Conversation

Covid-19 Vaccine Distribution: One of the Most Complex Tasks in American Public Health History

What can health systems and their public health partners execute on now to accelerate and amplify vaccination efforts?

  • Rebecca Weintraub, MD and
  • Namita Seth Mohta, MD
February 10, 2021
Summary

Rebecca Weintraub, MD, Assistant Professor at Harvard Medical School, and Associate Faculty member of Ariadne Labs, discusses examples of successful public-private partnerships for vaccine distribution.

Rebecca Weintraub and Namita Seth Mohta headshots on purple background.

Namita Seth Mohta, MD, interviews Rebecca Weintraub, MD, Assistant Professor at Harvard Medical School and Associate Faculty member at Ariadne Labs.

Namita Seth Mohta:

This is Namita Seth Mohta for NEJM Catalyst. I am speaking today with Dr. Rebecca Weintraub, faculty at Ariadne Labs and Harvard Medical School. At Ariadne, Rebecca leads both the Better Evidence program and the Vaccine Delivery portfolio. Ariadne Labs is a health care innovation center at the Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, whose mission is to reduce suffering globally through the design of scalable solutions to improve health care delivery. During the early days of the pandemic, Ariadne Labs, which in full disclosure I work with also, was called upon to help understand effective public health measures and create and disseminate new tools to support prevention and treatment.

Rebecca, you were one of the first to sound the alarm about the dangers of vaccine nationalism and the need for equitable distribution. You and your team have been leading the lab’s efforts to ensure safe, equitable, and acceptable vaccination.

It is a milestone moment, for sure, and we thank you for joining us today.

Rebecca Weintraub:

Many thanks for having me.

Mohta:

We have been now vaccinating for almost 2 months and hearing about both the successes and the challenges. Let’s start with the successes. What have been some of the successes?

Weintraub:

I want to take a step back for a moment, when we think about vaccine to vaccination. This has required success and inputs at the discovery. How do we produce a new vaccine in the midst of a pandemic? How do we then develop millions, now billions of doses? And then the delivery, moving the product into shots in arms to begin the generation of immunity in a population. To start with discovery, which we all acknowledge but to say it out loud, the time to approval of a new vaccine when SARS-CoV-2 was sequenced on January 10, 2020, and then the U.S. Food and Drug Administration had an external review of the Pfizer-BioNTech vaccine on December 10, 2020, and the next day [we were] vaccinating health care providers in the UK and the United States. That is an absolute accomplishment.

The second is on the development side. How do we start manufacturing a brand-new vaccine, mRNA vaccine, that we haven’t manufactured in millions of doses before? The manufacturing capacity that’s been established around the world is now self-organizing. For example, 2 weeks ago [as of this recording on February 4, 2021], Novartis decided to add its manufacturing capacity to make mRNA vaccines, Sanofi has already committed to fill and finish the mRNA vaccine, and Merck and others. We have to acknowledge that there is now voluntary horizontal collaboration across our pharma stakeholders.

On the delivery side, early on in the pandemic, Seth Berkley and others began the establishment of the COVAX facility, which is now prepared to distribute 330 million doses to developing nations in the first half of this calendar year.1

Mohta:

That is indeed remarkable. What have been some of the challenges and the gaps, as you’re seeing them?

Weintraub:

We have to acknowledge we’re on a learning curve here, that’s almost like a bullwhip between supply and demand. The supply has been difficult to predict. The early press releases from December were talking about 50, 100 million doses that would be available when they were in the single digits. So, demand forecasting how much vaccine will shift where and when. The second is the supply chain management, the distribution networks needed to monitor for the new bottlenecks, quality assurance, and adverse surveillance. All four of these systems needed to be created in the midst of a pandemic on this chronically underfunded public health infrastructure.

Mohta:

We have always known that public-private partnerships are a critical success factor to improving health for populations and communities, especially now during the pandemic. Can you share with us, Rebecca, some examples of countries or states where these public-private partnerships are working particularly well right now, and why?

