By Nina Pullano | Courthouse News

(CN) — The decentralized rollout of the Covid-19 vaccine in the United States is moving slower than anticipated, but a massive boost in funding this week — and a new plan from President-elect Joe Biden — could alleviate some of states’ most pressing concerns about distribution. 

On Friday, Biden said he will reverse the Trump administration’s distribution approach for second doses of vaccine. The move followed a letter from six state governors asking for the change. 

Both of the coronavirus vaccines allowed in the U.S. require two doses to achieve full efficacy, with the second shot administered three or four weeks after the first one. The federal government has so far reserved half of its total supply of vaccine to ensure that the booster shot is available to those who already received an injection.  

Given the current low supply, however, medical experts modeling vaccine distribution have said it’s most effective right now to get the first dose to as many people as possible.

“You can roll out vaccine doses a lot faster if you’re not saving that second dose,” said Charles Stoecker, associate professor at Tulane University’s Department of Health Policy and Management. 

Biden’s new plan lines up with the approach in the United Kingdom, now in its third lockdown after a variant of the novel coronavirus caused a spike in infections. 

The president-elect “believes we must accelerate distribution of the vaccine while continuing to ensure the Americans who need it most get it as soon as possible,” T.J. Ducklo, a spokesman for Biden, told CNN. “He supports releasing available doses immediately, and believes the government should stop holding back vaccine supply so we can get more shots in Americans’ arms now.” 

Biden’s team said he will give more details after he takes office. 

Friday’s announcement came after a letter from the governors of Michigan, California, Kansas, Illinois, Minnesota, New York, Washington and Wisconsin, saying the Trump administration has been withholding doses “for reasons unknown.” 

“While some of these life-saving vaccines are sitting in Pfizer freezers, our nation is losing 2,661 Americans each day,” the state leaders wrote. “The failure to distribute these doses to states who request them is unconscionable and unacceptable. We demand that the federal government begin distributing these reserved doses to states immediately.”

Stoecker noted that the decision not to reserve doses requires “making a leap of faith,” as state must then obtain more doses in a three-week period to vaccinate people who have already received their first shot. 

“It’s not clear exactly what the problem is of missing that three-week window is,” he said, “but that was what was in the trial, so we want to stick to that if possible.” 

Funding, in addition to vaccine supply, has been a worry across state governments that, unlike the federal government, lack the option for deficit spending.  

That could change soon: An additional $22 billion will head to states and territories in the new few weeks, part of the bipartisan coronavirus relief package signed in December. 

States had previously received a total of $340 million for vaccine planning. 

The U.S. Department of Health and Human Services aims to make the money available by Jan. 19, the agency announced Wednesday — the same day the country saw its deadliest day of the coronavirus pandemic, reporting 3,964 deaths. The record was again topped on Thursday. 

The pandemic has killed more than 360,000 Americans. 

With vaccine distribution underway — however chaotically — this week’s events signal the next phase of the ongoing pandemic. Here’s what we know so far. 

Timeline for vaccine rollout 

Operation Warp Speed, the U.S. effort to develop vaccine options for Covid-19 at an unprecedented pace, reached two key developments in mid-December when the FDA permitted use of the Pfizer and Moderna vaccines. 

Though the vaccines are not formally approved, states have been administering both versions under the emergency use authorization. 

Estimates of how quickly the vaccine will make its way through the population have shifted significantly over the past few weeks. Despite Vice President Mike Pence’s Dec. 21 claim that the U.S. was “on track” to vaccinate 20 million Americans by the end of 2020, only 5.3 million Americans had received a vaccine by Jan. 6. 

Dr. Anthony Fauci offered a more conservative estimate this week, saying we could soon vaccinate 1 million Americans per day, fulfilling Biden’s goal of giving out 100 million vaccinations in his first 100 days. 
That is “a very realistic, important, achievable goal,” said Fauci, the country’s top infectious disease expert. 

Lagging links in the supply chain 

Distribution of Covid-19 vaccines is up to each state, but they must request doses each week from the federal government. States learn what’s available each Tuesday, and order shipments on Thursday to be delivered the following Monday. 

It’s up to state governments precisely where vaccine shipments are sent, but once the vaccine arrives in a state, it has to be dispatched to hospitals, pharmacies or community centers for distribution. 

States report the numbers of people who have received a vaccine to the Centers for Disease Control & Prevention. 

At every step along the way, there is a natural lag, given the time between allocating and ordering doses; between ordering and delivery; and between administering vaccine and reporting it to the CDC database. 

