But will it Work? Reflecting on the “last mile”
The Big-Picture Plan
The Biden Administration’s COVID-19 “war plan” is official. Here are the bare bones of what it contains:
- 1 million doses a day for the first 100 days (equivalent to vaccinating 50 million people fully)
- A 100,000-person Public Health Corps to serve as contact tracers
- About $500 billion to make schools safe for re-opening
- Mandatory mask-wearing on all federal properties for 100 days
- A national “mask challenge” requesting all Americans to “mask up” for 100 days
- Robust financial support for states/local governments for vaccination efforts
- As part of the previous, partnering with states/cities to set up mass vaccination centers in stadia, gymnasiums, and conference centers
- Robust financial support for those unemployed or underemployed due to COVID
- Activation of the Defense Production Act to ramp up production of essential materials required for vaccine delivery (e.g., syringes, tests, PPE)
The Administration’s seven core goals:
… restoring public trust in government efforts; getting more vaccine doses into more arms; mitigating the spread – including mask mandates; emergency economic relief; a strategy to get schools running and workers back to work; establishing an equity taskforce to address disparities in suffering involving issues of race, ethnicity and geography; and preparing for future threats.
Additional details:
The administration will staff newsites with personnel from federal agencies as well as first responders and medical personnel serving in the military. The government plans to partner with federally qualified health centers to help reach under-served communities to distribute vaccines; mobile clinics will also be set up.
Is this enough? Well, yes and no. The Administration announced yesterday (Day 2 of Biden’s first 100 days) that the previous administration had left behind no national vaccination plan, which really shouldn’t have come as a surprise to anybody. The new people are left with nothing to work from, at a moment when vaccine distribution and delivery have already begun.
The stated number of vaccinations per day (1 million) is probably conservative; by Jan. 20, more than 800,000 vaccines were already being administered daily across the country.
Keeping in mind that the Pfizer vaccine, which is the only one currently being administered, requires 2 doses, 1 million doses a day isn’t that many – around 500 million doses of a 2-dose vaccine will have to be administered to get to herd immunity (250 million people x 2 doses). At 1 million per day, that means … a year, perhaps?
Thinking that “last mile” through (again)
Let’s say you’ve got a state in which 10 million people need to be vaccinated (that’s approximately the vaccination-age population in Illinois). Assuming vaccine supplies are sufficient, isn’t it preferable to set a goal of everybody getting vaccinated within x-time frame, and then work backward from that goal to determine what you’ll need to get the job done?
Ten million people = 20 million shots. Let’s say the Illinois Department of Public Health (IDPH) were to say, “Okay, we’ll start with 2 million a month, then double that to 4 million a month (for four months), then back to 2 million (month 6, as the 2-shot program winds down). How many months is that, six? Let’s say the program starts in mid-February – by mid-August, everybody eligible (and willing) has to be vaccinated.
(Note: We proceed on the hypothesis that it will be largely the Pfizer and Moderna vaccines being produced and distributed, which require two shots.)
Chicago and its suburbs are home to about 60% of the state’s total population – so, 60% of the supply (and syringes, etc.) needs to be earmarked for this region. In other words: 1.2 million doses in Months 1 and 6, and 2.4 million in Months 2-5.
How do you make that happen?
Month 1 = 40,000 people a day (greater Chicago area & suburbs); 10 delivery centers (at least for the Pfizer vaccine, you probably can only use a few mega-centers because of its storage requirements -80 C.). That’s 4,000 people a day out of a total regional population of 6 million.
Months 2-4 = 80,000 people a day: double the schedule from 12 to 24 hours a day with the same facilities or double the number of facilities and retain a 12-hour-a-day delivery schedule; in both cases, you need double the “delivery” and admin support staff in these months.
How many people does it take to deliver 40,000 shots? If each nurse/doctor/dentist/veterinarian/pharmacist enlisted to deliver vaccines (+ student nurses + medical-dental-veterinary-pharmacy students) delivers 6 shots an hour, and works 6 hours, that’s 2 shifts for (approx..) 40,000 shots; divide 40,000 by 40 shots (rounding up), that’s 2,000 people (= two 6-hour shifts, 1,000 people on each shift) to deliver shots daily (4,000 for Months 2-5).
Next: 1,000 (2,000) personnel (this is only for actual delivery; administrative and support staff are needed too – just enlist the National Guard for goodness’ sake, this is a national emergency).
