“Getting shots into arms”: How US states are addressing the vaccine distribution challenge

In the United States, more than 456,000 people have died from COVID-19. While the COVID-19 vaccines offer promise, the early weeks of the vaccine rollout fell over the US holiday season and reflected several challenges for patients, providers, states, and other healthcare stakeholders.¹Rebecca Spalding and Carl O’Donnell, “U.S. vaccinations in 2020 fall far short of target of 20 million people,” Reuters, December 31, 2020, reuters.com.²Danielle Ivory et al., “See how the vaccine rollout is going in your state,” New York Times, January 15, 2021, nytimes.com.³Selena Simmons-Duffin and Pien Huang, “Here's How the U.S. can jump-start its sluggish COVID-19 vaccine rollout,” NPR, January 8, 2021, npr.org.

As we noted in “The risks and challenges of the global COVID-19 vaccine rollout,” global risks for the vaccine rollout reflect production scaling and manufacturing concerns, along with increased labor and IT challenges. Raw material constraints, as well as production scaling and manufacturing issues, led to limited supply at the jurisdiction level. Logistics, labor requirements, wastages at point of care, and IT challenges all influence jurisdictional ability to administer these vaccines to the public.

As we look across countries and populations, four phases may exist in COVID-19 vaccine deployment:

1. Lack of vaccine supply, because of a delay in the approval process or the wait for initial delivery
2. Planning, logistics, and systems
3. Ongoing supply constraints to meet throughput
4. Demand constraints

Despite meaningful progress in administration of the vaccine from the end of December through January, the number of doses administered in the United States still lags the number of doses delivered, although reporting delays may be a contributing factor (Exhibit 1). The challenge is stark: Over the roughly 50 days since mid-December, almost 60 million doses have been distributed while around 42 million have been administered. The United States is currently experiencing a combination of the B and C phases above: Overall, planning, logistics, systems constraints are limiting vaccination progress while some communities, providers, and jurisdictions are supply constrained.

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When the system-level throughput capacity exceeds daily supply, the United States may shift into either a fully supply- or demand-constrained environment, instead of a planning, logistics, and systems-constrained one. As states proceed with vaccine implementation, they are left to manage vaccine deployment while facing meaningful barriers.

In a review of rollout progress across diverse US states, five lessons emerged that, if addressed, might allow states to better execute COVID-19 vaccine deployment:

1. Define the state’s role in vaccine deployment as it relates to local stakeholders and clearly establish supporting governance and a decision-making structure.
2. Establish and maintain a statewide view of vaccine throughput and consumer demand across the delivery network.
3. Promote access to vaccinations by matching consumers to administration sites and enabling smooth registration, scheduling, and follow-up.
4. Create population-specific approaches or tailored measures to reach groups with particular needs, especially populations such as the historically underserved or at high risk.
5. Engage and manage providers across delivery channels to achieve maximum throughput.

The administration challenge

Across the United States, the COVID-19 vaccine administration rate is slightly over a million doses per day.⁴“COVID-19 vaccinations in the United States,” Centers for Disease Control and Prevention, last updated February 7, 2021, covid.cdc.gov. Of the projected available supply of vaccines by the end of the first quarter, the United States can expect roughly an additional 160 million of doses supplied by March 31, which equates to a little over 3 million COVID-19 vaccines available each day on an average basis.

To use this supply, the United States would need to increase administration by more than 2x. This number—3 million vaccines in arms per day—is several multiples of the daily administration rate of previous flu vaccine campaigns (Exhibit 2).⁵Gaurav Agrawal, Tara Azimi, Jennifer Heller, Pooja Kumar, Mihir Mysore, Parag Patel, Adam Sabow, Shubham Singhal, and Joseph Truesdale, “The risks and challenges of the global COVID-19-vaccine rollout,” January 26, 2021, McKinsey.com.

