As pharmaceutical companies race to create, test and stockpile doses of vaccines to protect against the coronavirus causing the COVID-19 pandemic, Washington state is contemplating a similarly daunting challenge: distributing those doses as quickly and effectively as possible.
The state Department of Health on Wednesday released its draft plan to distribute vaccines in several phases, outlining for the first time who will have first access to vaccines, how they will be administered and how the state plans to promote vaccines — once they are deemed safe and effective — to its population, including to some people who might be wary.
The plan, which was submitted to the federal Centers for Disease Control and Prevention (CDC) last Friday and released to the public five days later, recognizes the disproportionate impact COVID-19 has had on some communities and promises that allocation of vaccines "will be guided by maximizing health and societal benefit while taking an equity lens into consideration."
The state plans to distribute the vaccine in phases, relying on frameworks developed by a CDC committee and also the National Academies of Sciences, Engineering, and Medicine.
In the first phase, when vaccine doses are likely to be limited, high-risk workers in health care settings, first responders, other essential workers, people with comorbidities and adults in long-term care are likely to be prioritized.
The state plan says more work remains to further prioritize distribution within those groups.
In the second phase of distribution, when doses of a vaccine become more widely available, the state will make the vaccine accessible in a "broad network of provider settings" such as pharmacies, community health centers, primary care offices and occupational health clinics, among other locations.
The third phase will seek to boost confidence in vaccination and address gaps in populations with inequitable access to vaccines.
"It's in line with everything we have been tracking, in terms of who the prioritization groups should be," said Kayla Scrivner, program manager in the communicable disease control-division at the Tacoma-Pierce County Health Department.
Decisions within each phase will be complicated. Dr. Douglas Diekema, director of education for the Treuman Katz Center for Pediatric Bioethics at Seattle' Children's Hospital, questioned whether health care workers should be prioritized over those at the greatest risk to die of COVID-19.
"If you can protect yourself with adequate PPE [personal protective equipment], should those people be first in line?" Diekema said.
Abigail Echo-Hawk, the chief research officer for the Urban Indian Health Institute in Seattle who helped develop the National Academies' nationwide framework, said it was important to see that Washington has committed its focus on equity.
Echo-Hawk said longstanding problems — such as a lack of access to healthy food, education or exercise — along with discrimination, have created health disparities for people of color, and the virus exploits those disparities.
"I'm not more likely to get or die of COVID because I'm Native. I'm more likely to do that because I'm a native person living in the U.S., because of systematic oppression and racism that increase risk factors," said Echo-Hawk, a Pawnee tribal member.
How a vaccine is distributed could mitigate some risks and lesson the impact for hard-hit communities of color, Echo-Hawk said.
The state plans to begin enrolling doctors to give COVID-19 vaccinations in November. Initially, sites that can administer vaccines quickly and at a large scale will be prioritized, the document says.
The plan says there are about 1,000 pharmacies in Washington state, and 90% of them are interested in eventually participating in a COVID-19 vaccination program.
"The easy part of this is probably who gets it first. The harder part is probably figuring out how to get it to them effectively," Diekema said.
Experts expect vaccine supply to be limited. Federal officials have begun to stockpile doses of several vaccines, in hopes they prove to be safe and effective. Researchers expect it will take more than one to vaccinate the U.S. population.
Several potential vaccines are in phase 3 clinical trials and manufacturers could seek authorization for emergency use from the U.S. Food and Drug Administration (FDA) in the next few months.
These clinical trials involve tens of thousands of people. The FDA will review data on potential vaccines' safety and efficacy. Dr. Peter Marks, who directs the FDA's Center for Biologics Evaluation and Research, has said the data will be reviewed and vetted publicly.
The FDA has said it expects vaccines to be effective in at least 50% of people. Some potential vaccines would, if approved, come with complicated logistical requirements such as ultracold storage, which would make them more challenging to distribute widely.
Washington state officials said the plan would change as they learn more about a potential vaccine.
"This is version one of the plan," said Michele Roberts, the health department's acting assistant secretary, who has oversight for COVID-19 vaccines. "This plan is going to evolve over time."
Roberts said the state has established focus groups with communities disproportionately impacted by COVID-19 and also for essential workers and particularly key industries.
"We want to hear from you," Roberts said of the public.
After a vaccine is approved with demonstrated safety, one of the most significant challenges the state faces is convincing people it's in their interest, and their community's interest, to get vaccinated.
The health department says it's already planning its strategy to promote vaccination, including via a 10-week paid advertising campaign involving Facebook, Instagram, billboards, TV, radio, newspapers and other information sources.
"Campaign funding was approved in early October and we will be moving into planning, design, and launch as quickly as possible," the plan says.
The department also plans to televise weekly media briefings, and to provide talking points for doctors and other health care providers, among other measures.
Many questions — such as details on storage, transportation and logistics — will remain unanswered until a vaccine is authorized for emergency use.
Roberts said the federal government has indicated the vaccine itself will be provided to every American at no cost, but health-care providers could charge insurers fees to administer the vaccine or for an office visit.
"We're waiting for more information form the federal government," Roberts said. "Are there going to be limits to what those fees are going to be?"
The plan estimates that Washington state in the first two months of distribution will receive about 2% of the initial supply of vaccine — enough to vaccinate between 150,000 and 450,000 people.
How long is supply expected to remain short?
"I think it's pretty safe to say it could be six months to a year where we have limited vaccine supply," Roberts said.
Said Echo-Hawk:
"It's really hard to plan for a vaccine when you don't know what it is."
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