In the US, 50 States Could Mean 50 Vaccine Rollout Strategies

Sometime in the next months—before the end of the year, according to optimists, or more likely early in 2021—the United States will have a vaccine for Covid-19. We don’t know which formula will be first to the finish line. We don’t know if that vaccine will be released under an emergency use authorization or a standard new-drug approval. We don’t even know how many doses will be available. But one thing is certain: The task of getting the shot into arms falls to state governments and health departments. And because each state is different—in geography, density, income, and in the trust its residents do (or don’t) have in their leaders—each state is going to have to devise its own plan.

Our attempt to control the coronavirus, in other words, isn’t going to be one war. It’s going to be at least 50 separate battles—maybe 56, if you count Washington, DC, Puerto Rico, and the other US territories—fought on different terrain and different timelines, with variable supply lines and no clarity yet about who is going to pay for all the personnel.

It could be messy.

State and local health departments, and the organizations that advocate for them, are trying to be cheerful about the task, but officials are clearly worried. “This is unlike any other effort we’ve had to make in 100 years or so—maybe ever,” says Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. “The closest we have ever come was the H1N1 flu, and in terms of vaccination, that was not the magnitude of Covid-19. So it’s a wholly new planning process. And it’s really difficult to plan when you don’t have all the information you need.”

The planning process has already started. The Centers for Disease Control and Prevention released a 57-page “interim playbook” in mid-September that lays out, in detail, what the states should be doing now: creating committees, identifying vaccination sites, working out ordering and storage, creating systems to track who receives the shots, and building the workforce to handle all those tasks. The work specified in the playbook is not optional; the states have to perform it in order to show the feds they are prepared to receive the vaccine once it is approved.

And it’s a process that’s moving fast. The states’ first communication back to the CDC—the first version of their complete plan for recruiting vaccinators, receiving the vaccine, and motivating their citizens to take it—is due today, October 16, exactly one month after the playbook was published. Yet the states must submit those plans without access to crucial information: not just when the vaccine will arrive, but how many doses they will receive in the first round, how much will follow subsequently, and when those subsequent releases will begin.

“States don’t know how much of the first supply they will be allocated,” says Marcus Plescia, a physician who is chief medical officer at the Association of State and Territorial Health Officers, and who led a call with state health department leaders last week. “Because that hasn’t been determined, they don’t know how to prioritize distribution.”

Two realities, not well publicized so far, underlie this decisionmaking. The first is that once a vaccine is approved, it is likely to arrive not all at once, but in tranches; a state’s initial allotment might be only a few thousand doses. The second is that any of the formulas are almost certain to require two shots, spaced 21 to 28 days apart, to be effective. So however many doses arrive in that first delivery, they probably can be used to protect only half that many people—which means the number of people allowed to come to the front of the line in any state might be pretty small.

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