States struggle to draft COVID-19 vaccine plans while in the dark on details, funding

WASHINGTON — Across the hundreds of pages of plans that state officials sent to the Centers for Disease Control and Prevention on distributing and tracking the yet-to-be-approved COVID-19 vaccines, there are more questions so far than answers on how exactly vaccine programs will be carried out.

Yet states will be on the front lines for a far-reaching vaccination initiative expected to cost in the billions, as the nation registers more than 8.3 million COVID-19 cases and 221,000 deaths. The federal government still has not done its part either, with additional vaccine funding stalled as Congress and the White House extend months-long talks over a new relief deal.

A review by States Newsroom of a dozen state plans found, for example:

• Virginia officials outlined millions of dollars in anticipated costs, but they don’t yet have the money to pay for them.
• Those in Arizona flagged that small rural clinics will need smaller allotments of the temperature-sensitive medications than the 1,000-dose increments expected in one scenario — a situation that seems likely to play out across states. 
• Colorado leaders cautioned that their phased plan for prioritizing who gets the vaccine doesn’t yet address children and pregnant women, because they haven’t been included in vaccine trials. 

And how exactly will states ensure that their residents return for the second dose of what’s expected to be a two-part vaccine? Officials in Ohio and other states say they’re working on it, through a combination of PR campaigns, postcards, text messages and help from the providers that will be administering those shots.

States are emphasizing that the initial documents they filed last week are just that: Drafts that will be updated repeatedly as it becomes clearer which vaccine is likely to make it through the approval process first and as the CDC releases more guidance on who should be prioritized for the initial doses. 

Some, including Pennsylvania and Minnesota, have so far declined to publicly share their draft plans, citing the need for further revisions and feedback from the CDC.

“It is important to understand that this plan will be continuously enhanced and adjusted to the various needs during each vaccine distribution phase,” said Maggi Mumma, a spokeswoman for Pennsylvania’s Department of Health. “It is better to look at this as a framework.”

CDC deadline 

The initial state plans for the massive logistical undertaking were due to the CDC on a fast timeline, only a month after the administration released its initial COVID-19 vaccination playbook. As those plans were being filed, the National Governors Association sent a long list of questions to the Trump administration, seeking more details on what states can expect when it comes to vaccine distribution, tracking and additional money to pay for those efforts.

“We need to answer these questions before the vaccine is available so that we are ready to go and no one is caught flat-footed when the time comes to vaccinate people,” New York Gov. Andrew Cuomo said in a public statement accompanying those questions.

CDC officials did not respond to requests seeking copies of the state plans. The dozen drafts that States Newsroom obtained from state governments followed the federal template, detailing when they began working on their vaccine plans, who is involved, and how they’re beginning to enroll providers that will administer the vaccine.

Vaccination experts say there’s some logistical precedents for states to follow from past public health crises, including the H1N1 outbreak in 2009, when it comes to initial planning steps. 

But the coronavirus pandemic and the vaccines currently in the trial phase also have a slew of unique challenges, including strict storage requirements that may involve keeping each vaccine dose at ultra-cold temperatures of -60 to -80 degrees Celsius. 

The storage question is a particularly thorny one, with state officials lacking details so far on how many doses they can expect, the allotment in each shipment, how quickly those doses will need to be used, and the allocation amounts to an unknown number of providers.

Faced with the daunting problem of finding enough dry ice or cold-storage facilities to store the vaccine, some states are planning to ship vaccines directly to facilities where they can be used within the days-long time frame before doses expire, said Claire Hannan, executive director of the Association of Immunization Managers. 

That approach has its own hurdles, she added, such as ensuring each location can schedule vaccine clinics that will use the doses fast enough but also do so while following social-distancing and other precautions.

“That’s a real challenge for rural areas,” Hannan said, adding that North Dakota has said it plans to repackage doses into smaller allotments, an approach that requires close tracking to ensure that the cold temperatures are maintained.

Rural areas also may face technological challenges: Arizona’s draft plan mentions that the National Guard is preparing to help with internet connectivity issues in rural communities that will need reliable internet access in order to do real-time reporting on how many vaccines are being administered.

Who gets the vaccine first?

The CDC’s Advisory Committee on Immunization Practices will issue guidance to states on which residents should get priority for what’s expected to be a limited initial batch of doses, but that panel won’t finalize its criteria until a vaccine is approved. 

In the meantime, the National Academies of Sciences, Engineering, and Medicine has outlined four phases, with high-risk health care workers and first responders in the first phase, along with those who have high-risk underlying conditions and older adults living in long-term care facilities. 

The second phase covers other older adults; those living in congregate settings like jails or homeless shelters; and critical workers in high-risk settings. The third phase includes children, young adults and workers in certain other industries; and the fourth phase would cover anyone else. 

Many states cited those proposed phases, with some tweaking the categories to reflect regional needs. 

Colorado’s draft mentions agricultural and ski-industry workers among those to be targeted in the congregate-housing category. New York’s proposal includes five phases, and a matrix to prioritize both groups of people and areas of the state where there is a higher prevalence of COVID-19 cases. 

Billions needed

Few of the state plans include estimates on how much the vaccine efforts will cost. 

Virginia’s plan does identify a range of projected costs, including $71 million to local health districts running vaccination clinics; $40 million for administering payments to health care providers and managing claims from the uninsured; $3 million for public education efforts; and $3.4 million for supplies like syringes, needles, and bandages.

CDC director Robert Redfield told Congress recently that states may need $6 billion; the Association of State and Territorial Health Organizations and the Association of Immunization Managers sent a letter to federal lawmakers requesting $8.4 billion.

The CARES Act, the massive coronavirus relief bill approved last spring, provided just a fraction of that figure, allocating $200 million for state vaccine efforts. 

Negotiations on additional coronavirus relief funds have stalled in Congress, with a wide gap between the $500 billion proposal from Senate Republicans that failed to advance on Wednesday and the $2 trillion plan that House Speaker Nancy Pelosi has been negotiating with Treasury Secretary Steve Mnuchin. 

Without agreement on Capitol Hill, states won’t see additional money flowing as they attempt to prepare for a vaccine that could be approved as soon as next month.

“The idea that they’re not going to get additional funding, I mean, it’s just crazy,” Hannan said. “These plans would just be a wishlist if they don’t get additional funding.”