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Some jurisdictions have experienced more success than others in the vaccine rollout. Some smaller states with larger delivery systems and strong established networks of hospitals, clinics, and pharmacies have been able to leverage the delivery system more quickly.⁶Sarah Mervosh, “How West Virginia became a U.S. leader in vaccine rollout,” New York Times, January 24, 2021, nytimes.com. Additionally, jurisdictions with clear strategy and guidelines have often encountered less confusion, such as who is eligible to receive the vaccine, and when they can receive it. Indeed, several states that have experienced higher throughput have opted for broader eligibility than states with narrower, more prescriptive eligibility.⁷Maia Anderson, Mackenzie Bean, and Gabrielle Masson, “Most successful vaccine rollouts in US: 4 state strategies,” Becker's Hospital Review, January 13, 2021, beckershospitalreview.com.⁸Jemima McEvoy, “Strategies used by states with the most successful vaccine rollouts,” Forbes, January 25, 2021, forbes.com. These broader strategies also may help with reaching the “cautious adopters” and “unlikely adopters” groups in the United States, as discussed in “COVID-19 vaccine: Are US consumers ready?”

While overall the United States is experiencing a planning, logistics, and systems constraint, true supply constraints exist for many stakeholders. These challenges include providers struggling to receive enough doses, leading some to cancel vaccination appointments⁹Anna Johnson, “NC hospitals are canceling appointments as state routes vaccine doses to mass events,” News & Observer, January 23, 2021, newsobserver.com; Darcy Spencer et al., “Virginia hospital center cancels 10,000 first-dose COVID-19 vaccine appointments,” NBCUniversal Media, January 22, 2021, nbcwashington.com. or turn down patient and employee requests for vaccination. Given the importance of the system-level coordination of getting the supply to the right location to vaccinate individuals in the phased approach, the role of the state leaders is viewed as increasingly critical. Additionally, constraints can be results of 1) policy decisions or 2) communication confusion. For example, many providers are trying to interpret policy guidance at the federal, state, and local level as to whether to hold supply in reserve for second doses based on concerns around upcoming shortages, or whether to give first doses to as many people as possible.¹⁰Dana Rubinstein, “After unused vaccines are thrown in trash, Cuomo loosens rules,” New York Times, updated January 10, 2021, nytimes.com.

Five critical lessons for states to consider to improve COVID-19 vaccine deployment

Lesson 1 – Define the state’s role in vaccine administration (for example, administrator, convener) as it relates to local stakeholders (for example, counties, cities local health jurisdictions) and clearly establish supporting governance and a decision-making structure.

Each state is now faced with a choice of how to best serve its citizens and rebuild public health within its jurisdiction. State leaders may consider asking if the state should play the role of administrator, adviser, or convener for optimal vaccine implementation. While approaches to supporting public health and the vaccine deployment differ, it is critical that states make design choices that best match their infrastructure, resource capacity, and jurisdictions’ needs.

In the state-as-administrator role, states have typically offered a state-hosted vaccination website to identify vaccine providers, provide updates on the vaccine rollout, and possibly support pre-registration and the scheduling of appointments. In this approach, a state could consider the demand and likely participation of its citizens, such as whether the sites would be trusted, managed, and used. A state may want to consider how to communicate where, when, and how consumers could visit these sites to receive the COVID-19 vaccine.

In the state-as-adviser role, states have centralized strategic decision making, such as selecting “preferred site locations,” but are delegating operations to localities (cities, counties, etc.). State leaders may view this strategy as allowing each county or locality to adapt based on specific needs, such as whether non-traditional hours, a mobile unit, or rotating sites to administer vaccines would be most appropriate. In this role, states may consider being prepared to provide robust guidance and communications to all stakeholders, potentially serving as a conductor, to ensure partners understand the states’ strategic plans and their implications, including where doses are being sent and the timing of the decision to move to the next phase.

Finally, states may choose to delegate much of decision-making and operational authority to localities and instead function in the role of state-as-convener, facilitating connections across public and private organizations that are essentially leading the vaccination implementation. With this approach, states are still typically seeking to have a centralized, statewide data infrastructure, but are engaging with federal and national partners as part of a coalition of entities supporting the vaccination effort.

