COVID-19 vaccine deployment: What’s next as we head into 2021?

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12/17/2020

After the FDA authorized emergency use of the Pfizer COVID-19 vaccine, the biggest question for healthcare leaders and patients in the final weeks of 2020 and the start of 2021 will be, “How soon will we get vaccines?”

Responses from medical practice leaders to a recent MGMA Stat poll revealed a range of responses when it came to how administrators would manage getting staff vaccinated in the coming weeks and months:

Numerous administrators said they would strongly encourage their staff members to get vaccinated but not formally require it.
Dozens of practice leaders say they are still evaluating their options or working from existing policies regarding flu vaccines until a formal COVID-19 vaccination policy is in place.
Others defined specific policies for various staff members depending on whether they work in patient-facing or Joint Commission spaces.
Many of the poll respondents said that they will let employees decide once doses of the vaccine are available to them.

An expert panel on immunization efforts recently shared their industry perspectives in an Alliance for Health Policy (AHP) webinar. Among those providing their expertise were:

Kate Sullivan Hare, MHSA, vice president for policy and communications, AHP
Claire Hannan, MPH, executive director, Association of Immunization Managers (AIM)
Jay McHarg, MBA, chief executive officer, Aerosafe Global
Ed Kaleta, group vice president, U.S. Government Relations, Walgreens
Snehal V. Gandhi, MD, vice president, clinical informatics and care delivery innovation, Cooper University Hospital; medical director, Division of Hospital Medicine, Cooper University Health Care; assistant professor of medicine, Cooper Medical School of Rowan University.

There’s been a lot of preparation

Hannan, whose AIM members work in state and territorial public health agencies, noted that state health departments have been working for months to be ready for vaccine deployment, with distribution plans provided in October in anticipation of this moment. “All of us on the panel had goose bumps this weekend as things started to get underway,” Hannan said of the initial release of vaccine doses in mid-December.

Who gets the vaccine first?

The vaccine is being spread across states in a pro rata allocation process, and then individual states determine where the doses should be sent.
Hannan noted that states are setting up private providers to enroll for vaccine distribution, in which those providers agree to not charge for the immunizations, along with other needed steps related to proper storage and dosing. That provider enrollment process will be expanded across the country to tens of thousands of enrolled providers (e.g., independent pharmacies, community health centers, federally qualified health centers) as more doses of the vaccine are available.
In the first phase, enrollment is focused on providers who serve healthcare workers and other high-priority populations, such as long-term care residents and staff.
Similarly, pharmacies with a national presence are being prioritized for enrollment in a federal partnership.

Who decides?

Recommendations from the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) are eventually reviewed and approved as part of the CDC’s Morbidity and Mortality Weekly Report (MMWR).

Hannan said these recommendations include a phased rollout with priority for healthcare workers and long-term care facilities in Phase 1A. Phases 1B and 1C “are not clearly articulated by ACIP” yet, but Hannan noted that:

Phase 1B includes essential workers.
Phase 1C includes those over 65 with underlying conditions.

Are more vaccines coming soon?

States will receive weekly allocations, especially once the Moderna vaccine receives FDA authorization and begins shipping out, expected in late December.

“Most states have, in some way, a plan for allocation: an equity strategy, an advisory committee, an ethics advisor, a way to engage communities, community-based organizations and get feedback from them,” Hannan said. “They also have very robust communication plans.”

How are vaccines being shipped?

McHarg, who has decades of experience in engineering operations and strategy, noted three stages for distribution of vaccine doses:

Primary distribution to large hospital systems, pharmacy depots and states
Secondary distribution from the pharma production facilities to smaller and rural doctors’ offices and smaller pharmacies
Daily “last-mile” trips from primary distribution sites to long-term care facilities.

Because the doses must be kept very cold during transit and storage, COVID-19 vaccines are normally delivered in a container designed to hold the low temperature (-70 degrees Fahrenheit) for 1,000 to 5,000 doses with dry ice.

For Pfizer’s distribution, there is a box recovery system to bring the delivery boxes back for refurbishment for future vaccine deliveries in the weeks and months ahead. “For every 10,000 boxes you produce, you can support about 100,000 shipments a year with this recovery system,” McHarg said. “With the amount of vaccines that have to be distributed, that’s an important piece of this supply chain.”

What about all that dry ice needed?

McHarg said the large containers for primary distribution sites can be re-iced every five days with about 25 pounds of dry ice, which can extend the usability of each box up to 20 days. Systems have been put in place to deliver ice to pharmacies and hospitals, and most in the initial distributions have opted to re-ice about twice a week to avoid ever reaching the five-day limit.

For secondary distribution sites, the Pfizer payload boxes are built for five to 150 doses, and they last for about four days. “The idea is that these smaller facilities will use these up in a week,” McHarg said.

For the forthcoming Moderna vaccine, it’s expected that standard refrigerator temperatures of 2 to 8 degrees Celsius/36 to 48 degrees Fahrenheit will keep the doses stable.

Immunizing your staff

Gandhi said that Cooper University Health Care, Camden, N.J., administered its first doses of the Pfizer vaccine on Dec. 15. “To actually get to this point, it was not an easy lift,” Gandhi said, because “we had to rapidly develop and deploy an end-to-end workflow so that we could not only … bring in all of our people who were going to receive the vaccines [but] also start administering in a timely manner without creating mass chaos.”

It is vital for administering organizations to adhere to the clinical guidance for each vaccine authorized. For the Pfizer vaccine, the second dose should be administered 21 day after the first. “We need to book both the first dose and the second dose of the vaccine before they even receive the first dose,” Gandhi said, using the analogy of booking a roundtrip flight to know both ends of the immunization experience.

This required going to Cooper University Health Care’s EHR representative and use the technology on hand to build a self-service workflow:

A patient interest form for anyone looking to schedule a vaccination
Cross-matching of interest form information with records in the EHR
Email and patient portal reminders for appointments for immunizations.

This process allows patients to check in online, receive a QR code or barcode on their smartphone or other device, have the code scanned and then advance to the vaccination site, with a greeter on hand to assist.

This setup had the added benefit of turning the Cooper staff who were among the first to be immunized into social media “influencers,” taking their own appointment confirmations and sharing screenshots of them on Facebook, Twitter, Instagram and other platforms, which helped show the public the system Cooper will eventually use. That kind of effect can help drive interest in the vaccine — especially after politicization of the pandemic may have dissuaded some people from seeking the vaccine — when healthcare workers are seen as being excited and confident about receiving their immunizations.

Gandhi recommended to stagger how many workers from a given unit or office are vaccinated, simply to avoid the potential of some workers developing symptoms, which can happen following an immunization.