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WASHINGTON — President-elect Joe Biden is promising to administer 100 million doses of Covid-19 vaccine in his first 100 days — but some of his top advisers are already warning that the early days of that effort are going to be rocky.

The 100-day goal, which would require the Biden team to administer 1 million doses a day, each day, for his first 100 days, would represent a significant ramp-up from the pace set by the Trump administration, which has vaccinated roughly 10.2 million Americans over the course of 30 days.

“The first days of that 100 days may be substantially slower than it will be towards the end,” said Michael Osterholm, a member of Biden’s Covid-19 task force who called the goal “aspirational … but doable.’’ “It’s not going to occur quickly … you’re going to see the ramp-up occurring only when the resources really begin to flow.”

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Nicole Lurie, one of Biden’s top pandemic advisers during the presidential campaign, said similar.

“It is completely unrealistic to think that anyone can flip a switch and everything is going to be fine. It’s going to take time,” she said. “I’m confident that within a few months things are going to even out, but I think people are going to need to be a little bit patient.”

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Most of the public health experts interviewed for this story still think Biden’s goal is achievable, even with the sluggish start to the U.S. rollout. But many cautioned that it won’t be easy, and that a failure to meet the goal could further erode America’s trust in the vaccination distribution effort.

“I would be more inclined to measure the expectations a little bit more … [to] start with a shorter-term goal and declare success so that we can restore faith in the process,” said Kavita Patel, a fellow at the Brookings Institution and a former Obama administration official. “Having said that, I have been on the writing end of so many of those 100-day memos, so I realize that that’s the currency of a White House.”

The challenges facing the Biden team are numerous. States have still not received billions of dollars in supplemental funding appropriated by Congress, hospitals and state health departments are warning of staffing shortages, and vaccination appointment scheduling systems across the country are crashing daily. The Biden team will also have to contend with massive, last-minute changes to the existing vaccine rollout that the Trump administration is throwing out in its final days.

“What we’re dealing with is months and months of dysfunctional management, and that doesn’t get fixed overnight,” said Tom Frieden, the former director of the Centers for Disease Control and Prevention. “It’s a bold goal … but I think it’s an achievable one.”

Biden is expected to release more details of his vaccine distribution plan in a press conference on Thursday. A Biden spokesperson did not respond to STAT’s questions regarding whether the president-elect’s plan will address these challenges, or when the Biden team expects to begin hitting that 1 million shots per day threshold.

Below, STAT walks through some of the biggest challenges Biden will face as he races toward his 100 million in 100 days goal.

Last-minute changes by the Trump administration and supply worries

On Tuesday, health secretary Alex Azar announced drastic, last-minute changes to the country’s vaccine distribution strategy, expanding the pool of Americans eligible for the vaccine to anyone over 65 and prioritizing the distribution of the shots to states that move quickest. He also reversed a previous policy to hold back second doses of vaccines rather than ship them directly to states.

The drastic changes are likely to create massive headaches both for federal officials managing the national vaccine supply and state and local health officials who were blindsided by the changes and are now likely to be overwhelmed with new demand for the vaccine.

“All three were surprises and each one has potential downsides,” said Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials. “When you combine them all together, it compounds those challenges.”

It’ll largely fall to a newly minted Biden team, just settling into their offices in the White House, to implement the sweeping changes.

“It’s the Biden administration that’s going to be doing this,” said Patel, the former Obama administration official. “That in and of itself is a good example of how the first several days could just be difficult. … That’s no small effort to change the allocation of vaccine.”

Casalotti, too, is warning that the last-minute changes could muck up Biden’s 100-day pledge.

“There’s even more question marks to an already challenging goal,” Casalotti said.

A persistent lack of funding

States have warned for months that they lack the funding they need to carry out the type of mass vaccination campaign necessary to combat Covid-19. That issue, despite recent congressional action, isn’t going away.

Late last month, Congress appropriated nearly $8.75 billion to help stand up state vaccination efforts, but the money still hasn’t reached states, according to the Association for State and Territorial Health Officials.

Some of the money is likely to arrive next week, but health departments will still need time to hire staff and ramp up efforts. Local health departments, which rely on states to funnel the money down to them, fear that they won’t receive their share of the money for weeks, if not months.

Osterholm, the Biden task force member, emphasized local and state funding as one of the biggest challenges facing the Biden 100-day goal. He said the expected infusion of funds will be helpful, but the benefits will not happen overnight.

It’s also unclear whether that funding will truly be enough to stand up the sort of mass vaccination effort Biden is envisioning. Biden himself has called the recent stimulus package a “down payment.”

“The Biden-Harris team has been in contact and have had very, very important and very meaningful conversations back and forth with state and local public health leaders,” Osterholm said. “They see it, they already recognize the resource needs are going to be more than the [8.75] billion.”

