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Image of man writing with a vaccine vial on desk near him.

The first vaccine is here, but the biggest challenges may be yet to come

The launch of the Pfizer vaccine and the first steps to vaccinate frontline health workers last week marked the start of an unprecedented effort to distribute and administer hundreds of millions of doses of the drug across America. Late Friday, the FDA authorized Moderna’s vaccine, clearing a second COVID-19 prevention tool for emergency use and setting the stage for a nationwide vaccine distribution effort that will only grow in size and complexity over the coming months.  

Developing vaccines to prevent a disease unheard of just a year ago presented monumental challenges, and the success has been a truly impressive scientific accomplishment. However, the next chapter in this epic story presents a new slate of challenges to government and health systems. In some ways, things may only get harder from here.  

The first week of COVID-19 vaccinations demonstrated the significant logistical challenges involved in distributing these vaccines. The careful planning by states, health systems, and other key stakeholders to prepare for this massive effort has largely panned out despite a few glitches and delays. However, as recent reports of unexpected adverse events related to the vaccination demonstrate, this campaign takes place under a microscope of public attention. As of this weekend, the Centers for Disease Control and Prevention (CDC) has received six reports of serious allergic responses from vaccine recipients in the United States — a very small percentage of the approximately 270,000 doses administered. The vaccine underwent clinical trials that included nearly 44,000 people and received clearance for emergency use by regulators. However, statistically speaking, even very rare adverse events and side effects will invariably occur as vaccination expands and tens and then hundreds of millions of people receive them. Managing the public's expectations and helping people assess their relative risks in context will be a tremendous challenge for government, industry, and media  — a task that will only get harder as misinformation and disinformation spread online. As state and local governments persuade a wary public to get vaccinated, even small missteps risk eroding the public's confidence. 

Already, hospitals around the country face daunting decisions as they prepare to vaccinate their staff. Hospitals do not yet have sufficient vaccine quantities available to vaccinate everyone at once, and vaccination side effects — including fever and chills — may send some healthcare staff into quarantine, further stretching limited hospital capacity. Consequently, hospitals must strategize how to distribute scarce vaccine resources deliberately and equitably to protect patients and staff working in at-capacity facilities. If allocation decisions are unfair – or perceived as such – it can erode public trust and disenfranchise staff. This public sensitivity was keenly demonstrated by this past weekend's public outcry over one hospital system's decision to deprioritize medical residents in their allocation processes. Expanding vaccinations beyond this initial group of healthcare workers will pose no shortage of Gordian knots. From essential workers and employers to parents, schools, and teachers, everyone will be looking to state health agencies for information and guidance. 

In many ways, the fight is just beginning. Here's where we go next on the COVID-19 vaccination effort

State public health leaders are confronting the following challenges as they start to put their vaccine distribution plans to the test:  

  • Six potential vaccines are being fast-tracked for use in the United States and cannot be given interchangeably — with some possibly having different recommendations related to safety and effectiveness for different populations.

  • Some vaccines will require transport and storage at extremely low temperatures, without a deviation of more than a few degrees. Localized dry ice shortages already exist, making it tougher to maintain a viable supply of these vaccines.

  • Five of the six potential vaccines must be administered in two doses — requiring subsequent booster shots at prescribed times. Individuals cannot switch between vaccines to be effectively immunized. States had to update their public health infrastructure significantly and will need to track and monitor these follow-ups or risk squandering scarce vaccine doses.  

  • Supplies of vaccines and the necessary boosters will be scarce. Public health leaders will develop, implement, and enforce frameworks for prioritizing the order in which people are vaccinated and planning the logistics of connecting people with vaccination clinics as individuals become eligible to receive them. As demonstrated by current access barriers to monoclonal antibody treatments that could protect certain COVID-19 patients from becoming critically ill, matching the right person with the right medical care at the right time is not a trivial challenge and not one that our public health system was historically set up to solve.

  • New vaccines will require monitoring, managing, and a robust system for reporting adverse events throughout this campaign. 

What can state governments do now? The six critical elements of effective vaccination coordination:

To ensure maximal success and impact from these vaccines, states will need to include six elements in their design and deployment of vaccine coordination hubs and public health outreach: 

  1. Make information dissemination transparent, easy, and responsive. Provide a clear-cut, uncomplicated customer service experience that provides transparency and promotes trust in government. 
  2. Set doctors and pharmacies up for success as partners to government. Enable providers and pharmacies to administer vaccines efficiently.
  3. Anticipate fraud, mismanagement, and human fallibility. Reduce "vaccine shopping" across providers, pharmacies, and geographies — and prevent efforts to circumnavigate the rules. From record-setting attempts to defraud CARES Act funds to pedestrian attempts to file phantom unemployment insurance claims, there has been no shortage of efforts to challenge the program integrity of state and federal coronavirus efforts. Finite numbers of vaccine doses available on a state-by-state basis offer novel incentives to dishonest actors looking to abuse public resources or cut to the front of the line to get themselves vaccinated early.  
  4. Take special measures to protect the most vulnerable communities. Ensure vulnerable populations, including rural and low-income residents, do not "fall through the cracks" by providing culturally sensitive service and fair and equitable access to vaccines.
  5. Enable two-way dialogue to build and maintain trust. State health agencies will be called upon to meet sky-high expectations and tremendous demand for information about vaccines, local availability, administration locations, differences between available vaccines, and guidance on who should delay getting vaccinated. Handling this surge in demand for government services and information will prove critical for building the public's confidence in the process — this is the key to ensuring compliance with public health guidance. By providing excellent customer service and straightforward, responsive channels for getting information, government can reduce fear, hesitation, and frustration as the pandemic wears on into next year.
  6. Public-private partnerships offer a tremendous opportunity to deploy quickly and manage costs. Unfortunately, not every partner has the resources or expertise to scale with state and local agencies' evolving needs. A private-sector partner will need a solid grounding in public health communications, privacy concerns, scientific knowledge, and technical expertise. Without this specific technical experience, contractors will struggle to get health messages disseminated broadly and connect people with vaccines at scale and will likely struggle to ramp up and down agents in line with demand surges.

One final thought: Contact tracing will remain critical into 2021 or beyond — even if the vaccine rollouts go perfectly 

The mass vaccination of a state's entire population during pandemic conditions will likely require coordination with ongoing testing, contact tracing, and social distancing efforts. Moreover, success will require regular course corrections as public health professionals respond to changing pandemic conditions, including the flexibility to limit, pause, or cease rollout of some COVID-19 vaccines. 

The logistical complexity required to vaccinate an entire population on an aggressive timetable will put immense strain on public health programs' staff and resources. The additional stress of answering thousands of phone calls and emails will only make this Herculean task harder. A Vaccination Hub would free up these critical public resources when they are needed most. 

The coming months will put the nation's carefully crafted vaccination plans to the test. The record-breaking scientific accomplishments over the past months offer a path out of the pandemic and a way back to "normal" — but only if the COVID-19 vaccine doses cross the "last-inch," of their trek and get the chance to make an impact. Accomplishing this will depend on citizens' trust in the vaccines and the government that provides them.