The first phase of the vaccine rollout, which is supposed to deliver shots to roughly 24 million health care workers and residents of long-term care facilities, has been stymied by poorly conceived distribution plans based on judgement calls. Without better use of sound science and data, vaccine plans for the next two phases of the rollout, which aim to inoculate nearly 180 million Americans, could descend into complete chaos.
Most of the missteps so far stem from the same problem: prioritization decisions that ignore the science of risk assessment and leave too much to chance. From Stanford Medical Center’s reliance on a simplistic and arbitrary distribution plan that kicked front-line health care workers to the back of the line, to Massachusetts General Hospital’s use of an app that relied on workers to self-report their level of risk, to an Arizona county’s misplaced trust in a survey issued to health care workers, we’ve seen that the people who need the vaccine the most tend to get left behind when allocation decisions are made by faulty risk models or are up to the discretion of a handful of individuals, despite their best intentions.
For all of the logistical complexities of distributing the vaccine, the solution to determining the order of the queue for shots is straightforward. In any target group — whether it’s health care workers or long-term care residents or individuals over 75 — an individual’s risk for adverse outcomes when exposed to Covid-19 should determine his or her place in line.
Many states seem to know that overlooking science and data when making vaccine plans is no longer an option. This is especially true when it comes to the fast-approaching task of reaching people with underlying medical conditions that increase their risk for severe Covid-19, since identifying and ultimately reaching these people is not as simple as knowing their occupation — a nurse, say — or, in the case of long-term care residents, their place of residence. Stratifying those between the ages of 16 and 64 with underlying health conditions is a far more complex undertaking that requires combing through individual health records and understanding the local social determinants of health at play. And then reaching these people — getting shots in arms — requires understanding their level of connection to the health system, such as whether they regularly see a doctor or go to a hospital, for example, or live near a pharmacy.
But here, too, states seem poised to repeat mistakes, as most are signaling that they will turn to a combination of two ingredients to identify high-risk individuals: the number of people who live in a given county and the Social Vulnerability Index (SVI), a tool often used in the aftermath of natural disasters such as hurricanes that combines 15 factors, ranging from the percent of people living in poverty to lack of access to a vehicle and crowded housing, to determine the vulnerability of each U.S. census tract. And in many cases, pharmacies will be the primary vehicle for distribution during upcoming phases of the rollout — a decision that falsely assumes all Americans have immediate access to a pharmacy.
That’s a recipe for disaster. Using population as a factor means that dense communities, merely because they are populous, will get far more doses than they need and more sparsely populated communities will get far fewer doses than they need. For example, Los Angeles County, the largest county in the country, would get more doses than it needs because it is home to 10 million people, not because it is home to the greatest share of high-risk people.
What’s more, the SVI fails to account for individual clinical history or key social determinants of health at the county level, such as air quality and proximity to grocery stores based on ZIP code. And relying on pharmacies for distribution leaves out people who live in pharmacy deserts, which are more common in low-income neighborhoods, communities of color, and rural areas.
Instead of the population size plus SVI model to determine vaccine allocation, states should turn to a three-pronged data set.
First, the SVI must be supplemented with available data on social determinants of health. Second, the model should be based on peer-reviewed medical literature about SARS-CoV-2, the virus that causes Covid-19, and other coronaviruses. Third, the model should include individual clinical history whenever possible. This, of course, would require states to work with health insurers, which is exactly the kind of public-private coordination needed to successfully roll out vaccines to all Americans.
Health insurers have a longitudinal view of their members’ clinical histories, meaning they have an exhaustive record of individuals’ care and treatment. Hospitals, on the other hand, have more of a transactional view, such as when a patient experiences an emergency health event. And to ensure that those without insurance are not missed, the model needs to flag communities with limited access to key points of vaccine delivery, such as pharmacies, hospitals, county health clinics, and federally qualified health centers.
I have seen firsthand how drawing on insights from more precise data sources can help tackle these urgent challenges for making vaccine plans. In December, my company, Cogitativo, conducted a pilot project at the request of the Department of Health and Human Services, which was exploring ways that states could optimize their prioritization decisions by identifying communities at greatest risk and determining the best pathways to reach high-risk individuals. We analyzed demographic, clinical, and social determinants of health data, along with peer-reviewed medical literature on Covid-19 and other coronaviruses, to create risk scores for more than 20 million Californians and precisely identify the communities with the most pressing needs, down to the ZIP code.
We identified a number of key risk indicators that have gotten almost no attention in the national conversation. We found, for example, that significant drivers of elevated risk of developing serious Covid-19 include not only conditions like high blood pressure and diabetes, but also conditions like lupus, sickle cell disease, and severe mental health issues.
Regarding social determinants of health, we also found that individuals who lived far from a grocery store, to take one example, were at an increased risk of ending up in the hospital with Covid-19. And in terms of vaccination pathways, we found that 20% of at-risk Californians aren’t engaged with the health care system. These individuals are among those who will be missed unless states launch targeted outreach programs communicating the critical importance of the vaccine.
