The Complexities of Vaccine Distribution: States Need Federal Guidance and Support

Developing the vaccine is just the first challenge.

by Arielle Kane, Director of Health Care

Ending the Covid-19 pandemic in the United States will require a large-scale vaccination effort. The good news is, vaccine makers have developed a vaccine in record time — almost exactly one year after the virus was first discovered, vaccines will start to become available. This is because of the hard work of researchers who have studied coronaviruses since the emergence of SARS nearly two decades ago. Prior to 2020, the fastest development of a vaccine was for Mumps and took four years.

But developing the vaccine is just the first challenge. Because some of the vaccine candidates for Covid-19 require multiple doses, successful vaccination of the population requires manufacturing and distributing more than 600 million vaccines and making sure the majority of Americans are able and willing to receive it.

Now the challenge will be prioritizing who gets the vaccine in a strategic and fair way. At the beginning, when there is a limited supply, it makes sense to have a centralized advisory body prioritizing where and who should get the vaccine. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) is providing guidance on how to prioritize the limited supply.

However, to be most effective states will need more than just general guidance. ACIP needs to collect real-world data and then use that data to provide recommendations of which vaccine works best for whom in what circumstances. Because there is public distrust of the vaccine, providing updated data and recommendations will be key to building trust and increasing compliance. Finally, states need additional funding to distribute and track the initial limited vaccine supply for the greatest societal benefit.

A crucial question is: who should get the vaccine first? Last week the Centers for Disease Control and Prevention (CDC) recommended that nursing home residents and health care workers should be first in line. Intuitively, this makes sense. Nursing home and long-term care residents have borne the brunt of the pandemic and account for nearly 40 percent of all deaths. Depending on supply, it may make sense to break health care workers down into sub-categories and give the vaccine to those most likely to treat patients with the virus first, hence leaving them more susceptible to transmission.

Though the federal government has ordered and paid for millions of doses of these vaccines, it is leaving the bulk of the distribution work to the states. Governors will be working with vaccine manufacturers and health care providers to distribute and manage the inoculation effort, but states are not always effective at large-scale vaccination efforts. In the 2009 H1N1 outbreak, states vaccinated only 23 percent of the adult population. Although the low rate was partially because of supply shortages early on, less than a quarter of the population is still a dismal vaccination rate. We cannot risk a similar outcome with a virus that is much more infectious and deadly.

Beyond the initial guidance to vaccinate health care workers and nursing home residents first, order of inoculation has been left up to state policymakers. These will be hard decisions to make and governors deserve clear federal guidance and real-world data analysis so they can make informed, timely decisions. Failure to provide this guidance leaves the results of the vaccination effort up to chance, with wide discrepancies across states.

Even after state policymakers establish prioritized groups for vaccination, they have to figure out how to distribute the doses, a veritable logistics nightmare. All of this is complicated by the different handling requirements of the four vaccine candidates likely to be approved.

The Pfizer vaccine is unusually difficult to ship and store: It requires two doses 21 days apart and needs to be stored at -100° Fahrenheit. Its distribution is currently in dry ice-packed boxes holding 1,000 to 5,000 doses, though it’s trying to make smaller distributions available. The boxes will stay cold enough to store the vaccine for up to 10 days unopened but once opened, they can only be stored for five days if not opened more than twice a day.

Moderna’s vaccine, based on similar technology as the Pfizer vaccine, has to be stored at -4 degrees, but can be refrigerated for up to 30 days. It also requires two doses, four weeks apart.

The Oxford/AstraZeneca vaccine can be refrigerated at 36 to 46 degrees Fahrenheit for up to six months. This vaccine is more traditional and uses a weakened version of the virus to stimulate an immune response. While the data is still forthcoming, it looks to be at least 70 percent effective in preventing Covid-19 infections.

Johnson & Johnson is also in the final stages of a vaccine trial for a traditional “viral vector” vaccine, like AstraZeneca. However, its vaccine will only require one dose and can be stored for up to two years at -4° Fahrenheit. Further, once ready to go to health care providers, it will be stable at 35.6° to 46.4° Fahrenheit for up to three months.

These differences might mean that the Pfizer vaccine should go to large health care facilities with the capacity to store large doses of vaccines at -100 degrees while the Johnson & Johnson vaccine should go to health care clinics that serve vulnerable populations less likely to be able to come in for a second dose.

Even with well-thought-out logistical planning and decisions, distribution and public campaigns to vaccinate people will not be cheap. State budgets are already strained from the economic downturn and will need financial assistance to effectively distribute the vaccine to all corners of the country.

Once manufacturing has caught up with demand, centralized distribution efforts may no longer be necessary. But over time, real-world data could show there are further differences across the vaccines. One of them may be particularly effective in people with compromised immune systems who cannot handle flu-like symptoms that may accompany inoculation. Similarly, one might work better among school children. It is vital that ACIP collect the data and make medical recommendations based on new information as it is available.

Though the end of shelter-at-home orders, shuttered restaurants, and children “learning” at home, may be near, the coronavirus will likely be around for years to come. We don’t know how long immunity from these vaccines will last, and like the flu, the virus could mutate and keep circling the globe.

Each of the forthcoming vaccines will have its own strengths and weaknesses. It will be important to continue to collect real-world data so that scientific recommendations can evolve with the information that we have.