'Not enough to go around': US states struggle to decide who should get Covid vaccine first

Colorado public health experts planning for an imminent Covid-19 vaccine recommended a vulnerable population living in crowded housing for early vaccination – the state’s prison and jail inmates.

It is a population living in tight quarters where it’s almost impossible to social distance, and these institutions have seen some of the largest outbreaks of Covid-19 in the nation. For all those reasons, they were part of an early phase of the state’s vaccination plan.

But inmates are not, as a rule, a politically popular constituency.

“There’s no way it’s going to go to prisoners before it goes to people who haven’t committed any crime,” said Colorado’s Democratic governor, Jared Polis, this week, in contradiction to the state’s plan for how to distribute potential Covid-19 vaccines.

That conflict in Colorado and others like it playing out across America could become more frequent as states look ahead to a daunting Covid-19 vaccination campaign with distribution guidelines laid out by federal advisers. A flurry of federal government activity suggests approval for Covid-19 vaccines could come as soon as next week as complex arguments rage about who could or should get it first.

And nothing short of justice and equity hang in the balance.

“I am concerned about the proximity of the rollout and the lack of clarity on the adequacy of state and local planning,” said Thomas Bollyky, director of the global health program for the Council on Foreign Relations and a law professor.

“We’re spending an awful lot of time thinking at the federal level [about] what those guidelines will be, and I don’t think we’ve spent nearly as much time thinking about how states and localities will faithfully implement them,” said Bollyky.

The federal government’s vaccine, therapeutics and medical supply development initiative, Operation Warp Speed, has spent more than $18bn to get pharmaceutical interventions for Covid-19 to market. But just a fraction of that has been allocated for distribution in the most logistically complex vaccination campaign in American history.

A widely cited study in the American Journal of Preventive Medicine found roughly 75% of US residents would need to develop immunity to “extinguish the epidemic”. That level has never been reached by the annual flu vaccine, which usually around half the population takes. The vaccines are untested in children, which means 70 million Americans under age 16 will not be eligible to receive the vaccine, underscoring the need for high adult uptake.

“I am very concerned about the fact we have only given states and localities $200m to do the largest vaccination campaign in US history, when by the CDC’s own estimates this would require $6bn for states and localities to do it,” said Bollyky. The incoming Biden-Harris administration has proposed allocating $25bn to distribute vaccines.

This tiny allocation for distributing vaccines has left places like Washoe county, Nevada, with just $74,000 to plan to undertake entire vaccine campaign. As a result, the county health officials said they have struggled to compete with companies such as Amazon to hire a logistics expert, and will need to use the same nurses now consumed by testing to – sometimes later the same day – administer vaccines.

In Arkansas, like in many states, the first allotment of a vaccine is not expected to be enough to reach even the highest-priority group, which includes healthcare workers and residents of long-term care homes.

“There just isn’t enough vaccine to go around,” said Dr José Romero, the secretary of health in Arkansas. “Our allotment here in the state will not be enough to vaccinate everybody who needs to be vaccinated,” said Romero.

“Institutions are going to need to decide who in their personnel will receive the vaccine first.” That could mean choosing between the intensive care unit and the emergency department, Romero said.

Some localities in Arkansas are also struggling to recruit credentialed nurses to vaccinate people, because they are in-demand bedside at hospitals coping with Covid-19 surges in the state.

Romero is also chair of the closely watched CDC advisory committee on immunization practices, which issues recommendations on how states should prioritize certain populations. The committee will review for a formal recommendation any vaccine approved by the US Food and Drug Administration on an emergency basis.

Two vaccine candidates lead the race. One, Pfizer and BioNTech, which has an infamously difficult -94F (-70C) ultra-cold storage requirement and was just approved by the United Kingdom. A second is developed by Moderna and the National Institute of Allergy and Infectious Diseases. If independent analyses bear out publicly released data, both would be among the most effective vaccines in medicine.

If both vaccines are approved, federal authorities believe there will be enough doses initially to vaccinate 20 million people. That may still fall short of vaccinating everyone in the highest-priority groups.

There are roughly 20 million healthcare workers in the US, ranging from nurses to home health aides to hospital housekeepers. Another 3 million people live in long-term care facilities, such as nursing homes and assisted living facilities.

Members of the CDC advisory panel said they hoped distributing the vaccine to health workers will stabilize the labor force during a time of enormous demand, and protect a group that has put their lives on the line to treat the ill. They also said they hoped to protect long-term care residents, who are among the most medically vulnerable in society. More than 100,000 long-term care residents have died during the pandemic.

“On the one side, I think we’re going to see a surge upon a surge,” said Romero, referring to what many epidemiologists believe will be a wave of new Covid-19 cases, hospitalizations and deaths this winter, especially in the wake of holiday season travel.

“We need to make sure we have the healthcare personnel to care for individuals who become ill, and we need to protect the most vulnerable,” said Romero. “That’s why the ACIP chose those two groups.”

But beyond this first formal recommendation, ACIP has not made formal recommendations for the second and much larger group of Americans in “phase 1b”. This group includes a much broader category of Americans, including essential workers, adults over 65 and people with high-risk medical conditions.

Collectively, those groups represent more than 100 million people, and include everyone from bus drivers to firefighters to people living with obesity and diabetes. This group was also the source of conflict in Colorado, where inmates were listed as a higher-priority group than people older than 65.

A recent review of state plans by Kaiser Family Foundation found that only 40% of states (19 out of 47) had estimated the number of people who fell into these priority groups.

States may also face snags as a result of federal health officials’ decision to allocate vaccine shipments based on state population, rather than populations of priority groups. Federal officials argue this allows them to use one methodology throughout the campaign.

But critics said the methodology ignores the complexity of the pandemic. Healthcare workers and long-term care residents are not evenly distributed across the country, nor are cases of Covid-19.

“It seems crazy to have devoted the amount of money we did to R&D, to supporting manufacturing, and the logistics, and then not give states and localities either the level of national guidance or resources they need to be put in a position to succeed,” said Bollyky. “I’m sorry to say, it’s largely emblematic of how this pandemic has gone in general in the US.”