The COVID-19 Vaccine Initiative: Is there a plan?

Today is just a short reflection on the efforts to vaccinate 330 M people. Thanks to discovery scientists exploring new means to initiate immune response to viruses, we saw a remarkably fast advanced development and manufacture of vaccines with > 90% efficacy in 9 months. The traditional vaccine platforms have historically required 5-7 years to achieve demonstrated efficacy and safety. Although the current mRNA vaccines have not demonstrated long term safety, there is no theoretical concern about long term effects.

It should also be noted that recent flu vaccines have achieved less than 70% efficacy, but in part that is attributable to the very rapid mutation of influenza strains. Currently, there are concerns about the mutations within the SARS-CoV2 virus, but these changes do not seem to have altered the spike protein so significantly that efficacy will decline. So, it appears that we have a major weapon in fighting this pandemic, if we can produce enough vaccine in rapid order, and actually get shots in arms.

This “last mile” issue has been problematic to this point (mid-January 2021). In part this is attributable to the lack of a coherent national process for immunization. The federal government has taken the position that it is their job to get the vaccine produced and delivered to the states (although supplies are still well behind demand). They have ascribed the immunization process as a state and local activity with only very broad guidance as to how to prioritize and actually deliver the immunizations to individual patients. This has led to a hodge podge of approaches, many not well thought out or managed.

The second difficulty in delivery of the vaccine is the people needed to administer the injections. This has presented problems in hospitals who got the first tranche of vaccines to protect health care workers. Many hospitals do not have adequate staff, trained to conduct the vaccination activity. Beyond hospitals, community public health (which has been decimated over the last decade), is also inadequately staffed to provide the service. Some localities have developed solutions through the use of already established Medical Reserve Corps (MRC) assets composed frequently of retired clinicians and public health personnel. Other communities are struggling to find adequate staff to meet immunization goals. This too would benefit from a national plan that identified available personnel both from within communities, and potential imported staff for bursts of immunization activity.

Lastly, the current zeitgeist is filled with distrust of existing institutions. The societal upheaval has been exacerbated by this pandemic and everything has become politicized. This has increased vaccine hesitancy among the population, and, even among healthcare workers in many locations, vaccine refusal has reached 35-40% of eligible health care staff. This may change with time as more people receive vaccines without complication, but is a most difficult hurdle if we are to achieve high vaccine uptake and provide the promised “herd immunity”.

These three problems do lend themselves to solution. First, a national plan needs to be articulated in cooperation with states and localities. The elements of the plan should include clarity of priority, adequate supply, consistent documentation, and clear consistent processes for patients to access the vaccines. The plan should include identification of personnel to actually administer the process and administer the vaccines. As noted above, more broad use of existing MRC assets, and recruitment of additional volunteers under that program could well expand the pool of staff to execute the program. This would include retired nurses, physicians, pharmacists, paramedics, and other clinically experienced staff. Other health providers such as dentists, veterinarians, various therapist categories (e.g., physical therapists) could be trained to administer the vaccines. This might require federalization of such staff to provide coverage under the Federal Tort Claims Act, and validation of expanded scope of practice. The other alternative is a state by state waiver of scope of practice, but this could be done more effectively through a central national process. The challenge of vaccine hesitancy is more difficult since the levels of mistrust are not easily addressed. Time may be a more important factor since more data gathered over time may mitigate concerns expressed (although true anti-vax folks are unlikely to be persuaded by data).

We have a challenge, but there are means and methods to overcome. We must act in a more civic whole if we are to beat this virus.

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