Weintraub:

I’ll highlight a few states: West Virginia, Louisiana, Connecticut, and Kentucky. West Virginia early on decided to use technology from a company called Everbridge, which allowed West Virginia officials to communicate with people instantly, alerting them if there were leftover vaccine doses. They identified where the people were who needed to be vaccinated, so they could set the signup based on their principles of prioritization. Second, they set up community vaccine clinics in all 55 counties, they summoned the National Guard to help with the logistics, and as of today the state of West Virginia has a 108.1% administration rate.2 They’ve been able to get more doses per vial and provide every vaccine dose that they’ve been allocated. A tremendous effort across the state.

Connecticut thought about, how do we simplify the process? In December, the department of public health expanded the pool of medical workers eligible to administer the vaccine, including ENTs [ear, nose, and throat specialists], dental workers, veterinarians, and podiatrists. They also developed a just-in-time inventory system3 to think about, how do I use the unused doses and transfer it to other facilities at the end of the day?

Kentucky created a partnership with Broadbent Arena, which is a truck rally site, and they’re now administering 1,500 doses a day.4 They’re staffed by volunteers, 4,000 people signed up to volunteer, and they created an incentive: If you volunteered for 40 hours you’d be eligible for the leftover vaccine.

The fourth example I want to mention is Louisiana. In Louisiana, the public health department was an early adopter of using a vulnerability index to redeploy vaccines to those counties that have experienced the most devastating effects of Covid-19, both in their health and economic outcomes. They then asked retail pharmacy chains and others to redeploy and reopen sites to serve those communities, including the [Federal] Retail Pharmacy Program that begins on February 11.5

Globally, many have called out how Israel has been able to respond in the midst of the pandemic. They’ve truly treated this like a bioterrorism event, not a routine vaccination campaign. Of note, Israel did “pay a premium.” They locked up an early supply of the Pfizer-BioNTech vaccine and struck a unique deal. They said, “Please give us the vaccine and we’ll give you the national data to study whether herd immunity is achieved after reaching a certain percentage of vaccination coverage in Israel.”6 There’s an unusual setting here, this is a relatively small-sized country, and every Israeli citizen and resident belongs to one of the four HMOs [health maintenance organizations] where you can then get access to a full repository of digital health records.

Mohta:

That is remarkable. I have to ask, how do you get to a 108% administration rate?

Weintraub:

Remember, each state was allocated doses per adult population and the assumption was you would get five doses per vial. But it turns out if you use a low dead–weight syringe you can get an additional one and sometimes two additional doses per vial, and that wasn’t counted against you.

Mohta:

They were able to administer more doses than the vials they had available?

Weintraub:

That’s correct, exactly. For example, the state of West Virginia received 10,000 doses7 and those vials actually had 10,100 doses and they administered all of them; they’re exceeding their allocation by the efficiency of being able to extract additional doses per vial.

An aside here, which is quite interesting, is that Operation Warp Speed is paying Pfizer and Moderna per dose, not per vial. Pfizer then decided because of that, because people are able to get additional doses per vial, to send this specialized syringe with the doses, so they could extract additional doses per vial, and then send fewer vials for each shipment.

Mohta:

And get paid for that extra dose?

Weintraub:

They decreased the number of vials that they would then ship. To take a step back here, when Pfizer and Moderna contracted with Operation Warp Speed, they made an assumption that they would get X number of doses per vial. In reality, with pharmacists utilizing different syringes, additional doses were able to get extracted from the vial. After a few weeks of deployment, that data went back up to Operation Warp Speed and then Pfizer renegotiated with Operation Warp Speed to say, “There are additional doses per vial, so we are going to send you the specialized syringe to get the additional dose out of each vial.”

