First Mile of the Vaccination Marathon
General Perna, the military official running Operation Warp Speed, said yesterday that the “last mile” of vaccinating the American public against COVID is going slower than expected.
We are not on the last mile of the race to vaccinate the public. We just passed the first mile marker by developing and approving a vaccine. Our vaccination marathon has 25 more long miles ahead to produce, deliver, prioritize, administer, and track the process of giving two shots to 80% of our citizens.
The first mile, vaccine development, although not easy, was actually fairly straightforward. A small group of companies and dedicated scientists were given near unlimited resources and a clear, singular objective. The government removed any regulatory hurdles and fast tracked the process. Unfortunately, a quick sprint from the starting line doesn’t make the distance any shorter. There aren’t trophies and champagne bottles at the first water station.
As we begin the next 25 miles, states face formidable obstacles that the companies who developed the vaccines didn’t have to contend with. Each state has been given the responsibility of administering the vaccine with little federal funding or resources to accomplish the largest and most urgent vaccination effort in human history.
Unlike the federal government, states cannot run budget deficits or enter into unfunded contracts. If a state needs to lease a large building to use as a public vaccination location, that can’t happen until that money is added into the state’s budget for the next year. If a state needs to hire 1,000 nurses to staff vaccination sites, those employees can’t be hired until funding is put into the state budget for it. COVID has already wrecked state budgets with lower tax revenue and strained public safety and health costs. There isn’t extra money in state budgets to fund the delivery of tens of millions of vaccine doses.
There is also no national playbook or plan for how the vaccine should be administered. Each state has been forced to figure out its own system for logistics, prioritization, and tracking without any additional staffing, resources, or funding. As a point of comparison, when a tropical storm causes coastal flooding and power outages, FEMA sends hundreds of federal employees with a roughly $100 million ‘major disaster declaration’ budget to manage a pretty simple delivery of bottled water and generators.
Mile 2: Production
The newly developed vaccines are only useful if hundreds of millions of doses can be rapidly produced. It remains unclear how many doses of vaccines are being produced and when batches will be available. As Moderna’s CEO noted, “no one has a factory sitting idle able to make 1 or 2 billion doses a year.” Beyond Pfizer and Moderna, other vaccines in development or pending approval. It’s unknown when or how many of these vaccines will be available.
Production is far from over - it has barely begun.
Mile 3: Planning
Planning becomes exceptionally challenging without a clear picture of production. Each state is left guessing how many doses will be delivered next week or next month. When these numbers are guesses, concrete plans cannot be made. A state can’t schedule 50,000 people to go to vaccination sites next week if only 10,000 doses of the vaccine show up.
Differences in the storage, handling, and dosing of different company’s vaccines also complicate the process. If it’s three weeks between doses for one vaccine and four weeks for the other, completely different schedules need to be developed. Communications need to be separated so that the people who got vaccine A in the first round aren’t accidently told to get vaccine B in the second round. Staff administering vaccines need special training because some vials get mixed and shaken, while others cannot be mixed or shaken.
Mile 4: National Distribution
If the federal government truly wants to take a hands off approach, once millions of doses of vaccines start rolling out the factories, they need to be divided into separate batches for all 50 states. If all prioritization and allocation decisions took place centrally at the federal level, distribution could lead directly to state level action. If decisions aren’t made centrally, the entire distribution process stalls with indecision at the end of the supply chain.
Mile 5: Local Delivery and Storage
Boxes of vaccine that arrive in each state need to be stored in facilities with specific refrigeration capabilities. When it’s time to give the vaccine, doses need to be transported from storage facilities to administration sites. Such a transfer seems fairly simple, but still involves trucks to move boxes and people to drive trucks. Both drivers and trucks cost money and state governments don’t have random employees in the state budget waiting to transport around vaccine pallets every day for the next 1–10 years.
