On Jan 14, Joe Biden announced an ambitious $20 billion “national vaccine program” that envisions community vaccination centers around the country to protect Americans against COVID-19. These include everything from primary care and mobile van outreach, to mass vaccination sites located in high school gymnasiums, sports stadiums, and the like. While these are all critical strategic initiatives, their execution will be complex and potentially exacerbate structural inequities.
Constructing supply chains for equitable distribution of scarce personal protective equipment has presented numerous challenges. We fear similar barriers to vaccine distribution. Three key areas — all of which have been blockers to PPE distribution — need attention to ensure the Biden administration’s efficient and fair distribution of scarce vaccines.
First, there needs to be better data collection and visibility. Supply-demand mismatches are already jeopardizing the vaccination rollout — just as they have impaired access to PPE. Several hospitals have received more doses than needed for essential health care workers, while others continue to lack enough supplies to get their workforce protected. Federal and state governments are often uncoordinated on proper allocation of doses. The sequence of the handover of vaccines from manufacturers to federal and state agencies and finally to the last-mile private organizations that are responsible for administration has also been plagued with challenges, such as inadequate monitoring of vaccine storage temperatures, lack of coordination between the arrival of vaccines and arrival of supplies, and inexplicable last-minute delays in the release of promised ones .Finally, keeping accurate records of who has received the first shot and ensuring compliance to the second shot within a reasonable period of time continues to be difficult given the lack of interoperability between electronic health record systems in the United States.
As we found for PPE, it is essential to consider the needs of not only large hospitals and powerful workplaces but also the “little guy”: Rural and safety net hospitals, outpatient clinics, and independent long-term care facilities. A centralized effort to collect accurate data on who has vaccines, who needs vaccines, and who is administering vaccines — and make it visible to all stakeholders in a transparent way — is needed.
Second, there need to be high-quality allocation algorithms. At Get Us PPE, a nonprofit we founded to deliver donated PPE to front-line workers and under-resourced communities, we have had to integrate several considerations into distribution of scarce PPE: Do we prioritize efficiency of distribution (e.g., geographic proximity), impact (e.g., sending it where there is the highest burden of COVID patients), or structural barriers (e.g., providing to safety-net facilities)? How do we weigh seemingly equivalent factors when there isn’t enough PPE? The same considerations apply to vaccines. If a recipient location such as a hospital has more vaccines than needed for essential workers, should it use these vaccines on administrators working from home, give them to doctors in non-affiliated clinics, or offer them to the highest-risk members of the community? The answer may depend on a variety of demographic and geospatial factors, as well as local regulations and liability concerns.
From our perspective, the key is to provide states and vaccination systems with the right tools to make an informed and defensible decision. While vaccines remain scarce and priority algorithms have to be used, it is essential to make these algorithms battle-ready. A clear, mutually agreed-upon definition of “fairness” in allocation should be used. Transparency in the inputs, outputs, and testing mechanisms should be provided. Involving all stakeholders in measuring priorities and testing proposed algorithms using simulation is critical to the success of this endeavor. Equity and efficiency can be complementary if properly executed within the right framework.
Third, there must be creative solutions to last-mile logistics. Just as during the early days of the PPE crisis, when it was nearly impossible to get a plane out of China, similarly the last-mile trucking network (such as FedEx and UPS) is already groaning. Meanwhile, widespread shortages of health care workers have been reported, and the network density provided by private pharmacies such as CVS and Walgreens is probably inadequate for the country’s vaccination needs. Moreover, mRNA vaccines require deep freezing in both storage and transport. Combine this with a health care delivery architecture that is predominantly private and decentralized, and we have a recipe for disaster.
The Biden administration’s focus on alternative vaccination sites and development of a pool of workers capable of administering vaccines is certainly a step in the right direction to alleviating this barrier. However, that alone is insufficient. Given the unique nature and continued scarcity of these vaccines, they must constantly be on the move. The low ratio of administered-to-distributed vaccines implies that a lot of the stock is sitting in intermediate points, probably due to inadequate cold-chain transportation capacity. And any deployment of last-mile logistics has to be flexible. It has to take into account the shifting nature of the coronavirus pandemic as measured by various dynamic metrics such as infection, hospitalization, and fatality rates.
The distribution of COVID-19 vaccines is the largest undertaking of its kind since the eradication of smallpox in the 1970s. It could succeed — or it could hit the same failures as the PPE distribution debacles. The public health infrastructure’s ability to conquer distribution barriers is crucial to the program’s eventual success. The Biden administration can address this challenge by moving into the tactical execution phase with both expediency and equity.
Ram Bala is an associate professor of supply chain management and analytics at Santa Clara University ; co-founder of Project Stanley; and board member of Get Us PPE. Dr. Shuhan He is an emergency medicine physician at Massachusetts General Hospital, instructor of medicine at Harvard Medical School and co-founder and executive board member of Get Us PPE. Dr. Megan L. Ranney is an emergency physician, director of the Brown-Lifespan Center for Digital Health, and cofounder and executive board member of Get Us PPE.