Why I mention this is because this creates a new delivery bottleneck. The syringe companies were not ready to manufacture this type of syringe at mass. As Pfizer makes this different choice, we now have a new implementation bottleneck that will be resolved in these coming weeks.

Mohta:

Always learning. Let me bring us back up a couple of notches. Given where we are today with the systems that we have now, what are two or three tactics that both health systems and their public health partners can execute on now to accelerate and amplify vaccination efforts?

Weintraub:

There has been a host of agile adaptable leaders today who are just wonderful examples. The bottleneck right now is adaptive scheduling systems. If an individual goes to their state website, they want to know the next available appointment. Sometimes people are agnostic, they’ll go anywhere, and they’ll travel. Other folks, unfortunately, are homebound or transportation would be quite difficult. So, deploying at a state level an adaptive scheduling system is truly a bottleneck today. Compliments to all the software companies that have offered their services — we wish we had you on board months ago to help prepare the states, as such.

The second is a centralized dashboard for every state to have that real-time data on equitable distribution. Once again we’ve realized there’s a lag in data reporting at every step in this process, which makes it difficult on a weekly basis for the state to think through replenishment, opening up new sites, setting expectation by opening up new appointments. I believe it’s going to get better. We have to acknowledge that this is a decentralized system to begin with. Even for routine flu [vaccine] administration, the minority of flu shots are reported into the state central registry.

The last [point] is truly preparing our last-mile delivery channel. We are now in a low-supply, high-demand part of the curve, but I suspect by early spring we’re going to be in a high-supply, low-demand part of the curve. Where we truly need our last-mile delivery channels is your primary care provider, for example, your local pharmacist, your local provider to have access to the vaccine to give it to you in the midst of routine care.

Mohta:

Are there immediate things that we can be doing in the next few months, in addition to the suggestions that you made or recommendations that you’ve made, to help us close that last mile and cross that last mile most effectively?

Weintraub:

I’m quite optimistic with the Johnson and Johnson vaccine being both thermostable and one dose; [it] may be a viable vaccine to be able to administer at, for example, a local primary care practice with a low volume of patients. First, how do we help primary care providers who want to administer the vaccine to integrate this within their routine care? To help reestablish care for those they may have not been able to see in the early months of the pandemic, and the lag we’re facing regarding other aspects of preventative health for the general population?

The second is in the sense of some of these data lags, and thinking about how do we have other sensible data and routine data that we need to help prepare week by week for the vaccine deployment? I have to say, even in the early days of the Biden administration they’ve done a tremendous job in four categories to help understand what the states need: expanding eligibility for the vaccine, creating federal vaccination sites, they bolstered the public health workforce, and they secured the production for sufficient supply for spring 2021.

Mohta:

What is a recent win that you can share with us from your own experience from the last few weeks?

Weintraub:

First, it’s been an absolute honor to learn and support and listen to the state leaders who are leading these efforts. Our state public health departments have been beleaguered by the pandemic and are constantly underfunded. And they now have had to shoulder this burden of being the established voice for shelter-in-place, masking, testing, closing schools, understanding workplace and transportation protections, and now deploying a scarce resource, maybe a vaccine, to their communities. The agility of these state leaders who have asked for help, who are utilizing tools that our team and many other teams have established, has been tremendous.

The second is, there has been a tremendous interest in developing trust and empathy during this time. Our team worked [with Surgo Ventures] on a tool called the Vaccine Allocation Planner8 and then worked with media companies, including the New York Times, to build something called Find Your Place in the Vaccine Line.9 And that moment in December when we knew doses would be coming to the states, there was an overwhelming response and understanding that, “I understand I am further back in the line, but I am protecting the person in front of me,” and that is the majority of Americans. The majority of Americans want to end this pandemic, they want to protect their elder who is at risk of death, and decrease their risk of transmitting to their community members.

Mohta:

Ending on that positive note, Rebecca, thank you for speaking with NEJM Catalyst today.

Weintraub:

Many thanks for having me.