Health department officials in Minnesota said that, despite these delays, the gears are turning. 

“Vaccine is not sitting anywhere in Minnesota,” Kris Ehresmann, director of the state health department’s infectious disease division, said during a press call Thursday. “It’s constantly moving, and it takes time for the whole process to happen.” 

Several state government officials have attributed the primary holdup for distribution to the low supply of vaccine being made available.

New York Governor Andrew Cuomo said the state does not have enough doses for even half its health care workers. 

“The supply is our issue,” Cuomo said during a press call Thursday. “It’s not going to be a distribution problem.” 

Logistics like vaccine storage pose more potential disruptions.  

The Pfizer vaccine candidate needs to be frozen at -70 degrees Celsius. It has to be packed and shipped with dry ice (the surface temperature of which, for comparison’s sake, is -78.5 C), carefully handled, and timely transferred between carrying cases and deep freezers. 

Moderna’s product is less vulnerable, needing to be kept at -20 degrees C, similar to a typical freezer. 

To get around storage issues, state distributors are moving quickly, keeping doses in their traveling containers to avoid too much disruption. If vaccine doses are in danger of expiring, they can be redistributed to a site with bigger demand. 

More vaccine options may be on the way. The Oxford-AstraZeneca vaccine candidate is being used in the United Kingdom and in Mexico. It’s cheaper than other options, and stored in normal refrigerators, making it easier to administer it at clinics outside of hospitals and to deliver to rural areas.  

Johnson & Johnson is also working on a Covid-19 vaccine, initially designed to be administered in one dose. In November, the company also began trials for a two-dose version. 

Finally, health department officials in states like Georgia and Washington have said they don’t have enough staff to maximize efforts, which could pose bigger problems as vaccine distribution scales up. 

Asked about potential staff shortages at nursing homes in Minnesota, officials said they weren’t aware of staffing issues, and noted that partner pharmacies had signed contracts declaring they have the capacity to meet state goals. 

Phases and politics of vaccine distribution 

Though vaccine supply issues understandably frustrate state governments, having a temporary shortage was part of the plan. 

In September, the Centers for Disease Control and Prevention handed states its 57-page interim playbook for rolling out the vaccine, which identifies three phases of distribution. Phase 1 indeed anticipates a limited supply of vaccine, leading up to phase 2, when it will be available to the general public. 

Broadly, phase 1 focuses on critical groups: health care centers, education agencies and providers, detention facilities, tribal leaders and organizations serving minorities communities, among other groups. 
But we’re not quite there yet. Phase 1 is subdivided into benchmarks 1a, 1b and 1c, and most states are somewhere between 1a and 1b. 

The very first to get the vaccine are health care personnel and residents of long-term care facilities, about 24 million people, according to the CDC guidelines

States like Colorado have begun to move into phase 1b. Maine expects to make the shift later this month.  

The CDC guidelines, however, are just that. They are “not mandates,” as U.S. Surgeon General Jerome M. Adams tweeted Thursday. 

States have devised their own rollout plans, which will vary more widely during phase 1b, which opens up the vaccine to 49 million people, per the CDC. 

Those eligible in phase 1b include non-health care frontline workers, a class that would include police officers, firefighters, grocery store workers, teachers and public transit workers. 

As more states reach that point, their policies and practices could highlight deep political divides. Whether to vaccinate incarcerated people and law enforcement officers have been contentious issues in several states. 

Massachusetts included detainees at the front of the line for phase 1b, while Colorado put the group as the very last to receive the vaccine.

“There’s no way it’s going to go to prisoners before it goes to people who haven’t committed any crime,” Colorado Governor Jared Polis said last month. “That’s obvious.”

Currently, the CDC’s phase 1b guidance includes corrections officers but not detainees. The federal Bureau of Prisons plans to save its early-phase vaccinations for staff only

Groups of medical experts, including the American Medical Association, have tried to lobby the CDC to change that, and to prioritize vaccinations for people in prisons. 

Covid-19 case rates are four times higher and 30% more deadly in prisons, a September 2020 report found. According to data from The Marshall Project, at least 329,000 detainees have tested positive for the novel coronavirus, and at least 2,000 have died. 

The president-elect has repeatedly said his Covid-19 plan will “follow the science.” Friday’s announcement on second-dose distribution so far supports that pledge. Whether that will extend to medical experts’ advice regarding prison populations remains to be seen.