Mile 6: Vaccination Sites and Staffing
The truck and delivery driver is the cheapest part of the process compared to the public site where people will go to get the vaccine. A dozen nurses and support staff can give about 1,000 vaccines a day — if the process is run with maximum efficiency. Such efficiency means that everyone is lined up with all paperwork completed, medical screening done, and they sit down to get the shot the as soon as the person ahead of them is done. Recipients need to be monitored afterwards in case of allergic reaction. Someone needs to enter the information about their vaccination in the database. Someone else needs to direct traffic and someone else needs to tell people where to line up. A police officer should be there in case anyone cuts the line or too many people show up. Such an endeavor ends up being a 70 person operation that costs about $30,000 a day just for labor to vaccine 1,000 people. That adds up to $9 BILLION dollars to vaccinate 80% of the population — again, assuming peak efficiency at each site. This figure isn’t counting the leasing cost of facilities or equipment (tables, chairs, tents, signs, generators, computers, heaters, refrigerators, lights…)
Mile 7: Prioritization
I’ll keep this one short because I wrote an article all about prioritization in November. There is still no system for prioritization. The guidance from the CDC includes the majority of the entire US population in Phase 1 because basically everyone who is employed can claim to be an essential worker, 40% of the country has high-risk health factors, and people are over 65 are all high priority based on increased mortality. When everyone is a priority, nobody is a priority.
There is total gridlock at the state level because nobody has a clear method for how to decide who gets the vaccine.
Mile 8: Communication to Public
Until there’s a clear method for prioritization, there isn’t a way to tell the public who’s getting the vaccine, when they’ll get it, and where to go. This is further complicated by the lack of information about how many doses will be produced and delivered. Even rough estimates as to when broad groups will get the vaccine are total guesses. Communications need to be targeted to individuals because notifying large groups of people will result in more people showing up at a vaccine site than the number of doses available.
Mile 9: Administering Shots
Without prioritizing who gets shots and a reliable communication system, nobody knows when to get their shots. To administer vaccines efficiently, everyone needs to have a risk score and based on the number of doses available, people are notified when and where to go. If there are 1,000 doses, everyone who is 99/100 in the system can be notified to go. If there are 10,000 doses, everyone who is between 96–99 can be notified. The exact people who are notified need to be the only people who show up at the vaccination site or total chaos ensues.
Mile 10: Tracking
Vaccination isn’t over when someone gets the first shot. The staff at vaccination site need to record the vaccine brand, date, and batch number. If documentation happens on paper, someone else needs to enter information from the papers into a database (another unfunded labor cost). All of this data will go into state, national, and potentially international vaccine tracking systems including a “vaccine passport” app. If data doesn’t get entered correctly, someone who got vaccinated might get denied entry at an international airport in the middle of a trip. The data entry process needs QA/QC staff (another unfunded labor cost).
Mile 11: Second Dose
3 or 4 weeks after getting the first dose, someone needs to be alerted and scheduled for the second dose. This notification becomes complicated because it needs to be matched up with the correct brand on the correct day. Vaccines need to be thawed ahead of time in batches and unused vaccines need to be trashed. If 1,000 people are scheduled for dose 2 on Wednesday and only 950 show up, 50 doses go in the trash. If those 50 people who missed Wednesday show up Thursday, there are 50 more people than the vaccines planned for that day. There also needs to be a careful screening process to make sure the right person is getting the right vaccination on the right timeline. It’s entirely possible that 3 or 4 different brands of vaccinations could be administered at the same location depending on the number of available doses and who needs 2nd doses.
Mile 12: Reporting and Identifying Side Effects
Beyond making sure that people get the right dose at the right time, there also needs to be a system for reporting and tracking side effects. If someone goes to a public vaccination site that is open from 9–5 in the parking lot of a government building for 2 weeks, what happens when they have side effects 3 weeks later? How do they report the side effect? Who do they tell? How does that person record and report it so that it gets into state and national monitoring systems?