You now have ten delivery sites (stadiums, convention centers, arenas, etc.) available for 40,000 people total per day in Month 1, and 2,000 people to administer the shots per shift. Divide that 2,000 by 10 and assign 200 (for two shifts) medical staff to each center (+ admin staff). When a person receives their shot, provide them a record (electronic, to email or in SMS form) of which vaccine they received, on what day, and a return appointment for their second dose.
(Note: we have been shocked and dismayed to read that in many places, people are being vaccinated with no electronic or written record of which vaccine they received and on which date – how can this be?)
Two points are made clear from this amateur “plan”:
- Can Chicago find 2,000 (Months 1 & 6) / 4,000 (Months 2-5) people to deliver shots each day for six months? [vitally important to ensure adequate staffing]
- People will have to be paid to deliver shots (say, $30 an hour), and if the National Guard isn’t employed for administrative support, people will have to be paid to do that, too.
On to determining who receives the shot and on which days:
For better or worse, states were left to determine their own priorities for recipients of shots; most are more or less following CDC Guidelines (Priority groups 1a and b, group 2, group 3, etc.) but there are a lot of deviations within these groups. Our plan is structured for the general population, not the initial priority groups, for whom vaccination is already well underway – and yes, we have/had ideas about how to structure delivery for these groups, too.
For the moment, let’s say we’ve arrived at the general-priority age groups, working downward from oldest to youngest as the CDC Guidelines recommended (and as states are doing, in fact). Each area then analyzes its age demographics and divides that by the total number of days available for the first shot (in our case, 3 months = 90 days). Divide the total eligible population first by 90 – let’s say we’ve got a county with 180,000 people for the purposes of calculation, so that would be 2,000 people per day. Then “slice” that figure horizontally by age groups – what percentage are over 80? How many 75-to-80?, etc. all the way down to age 18, and determine which birth years will be asked to come to their assigned vaccination center (determined by zip code) on x-day. Want to make it even more efficient? Ask people to show up by month of birth: Hour 1 = January, etc. (This, to avoid crowding at mega-sites; you really don’t want “Vaccination Day” turning into a super-spreader event.)
Any plan of this sort assumes that all the analysis has been done long in advance, reported to the state health department and local COVID-19 distribution center (there are 10 such centers in Illinois), and that the distribution center/IDPH has ordered and will receive the requisite number of doses from the state in a timely manner. And that, in turn, means that the state must be assured of an adequate, regular supply from the manufacturers – here, the federal government can (must) assure supplies are properly distributed to the various states and territories.
Here’s where the absence of a federally-coordinated vaccine rollout plan has got us:
Over a month into a massive vaccination program, most older Americans report they don’t know where or when they can get inoculated for covid-19, according to a poll released Friday.
Nearly 6 in 10 people 65 and older who have not yet gotten a shot said they don’t have enough information about how to get vaccinated, according to the KFF survey. (KHN is an editorially independent program of KFF.)
Older Americans are not the only ones in the dark about the inoculation process. About 55% of essential workers —designated by public health officials as being near the front of the line for vaccinations — also don’t know when they can get the shots, the survey found. Surprisingly, 21% of health workers said they are unsure about when they will get vaccinated.
Can the Biden Administration fix this? And how will it go about doing so now, when vaccination programs are already underway, even if rather anemically (in Illinois, around 550,000 people have received at least one dose to date, and around 120,000 – 0.95% – are fully vaccinated)?
Our analysis above demonstrates two things: (a) the critical role of that “last mile” and how important supply + equipment / staffing / demographic analysis / coordination at the local, state, and federal level really are (were) and (b) why “leaving it to the states” (some of which then “left it to the counties”) would never have worked.
Regular readers may recall that we already engaged in a similar exercise less than three weeks ago. What’s the point of a second go at it? Well, for one thing, it makes crystal-clear for a generalist observer the many specialist issues that arise when you’re trying to carry out a mass vaccination program within a limited time frame. It’s particularly useful in highlighting the challenges – and they are very real – of that “last mile”, as we’ve seen here (again), and in underlining the crucial role of the federal government as coordinator and distributor-in-chief (again).
If I’d been a policy-whisperer to someone on the Biden COVID-19 policy team, I might have suggested that a nationwide testing and contact tracing program manned by 100,000 people (“Establish a U.S. Public Health Jobs Corps to mobilize at least 100,000 Americans across the country with support from trusted local organizations in communities most at risk to perform culturally competent approaches to contact tracing and protecting at-risk populations”) was a day (year) late and a dollar short, and instead proposed the entire Corps be assigned to providing administrative and logistical support to the vaccination program.
But that’s just me.