Workforce challenges

Both state health departments and hospitals have warned that they do not have the staffing to conduct the massive vaccination efforts needed to tackle Covid-19.

“Hospitals are committed to be a central part of the vaccination effort, but hospitals alone cannot do it, especially as we care for burgeoning numbers of critically ill COVID-19 patients, and struggle to maintain sufficient staffing work to have enough personal protective equipment and other resources,” the American Hospital Association warned in a letter to Azar on Jan. 7.

Some state health departments, meanwhile, including Oregon and Ohio, are already mobilizing the National Guard to help with the vaccine effort.

“Of the big three: space, stuff, and staff, the workforce issue is the biggest challenge,” said Jim Blumenstock, senior vice president, pandemic response and recovery, at ASTHO. “States are exploring all of the options … along with working existing staff overtime and contracting services as force multipliers, which takes money.”

Ashish Jha, dean of the Brown University School of Public Health, said he believes the Biden team should send in some form of federal workforce to help with the vaccination effort.

“FEMA does this all the time in natural disasters. FEMA doesn’t just say, ‘Here’s a bunch of supplies, good luck, call us after the hurricane is over.’ FEMA sends in people,” Jha said.

Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security said Biden could increase the vaccine workforce by further mobilizing the National Guard and U.S. Public Health Service, allowing civilians to get vaccinated at the Department of Veterans Affairs, and changing regulations to let other health providers, including EMTs and dentists employed by the government, to deliver vaccines.

“All of that can be brought to bear, almost like a warlike setting — just the way that they did with Operation Warp Speed to get the vaccine developed. They need to have that same type of intensity,” Adalja said.

Chain pharmacies have also insisted that they could help fill the staffing gap. A National Association of Chain Drug Stores briefing document shared with STAT claims the group’s members, which include Walgreens, Walmart, and CVS, could administer 100 million vaccine doses in just 30 days. That estimate, however, is dependent on both there being enough supply of the vaccine and enough people willing or eligible to be vaccinated.

Computer system woes 

Around the country Americans’ efforts to get vaccinated are being thwarted by lack of planning and faulty technology.

New Jersey’s vaccine scheduling portal experienced widespread crashing after it was launched this month. So did the website for Salt Lake County, Utah.

New York Comptroller Scott Stringer took to Twitter earlier this week to slam his own city’s vaccine website for being “complex, burdensome, and buggy.”

“It will present an obstacle for too many people — particularly seniors — trying to sign up. This is a major problem,” he wrote.

Many states, including Florida, haven’t even developed a centralized appointment system for their state. Every county in the Sunshine State is handling its own appointments, with some relying on the website Eventbrite. The state is now developing a centralized appointment system, according to the New York Times.

Technological problems, however, aren’t easy to fix. After all, it took a massive effort by the Obama administration to fix the glitches that overwhelmed the Obamacare website in 2013, HealthCare.gov.

“I literally feel like I’m reliving the HealthCare.gov disaster, on an hour-by-hour basis,” said Patel, the former Obama administration official.

  • Is the Biden pledge that there will be 1,000,000 1st dose recipients each day for first 100 days, or that a total of 1,000,000 doses will b e administered each day (1st dose recipients and 2nd dose recipients added together)? What is latest data on daily production releases by Pfizer and Moderna?

  • Why is everything slanted so negative? The latest vaccination rate is already at 1M a day…… so if it keeps growing, does that mean the new administration will slow it down to 100M shots in 100 days? The States are clearly expanding the sites and will handle whatever vaccines show up. The only issue is how many vaccines are produced. I have been in production my whole career and things always start slow but quickly improve with learnings….

  • There IS staffing out there…..put out a call to retired RN’s MD’s and other medical trained people…… many, many of us would volunteer to administer vaccines in our local areas. Those of us over 75 would hopefully have our shots and be able to safely help, and our local Health Dept.’s need that help.

  • States should take out bridge loans to hire the people they need and pay it back when the tons of money appropriated by congress arrives.

  • A mass vaccination took place on Vancouver Island yesterday, for a native tribe that had sharply increasing Covid cases. It was a drive-through operation. First questionnaires & care cards & allergy history in several lines. Cars were then funnelled to nurses ready with needles, vaccines, sterile wipes and bandaids – jabbing one after the other patient still seated in their cars. Safe, swirft vaccinating, with jabs looking far less torturous than from other angles (desks) seen on TV. Well-organized, no big administrative overdrive yet all necessary data obtained & recorded. See you back in 4 weeks. That Canadian work was impressive, certainly compared to current chaos in the US with administrative / directive overkill. Biden and his administration can only do better than the current over-blown incompetent gong-show.

    • That area and country have provincial and federal health care systems and funding. Seems that Canada has its money flow better set up. But they have not vaccinated as many per capita as in the US – which might be due to preferential delivery to the US ? So many aspects to deal with in this enormous undertaking.

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