In order to deploy any role strategy, states may consider engaging in several actions, including the following:

1. Determine state capabilities, resources, data flows, IT and data infrastructure, and needs (for example, staffing, skill sets, systems capabilities, degree of geographical variability, diverse populations, and where decision rights and responsibilities sit throughout the state).
2. Identify key stakeholders and define roles and decision-making authority for each.
3. Establish clear, consistent, and proactive communications about how the state will support vaccine implementation, including clarity on which aspects of the effort states will “host” and which will be administered via partners, such as pharmacies and primary care practices.

Lesson 2 – Establish and maintain a view of vaccine throughput and consumer demand across the state’s delivery network.

One of the most critical parts of effectively managing the rollout is achieving an accurate, up-to-date, and ideally daily end-to-end view of vaccine throughput. This view requires a record of doses received, on hand, administered, and wasted or lost (for example, due to temperature irregularity), and consumer demand at each point of vaccine dispensing. Regardless of its selected role, states face several challenges in attaining this view at a statewide and consistent level, including a tension between adhering to a rigid reporting structure and allowing flexibility to facilitate agile decision making that could maximize the number of shots administered. States are finding they have to contend with blind spots in parts of the distribution system and creatively support registration/scheduling across vaccination sites. Most states are finding themselves in the position of needing to urgently integrate disparate data sources and multiple systems in order to build a data-backed view sufficient to guide decisions.

To achieve and maintain an end-to-end view of vaccine throughput and consumer scheduling demand, states may want to consider several steps:

1. Prioritize efforts to improve visibility of consumer scheduling for mass vaccination sites, given that these sites require the most scheduling support and are most likely to be supported by the state.
2. Consider segmenting IT and data requirements by site type and vaccination strategy to ensure that the consumer experience is optimized and most critical data are appropriately prioritized. Allow for approaches that do not rely on tech-heavy expertise (for example, partnerships with community organizations for scheduling populations with special needs).
3. Centralize data and visualization capabilities that enable rapid decision making, support monitoring of equity and efficiency, and promote leadership transparency.

Many states are enabling data necessary for decision making. For example, states are creating consumer-facing websites and launching central scheduling resources, though not all providers may choose to use them.¹¹Kat Jercich, “States rely on wide range of IT systems to manage COVID-19 vaccines,” Healthcare IT News, January 14, 2021, healthcareitnews.com. Many are relying on the immunization information systems to track site-by-site administration progress and may be choosing to supplement this information with surveys regarding transfers, throughput, and capacity.¹²Aleszu Bajak and Janet Loehrke, “Where’s the COVID-19 vaccine? Who’s been vaccinated? Here's how we'll know,” USA Today, December 16, 2020, usatoday.com.

The risks and challenges of the global COVID-19-vaccine rollout

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Lesson 3 – Promote access by matching consumers to administration sites and enabling smooth registration, scheduling, and follow-up.

Vaccine administration sites may be state-led, local-government-led, or privately operated, or a combination of all three, depending on state strategy, provider capacity and throughput, and the presence of private-public partnerships. To promote broad vaccine access, states can consider multichannel engagement efforts leveraging stakeholders across private and public sectors (for example, payers, primary care providers, National Guard, employers, community organizations) as either direct administration points, facilitators/navigators, or educators in the vaccination journey. States face several barriers in achieving successful consumer–site matching, including minimal lead time on allocation, potential shifts in policy impacting eligibility criteria, consumer education and clarity on eligibility, consumer compliance, provider/site systems interoperability, scheduling/appointment challenges, and the need for clear governance for coordinating with non-state-led sites.

While several barriers are beyond states’ influence or control, states can consider steps to try to promote improved consumer–site matching:

1. Develop centralized resources, including digital and analytics capabilities (for example, consumer-facing portals), and other operational tools (for example, pre-registration/registration and scheduling systems) that state-led and non-state-led sites may utilize to facilitate consumer–site matching.
2. Dynamically measure consumer demand and behaviors (for example, phone/scheduling traffic by site type) to inform/change operational decisions (for example, allocation to site types, suggested site hours, locations and design of new sites).

Lesson 4 – Create population-specific measures or tailored approaches to reach groups with particular needs, especially large populations at high risk such as those who are historically underserved and the homebound elderly.

