Leaves states to grapple.......

Trump administration leaves states to grapple with how to distribute scarce vaccines

The Trump administration has told states that they have ultimate authority for determining who gets vaccinated first.

By SARAH OWERMOHLE, RACHEL ROUBEIN and ZACHARY BRENNAN

The Trump administration is shunting to the states hard decisions about which Americans will get the limited early supplies of coronavirus vaccines — setting up a confusing patchwork of distribution plans that could create unequal access to the life-saving shots.

Federal and state officials agree that the nation’s 21 million health care workers should be first in line. But there is no consensus about how to balance the needs of other high-risk groups, including the 53 million adults aged 65 or older, 87 million essential workers and more than 100 million people with medical conditions that increase their vulnerability to the virus.

The Trump administration has told states that they have ultimate authority for determining who gets vaccinated first. It has also decided to allocate scarce early doses based on states’ total populations, forcing hard choices in states with a greater proportion of residents at high risk — including Black, Indigenous and Latino communities that have suffered disproportionate rates of hospitalization and death from Covid-19.

Public health experts say that could undermine already shaky public confidence in the vaccine effort, whose success depends on convincing large numbers of Americans to get immunized.

“States are going to have to pick and choose who gets the first doses,” said Josh Michaud, an associate director for global health policy at Kaiser Family Foundation who has reviewed nearly every state’s distribution plan. “It’s very obvious that states are in different places when it comes to planning and identifying who those people are.”

Moncef Slaoui, the former GlaxoSmithKline executive who leads Operation Warp Speed, the government’s vaccine accelerator, said there are no easy choices.

"I don’t expect the states to make uniform decisions,” he told POLITICO. “Some may prefer long-term care facilities or the elderly, while others may prioritize their health care workers. It would be wrong to immunize 18-year-olds first. I hope no one does that. But otherwise it’s shades of gray.”

The time to prepare is growing short. Two potential coronavirus vaccines, from Pfizer and Moderna, could be available in December. Two more, from AstraZeneca and Johnson & Johnson, are barreling through final hurdles before Food and Drug Administration review.

The federal government’s vaccine accelerator, Operation Warp Speed, has said that 40 million doses of vaccine could be available next month, assuming that regulators greenlight both the Pfizer and Moderna shots. They are now preparing to send the first 6.4 million doses out as soon as a vaccine is authorized, Gen. Gustave Perna, the head of logistics for Operation Warp Speed, told reporters Tuesday.

The Centers for Disease Control and Prevention normally lays out the guidelines for who should get priority for each vaccine, based on recommendations from a group of experts known as the Advisory Committee on Immunization Practices. The panel had not been scheduled to finalize its recommendations until after the first vaccine was authorized by the FDA. But that changed abruptly over the weekend, with the panel now set to meet Tuesday to hammer out advice for the highest priority groups — health care workers and residents of nursing homes and long-term care facilities.

“Typically there is a window of time after ACIP recommendations and before the vaccine hits the shelf,” said Nancy Messonnier, director of CDC’s National Center for Immunization and Respiratory Diseases, during the panel’s meeting last week. “This time we’re talking about an almost instantaneous rollout.”

States are sketching out the potential scenarios as they wait for information on which vaccine the government will authorize first and how many doses they will ultimately receive.

Oregon, for instance, is creating an advisory committee to help hammer out which groups should get the vaccine after the first shots likely go to health care workers and nursing homes.

“After that, it's a little wider open, and as vaccine starts to trickle or pour in, we're going to have to make decisions about where does it go,” said Paul Cieslak, Oregon’s medical director for communicable diseases and immunizations.

Looming questions include whether the vaccine should be disbursed equitably to each county based on their population or to places in the state with high infection rates. The state is also grappling with how to ensure people who have been disproportionately hit by the coronavirus, such as Latino communities, get the vaccine.

In North Dakota, officials had been running through different options of how they could prioritize doses, based on which vaccines could be available first, and what the state’s initial allocation of shots might be.

“Seeing that these vaccines do work in the elderly population, we’re also having discussions about moving long-term care residents up on the priority list, right with health care workers,” Molly Howell, North Dakota’s immunization program manager, said this month.

Arthur Reingold, an epidemiologist at the University of California at Berkeley who’s leading the California vaccine safety panel, said that states will have to be nimble and reassess where to ship doses based on how many people decline vaccination.

The federal government had originally told Illinois officials that the state should plan to receive an initial shipment of about 400,000 doses once the FDA authorized a shot. But in the last few days, federal officials slashed that figure to about 80,000 doses, Ngozi Ezike, the director of the Illinois Department of Public Health, said at a press briefing Tuesday.

“We are staying very nimble to be able to adjust as the feds give us more information,” she said.

Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security, said that the federal government is giving states the autonomy they need to allocate vaccine in ways that meet their residents' needs.

“Every state needs to have some flexibility within the general guidelines to decide the order in which they vaccinate certain people,” said Toner, who led a framework for vaccine allocation and distribution created by the Johns Hopkins Bloomberg School of Public Health.

“During this whole pandemic, every state has done things a little bit differently, and to some extent, that’s okay,” Toner said.

But that autonomy translates into an uneven rollout among states, that could shake the public's already fragile confidence in the government's coronavirus response and possibly even in the vaccines themselves, Michaud said. Production delays caused a chaotic rollout of a vaccine for the 2009 swine flu outbreak, and that “certainly led to a loss of confidence in the government's ability to distribute the vaccine in 2009,” he added.

The state demand for coronavirus vaccines, amid a pandemic that has killed more than 260,000 people in the U.S. so far, already eclipses that seen in 2009 for the flu vaccine. That raises the stakes for success — or failure.

“This is all going to be very messy," Michaud said. "There’s no question that plans on paper are one thing, but putting it into practice and getting vaccines into the arms of people is a whole different ballgame. It’s going to be a Herculean task.”