Mile 13: Reaching Vulnerable Populations
Everything up to this point assumes that citizens can read, access information, and get themselves to a location to be vaccinated. How do homeless, low income, disabled, and non-english speaking populations get vaccinated? If teams of providers will go out into communities to register and drive people to vaccination sites, this is another unfunded labor cost. If special vaccination clinics are set up in these communities, they will be at a higher cost than larger centralized locations. Many of these communities have a baseline level of mistrust for both the government and vaccinations, but we don’t get to 80% without them.
Mile 14: Reaching Anti-Vaxxers
There are people who have said they won’t get this or any vaccine. To get to 80%, additional effort and outreach will need to go into these communities. Some have suggested paying people to get vaccinated. Other experts have suggested careful public health outreach and education using social media and other tools. Who will cover that cost? Each state?
Mile 15: Children under 16
None of the current vaccines are approved for children under 16. If safety is unproven in children, will teens be notified on their 16th birthday to get the vaccine? Where will they go to get it? Severe COVID cases are rare but not impossible in children. How will social distancing and other precautions be maintained as adults are vaccinated?
Mile 16: Measuring Efficacy
With multiple different vaccines being administered, tracking effectiveness is critical. The date, time, brand, and batch will need to be compared with future COVID cases to identify which one is most effective. If people have different levels of immunity, will there be different guidance given on how to interact in public based on vaccine type? If one vaccine ends up being less effective than another once a critical mass are vaccinated and studied, will high risk people go back to the front of the line for getting a second course of the superior vaccine?
Mile 17: Ongoing Disease Surveillance
New COVID cases also need to be tracked based on vaccinations to identify drug resistance or mutations of the virus. Public health surveillance efforts will also need to determine if areas with low vaccination rates are leading to community spread elsewhere. Nobody wants to entertain the nightmarish idea, but we very well could have a COVID-21 that this vaccine does not target.
Mile 18: 2nd and 3rd World Countries
To be a global leader, the US can’t just think about its own population. The United States will also need to shift vaccine doses and resources to administer them to developing nations. Should this process start before the entire US population is vaccinated?
Mile 19–26: Everything We Haven’t Expected
As we approach the final quarter of this marathon, we need to understand that things will happen that we haven’t planned for. There may be delayed side effects from the vaccines. There could be major production problems that halt the delivery of new doses. Website and databases might crash or be hacked, preventing vaccination records from making it into international travel passports. People may sabotage the vaccines (as happened with a healthcare provider deliberately leaving doses out of a refrigerator). There could be protests or civil unrest at public vaccine sites by people who are lower on the priority list.
Things could get ugly.
Water Stations at Every Mile: Funding
Each one of these miles requires money. States don’t have it and the federal government needs to take responsibility. Thousands of nurses giving millions of shots costs millions of dollars. Tech solutions, like an application for scoring prioritization and notifying people where to get their vaccination, need to be developed. When this process is going to take a long time, the parking lot of the elementary school or community center can’t be used for years at no cost. Facilities designated as public vaccination sites may need to function for at least a year, maybe longer. Such facilities will require leases and agreements. Equipment needed to make sites functional needs to be purchased. These expenses will cost millions.
The only way we get through this race is having federal money allocated for every mile of it.
Crossing the Finish Line
Every part of this process NEEDS to be done for everyone to get vaccinated. Vaccinating everyone is not an insurmountable challenge. The first step is realizing that we aren’t on the last mile. We aren’t almost there. The hardest, most complex, and most labor intensive work is still ahead of us. The federal government needs to take the lead in making decisions and funding operations so that states can focus on taking action.
If we accept that we’ve only run the first mile, we can salvage this operation. Swift actions can allow a successful execution of the largest public health operation in history in one year instead of ten. The future of our nation depends on this undertaking and the consequences of failure are too dire to accept.
David Riedman is Ph.D. student in Sociology at the University of Hawai’i and an expert in critical infrastructure protection, homeland security policy, and emergency management. He was a volunteer firefighter for 18 years and is a co-founder of the Center for Homeland Defense and Security’s Advanced Thinking and Experimentation (HSx) Program at the Naval Postgraduate School.