As the rollout unfolds, it is increasingly clear that a one-size-fits-all approach to administration will not successfully meet access needs across diverse populations. Instead, subsets of populations may require dedicated approaches to overcome barriers to getting vaccinated. Diversified channels or related measures can promote efficiency and equity in reaching especially underserved populations that may experience access barriers, such as transportation, mobility, and health information or literacy challenges. Tailored approaches will likely be important in the near term, in particular for individuals who are homebound and may require a home health visit; those who may not be able to get to an alternate site due to work and transport challenges, and may benefit from an at-work opportunity to be vaccinated; and those who are historically underserved (for example, homeless populations, undocumented workers, or those living in congregate care) who may benefit from alternate options due to logistical concerns or fear/mistrust of government or healthcare providers. States can face considerable challenges to promoting access among these groups, including lack of transportation, language barriers, and risk of loss of wages or employment.

To engage these populations, states need to take tailored approaches that require several steps:

1. Clearly define and identify the members belonging to these populations.
2. Proactively reach out to these members via current healthcare access points, payers, or trusted community organizations with multilingual communications.
3. Understand granular sentiment and address concerns.
4. Create scheduling or administration sites where these populations are located.
5. Deploy nontraditional approaches as needed and permissible under applicable regulations (for example, mobile vaccination sites,¹³“COVID-19 vaccination plan: New Jersey,” New Jersey Department of Health, December 15, 2020, nj.gov.¹⁴Stacy Lange, “Mobile health facility ready to roll when coronavirus vaccine ready,” WNEP-TV, November 10, 2020, wnep.com. home visits, and transportation¹⁵Bruce Jaspen, “Lyft preps rides for 60 million low income Americans to Covid-19 vaccinations,” Forbes, December 23, 2020, forbes.com. support).

Lesson 5 – Engage and manage providers across delivery channels to achieve maximum throughput.

States may consider activating providers to support vaccine administration beyond traditional channels, and beyond their own employees or patients. Given the challenges that healthcare providers have faced over the last year, states can consider ways to support providers in the goal of maximizing reach, equity, and vaccination throughput. Indeed, quickly increasing access to and deployment of the vaccines requires public and private partners alike to work together to offer shots to all. Besides the critical role that providers play in administering the vaccine, healthcare providers are the most trusted source of information about the COVID-19 vaccine, according to recent McKinsey Consumer Health Insights data.¹⁶Jenny Cordina, Andrew Ramish, and George Stein, “COVID-19 Consumer Healthcare Insights: What 2021 may hold,” January 22, 2021, McKinsey.com. States may consider ways to engage providers to administer the vaccine beyond their existing patients or employees.

Given the already strained workforce, states also could consider allowing providers to participate in open administration and provide communication and support (logistical, tactical) on how they can help states reach immunization targets. Effectively collaborating with providers requires enrolling and training them to participate in public (open) sites of administration, providing guidance/communications on state expectations/targets, understanding what type of support would be most helpful to them, delivering on those supports, and developing mechanisms for performance management and contingency plans when targets are not met. Barriers exist across each of these options, potentially fueled by some providers already being overburdened in a strained healthcare system. Still, states may take several actions to mitigate barriers, including exploring policy actions that may increase the pool of vaccine providers, for example, by expanding the scope of non-physician healthcare providers and/or other personnel. Several states rapidly increased the number of potential vaccinators by expanding policy of who is able to administer the vaccine. Pennsylvania expanded its network of administrators to include pharmacists.¹⁷“COVID-19 Vaccine,” Illinois Department of Health, January 2021, dph.illinois.gov.

States can mitigate barriers by offering custom support to providers who need it, including staffing and logistics concerns. States can send clear communications on expectations and targets, coupled with performance management processes, to ensure doses are reaching localities efficiently and meeting their needs.

Conclusion

While the road is still uphill for states at the moment, we have observed actions that may be helpful in accelerating vaccine implementation, which in turn could help mitigate the pandemic. As we have noted earlier, swift vaccine administration in the United States can help reduce mortality, protect those at the greatest risk, and play an important role in preventing further viral mutations. States have a critical role in helping as many members of the public have access to vaccination, protect against COVID-19, and return to their normal lives and livelihoods.