This HHS pilot project shows the kind of granular insights that can be uncovered when we turn to science and data. Our nation — and our economy — cannot afford more vaccine missteps, and budget-strapped states cannot afford an endless series of costly do-overs.
Of course, reaching this comprehensive view of risk requires sifting through massive amounts of data that would be impossible for any one state or public health agency to do alone — but that’s no reason to take an easier path. To complete the vital task of making effective vaccine plans, states must partner with major provider and payer networks as well as county health clinics and federally qualified health centers that typically deliver care to underserved populations, all of which have the best line of sight into the needs of their patients and beneficiaries.
The health of our country and economy depend on it.
Gary Velasquez is the co-founder and CEO of Cogitativo, a data science company.
Wondering how long they keep those vials of the Pfizer vaccine out like that in the article’s photo. I do believe Pfizer recommends no more than 2 hours of exposure to average room temperatures(not certain about defrosting time) for their mRNA vaccine to remain “usable/functional/potent”. After 5-6 hours it just becomes “as good as a placebo” or essentially useless for its purpose.
This article is exactly why the vaccine rollout is failing so miserably at the moment – complete and total overthinking and over complication of the process. Keep it simple. Everyone who is 65+ or a frontline worker – medical, police/fire, teacher, etc is eligible. Get the shots in the hands of all the people usually responsible for distributing the flu vaccine. We normally get half the country vaccinated for the flu so trust that the private sector knows how to get that job done year in and year out. Stop choosing this moment in a pandemic with many dying and millions out of work to right hundreds of years of wrongs against the poor, minorities etc. Get as many shots into as many arms as possible without wasting a single dose and we will all benefit.
The problem is maintaining temperatures for storage and distribution. The Pfizer vaccine requires around -90* F temperatures for long term storage and no greater than 40* F temperatures for short term(approx. 5 days) storage. The Moderna vaccine requirements are slightly better with -4* F long term and 32* F for a month of storage. The vials of vaccine can’t be left out in warm temperatures(or the complex mRNA component inside becomes useless).
These need special freezers not found everywhere for storage. Only the Moderna vaccine(right now) is really suited for (short term) distribution to “normal” flu vaccine clinics outside hospitals. But small scale Moderna lacks the production capacity of pharmaceutical giant Pfizer, so most available vaccine is from Pfizer.
Speed is far more important than precision, though it’s not surprising someone who gets paid for “granular analysis” would delay to get precision. But the author fails to mention the most important way to speed up vaccination of the vulnerable: Acknowledge that the vast majority of Covid-recovered persons, more than 100 million Americans, already have acquired immunity, and vaccinate those without immunity first. The refusal of public health authorities to follow this path amounts to wasting a third of the vaccine doses available, giving them without distinction to the immune and the non-immune.
You say: “Health insurers have a longitudinal view of their members’ clinical histories, meaning they have an exhaustive record of individuals’ care and treatment..” Maybe so. But in switching to EHR, my physician has only 5 years history on me – and I have been going there for over 20 years. So there is that. I am 76. But I cannot find a Covid-19 vaccine anywhere in NYS, despite what their apps tell me. I have followed all the social distancing rules and have not seen my children and grandchildren since 3/2020. I am not happy.
Couldn’t disagree more with the author. The roll-out of vaccines has been slow for a number of reasons, including the fact that a substantial number of medical personnel either don’t want the vaccine or want to wait to find out about adverse events. Further, nursing homes had to get doctor permission for residents to start administering the vaccine. The result has been lost reservation spots and thus, no vaccinations.
The idea is to keep it simple and verifiable. The notion of basing distribution on occupation is absurd…it cannot be verified in a large number of cases, and this only leads to actual and perceived line-jumping. Similarly, many people will not release their medical records regarding Type 1 diabetes or any number of things. Thus, waiting for such information is a complete waste of time and lives. Fortunately, a number of states have moved to make the vaccine available to people 65 and older…which is what the vaunted CDC advisory committee should have done.
This seems like a case of excess precision. Whether the individuals with type 1 go before or after those with type 2 is less important than getting them both done within weeks rather than months. Getting it slightly more right means enormous time spent discussing exactly who is at slightly more risk than someone else, generating wasteful competitions among groups. More shots now for more people is the right move. The one shot/half dose discussion is far more productive.
As a retired self employed primary care internist with 4 decades hands on experience I can tell you that these plans to rank people queing for covid vaccination are unworkable. They violate the KISS principle: keep it simple, stupid! There is not the staffing and staffing by actual physicians who comprehend complexities of diagnoses and pathology to rank all the people in the practices. Further the medical records being generated today are billing devices not designed to transmit medical information between physicians. Just find people with willing arms and put the needles in. Let’s use the “Nike principle”: just do it!
As an OB/GYN with over 25 years of active practice you are saying what I have been saying for some time now also. The problem is not making it fair in every last little case, the problem is rolling out the vaccination program and getting more shots in the arms.
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