be authorized comes from Pfizer/BioNTech. It must be stored at minus 94 degrees, which requires ultracold freezers that cost upwards of $20,000 and are mostly used at large hospitals and medical centers. States have been surveying everyone they can to find out who have freezer space to determine where the first doses should go.
For some states with multiple medical systems, there were lots of choices. Others less so. Alabama found it had six for a population of 5 million, said Dr. Karen Landers, the assistant state health officer with the Alabama Department of Public Health.
Then there’s the dry ice conundrum. Pfizer’s shipping container for the vaccine is shipped with about 20 pounds of dry ice inside to keep the vaccine vials at the necessary temperature. It’s designed so that it can be refilled with dry every five days as a storage unit for up to 20 days. But not every area has a ready supply of dry ice.
Even in North Dakota, where January temperatures average in the middle of the state can hit minus 4 degrees, it’s still not cold enough to store Pfizer’s vaccine. Molly Howell, state immunization program manager, says they’ve bought a dry-ice-making machine because “there just are not that many and they’re not generally in the rural areas.”
Conducting a mass vaccination campaign in the middle of a global pandemic costs millions and the money is going to have to come from the federal government.
Mississippi is very straightforward. It will need $30 million to distribute vaccine statewide, and state Health Officer Dr. Thomas Dobbs was confident the needed funds will come from the federal government.
Others are less convinced. Federal funding is essential for the vaccine initiatives, said Kentucky Gov. Beshear.
“I can’t overstate how bad it would be if Congress doesn’t act and they basically say, ‘You’re on your own,’” he said.
Keeping the vaccine safe is another contingency to plan for. After spending billions to create these vaccines, no one wants to see supplies stolen, destroyed or see clinics disrupted. For that reason, vaccine shipments will have security as they move through the system and in some cases once they arrive at hospitals and clinics.
In Kentucky, state police will work with local law enforcement to secure stored vaccines. The Department of Transportation will assist in security of the vaccine while it’s being transported. The state’s emergency management office will provide credentials, vehicle markers and communications devices for drivers of state-operated vehicles moving the vaccine.
In Louisiana, redistribution within the state will be in unmarked cars or ambulances. Vaccine arriving at sites must be signed for by a designated staff member and secured in a locked storage area accessed only by trained and designated staff. Sign-in sheets will be used anytime anyone enters the storage areas. The state’s immunization program headquarters, which will store some vaccine, has 24-hour security seven days a week.
Oregon doesn’t think anyone will steal the vaccine because it has to be kept at minus 94 , said Sullivan, the senior health adviser at Oregon Health Authority. Maryland’s Tate noted someone would only steal if they had the capability to administer it.
Visible and vocal public opposition to the vaccine itself is something else public health officials worry about and must contend with.
The weekend after Thanksgiving, on one of the busiest driving days of the year, Jacksonville, Florida, drivers saw a banner across a major highway that read, “COVID-19 manufacturers are exempt from liability.” While that’s true, it’s because the U.S. government took on liability for the vaccines under the White House’s Operation Warp Speed program.
In Nevada, where people already protest back-to-school immunization events, officials are concerned such protesters might show up for COVID-19 clinics. “I do think that there’s a possibility,” Bennett said.
In West Virginia, Gov. Jim Justice assured residents Friday that the government will not use the vaccine to track them.
Security won’t only be for those who oppose vaccines but also for crowd control and to keep people calm.
“People are tired and they’re just ready to get back to their lives,” said Maryland’s Tate. Already in flu clinics her staff sometimes sees people being pushy and getting vocal about their place in line or the time it takes to get a shot.
“We need to be prepared for that kind of energy,” she said.
None of this is going to happen quickly. There are many dark months ahead – though exactly how many depends on who you ask.
In New Jersey, the state health department’s goal is to inoculate 70% of the adult population, or 4.7 million people, within six months. Gov. Phil Murphy said he expects everyone in the state who wants a vaccine will be able to get one by April or May.
“When we talk about light at the end of the tunnel, this is real,” he said.
Others, however, think it could take twice as long.
“We’re going to be rolling the vaccine out through the winter, spring, and well into the summer. It’s going to take a significant amount of time to vaccinate everyone in Pennsylvania,” said Pennsylvania’s Levine.
A big fear is once people get vaccinated they will think they can immediately go back to normal life.
“Help is definitely on the way. These vaccines are highly effective and highly safe. But they are going to trickle into Rhode Island over a matter of months,” Gov. Gina Raimondo said.
There are still many months of “being careful, mask-wearing, social distancing and following the rules” ahead, she added.
Helen Eddy, director of the Polk County health department in Iowa, said public health officials worry people will believe the vaccines’ arrival heralds a quick end to the crisis. If the public stops taking precautions, such as wearing masks and avoiding crowds, the outbreak could get much worse before it gets better, said Eddy, whose county includes Des Moines.
“January, February, March could be really tough – really, really tough,” she said. “We’re still going to have to wear masks for a period of time. It’s going to take us a while to get enough people immunized.”
In the meantime, health officials nationwide are asking for the public’s patience.
“What I would hope is people would be understanding that this is going to be a bumpy process,” Oregon’s Sullivan said. “When there’s inadequate supply, people get antsy. It’s going to be a slow process over the next few months to get this vaccine out. It will not be a smooth rollout, but we will get it done.”
While the effort is a “monumental management issue,” Connecticut Gov. Ned Lamont expressed optimism the nation will pull it off.
“Right now, I’m very hopeful,” he said. “We need some ‘hopeful.”
Contributing: Howard Altschiller, Elinor Aspegren, Laura Benedict, Melissa Brown, Robert Byers, Misty Castile, Nicole Cobler, Wheeler Cowperthwaite, Algernon D’Ammassa, Maria De Varenne, David DeMille, Jonathan Ellis, Patricia Ferrier, Carmen Forman, Sarah Gamard, Brian Gordon, Brent Hallenbeck, Nicole Hayden, Stephanie Innes, Mary Landers, Barbara Leader, Tony Leys, Tracy Loew, Nora Mabie, Kevin McCoy, Michael McDermott, Jane Murphy, Marcus Navarro, David Nelson, Encarnacion Pyle, Tomari Quinn. Leisa Richardson, Will Richmond, David Robinson, Nikki Ross, Keisha Rowe, Shari Rudavsky, Samantha Rutland, Jeanine Santucci, Kristen Jordan Shamus, Donovan Slack, Mary Spicuzza, Dennis Wagner, Lindy Washburn, Dana Williams and Alia Wong