COVID-19 vaccine plan means some states will lag in getting shots to highest-risk groups

As health care workers and nursing home residents await the first scarce syringes of COVID-19 vaccine, few realize that when they will get a dose depends a lot on what state they live in.

Though they’re first in line for the vaccine, some people in those groups may end up getting vaccinated after people in other states who are deemed lower priority. 

The vaccine is allocated according to the number of adults in each state, which doesn’t correlate to the number of high-risk people there. As long as supplies are limited, some states won’t get doses proportionate to their needs.

In those places, medical workers and residents of long-term care facilities will be exposed to the coronavirus for weeks or months longer. They’ll be more vulnerable to sickness and death.

Nevada is one of the winners. According to a USA TODAY analysis of data from Surgo Ventures and Ariadne Labs, the state has relatively few residents in the highest priority group. Based on the federal formula, it will be able to vaccinate all front-line health workers and nursing home residents once the federal government distributes 13.6 million doses nationwide. 

Massachusetts, which has a lot of medical workers, won’t hit that threshold until 25.5  million doses have been distributed across the country – potentially weeks into the new year. By the time Massachusetts vaccinates the last person in its highest priority group, Nevada could have moved on to lower priority groups such as elderly people, teachers and grocery workers. 

Washington, D.C., fares worst in the country. It won’t be able to vaccinate all its health care workers until 27.3 million doses have been distributed nationwide.

Mayor Muriel Bowser sent a letter this month to Operation Warp Speed leaders complaining about the “one-size-fits-all formula.” The distribution plan, she wrote, “will leave the district unable to provide vaccinations to the vast majority of our healthcare workers.” 

Health and Human Services Secretary Alex Azar touted the per-person formula as fair. “We wanted to keep this simple,” he said. 

Some immunization experts agree with that rationale. Others contend the point of prioritizing doses is to protect the most vulnerable, and a rationing system based on population doesn’t do that. 

“Easiest may not be ethically best, most defensible or best for public health,” said Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “You want something that’s lifesaving to go where it’s most needed, not just evenly spread across the country.”

Vaccine rationing is inevitable 

Each day, about 2,600 Americans die from COVID-19, and about 211,000 new cases are reported.

U.S. coronavirus map:Tracking the outbreak

Federal officials said they expect 20 million vaccine doses – enough to provide the first shot to that many people – to be distributed by the end of the year. That includes vaccines produced by Moderna and Pfizer/BioNTech, both of which require two doses. 

This month, the Centers for Disease Control and Prevention issued guidelines urging states to dispense vaccines in three phases. Phase 1a includes about 21 million health care workers – doctors, nurses, nursing home employees and support staff – and 3 million long-term care residents, including those in nursing homes. 

Phase 1b covers essential workers such as police, firefighters, food workers, teachers and grocery store employees, as well as people older than 75. Phase 1c includes people 65 to 74, people 16 to 64 with high-risk medical conditions and other essential workers.

The 20 million doses expected by the end of the year would be nearly enough to inoculate every American in Phase 1a, according to estimates from Surgo Venturesand Ariadne Labs, a partnership between Harvard University and Brigham and Women’s Hospital in Boston. 

But under the per-person formula, 18 states and the District of Columbia would not have enough, leaving many in the highest priority group unvaccinated by the time the government distributes the first 20 million doses, according to a USA TODAY analysis. 

Other states would have a relative bounty of vaccines – enough to move on to other risk groups, vaccinating firefighters, teachers, supermarket clerks, people older than 75 and others.

The analysis does not include doses allocated to five federal agencies, including the Department of Veterans Affairs and Indian Health Service. Warp Speed officials have not said exactly how those will be apportioned. Nor does it account for a 5% reserve, which federal officials said is to cover distribution emergencies such as the crash of a plane loaded with supplies. 

The inequity of the per capita formula is evident in Wyoming and South Dakota, neighboring states in the northern Plains. 

About 9.5% of South Dakota’s adult residents fall in Phase 1a of Operation Warp Speed’s plan, according to Surgo and Ariadne's estimates. They would not all be vaccinated until the government has distributed 24.5 million doses across the country. South Dakota would be the third-to-last state to cover its highest-risk group, behind New York and Massachusetts.

Health care workers and nursing home residents account for just 5.8% of Wyoming’s population. They would be inoculated when 14.8 million doses of vaccine have been sent out nationwide – the second-fastest state to cover its highest priority group, behind Nevada.

Health care workers and nursing home residents first in line 

The Trump administration, aware that rationing is a certainty, publicly debated who should get vaccines first. The president’s Coronavirus Task Force, Operation Warp Speed and the Department of Health and Human Services contemplated the ethical, logistical and political factors.  

A CDC vaccination program playbook spells out the essential goal: “The first step in planning is to identify and estimate the critical populations within a jurisdiction.”

This month, the CDC Advisory Committee on Immunization Practices  recommended that health care workers and residents of long-term care facilities be first in line.

Instead of setting up a national distribution system based on those groups, Operation Warp Speed leaders announced that states would receive vaccine supplies based on their adult populations. 

Lynn Goldman, an epidemiologist and dean of the Milken Institute’s School of Public Health at George Washington University, said it makes no sense that federal authorities instructed states to figure out who should get vaccines first but didn’t allocate based on that principle.

“Logically, distribution should follow the priority patient scheme,” Goldman said. “There are ways that could have been planned in advance.” 

Lori Freeman, chief executive officer of the National Association of County and City Health Officials, said Warp Speed leaders did not get input from local authorities, who have to carry out the national vaccination program and may get blamed for failures. 

“We’ve been struggling the whole time to get a foothold” in federal decision-making, Freeman said, adding that community health officers were left out of planning for COVID-19 testing and tracing, too.  

“This is challenging no matter how you slice and dice it,” Freeman said. “There’s not going to be enough vaccine in the first rounds.” 

Why the feds chose this formula 

Not all immunization experts view Azar’s decision as unfair or unreasonable. 

Dr. Kelly Moore, associate director of the nonprofit Immunization Action Coalition,described the vaccine distribution effort as an “extraordinarily delicate dance,” in which distribution is the most difficult maneuver.  

The first and most important objective is to vaccinate key populations as quickly and efficiently as possible, she said. Because there will be multiple complications, including changes in supply and demand, Moore said a per capita formula makes sense.  

“There is great appeal to doing something simple and understandable,” she said.  

“Sometimes a blunt instrument is more useful in a situation like this,” Moore said. “I’m not sure the choice was an absolutely right choice, but it is a reasonable approach.” 

She acknowledged the simple formula may not work everywhere, and there should be some flexibility. She said cities such as New York and Washington may need extra doses because they have so many health care workers who commute from other states. 

Virginia and Maryland, recognizing that issue, each plans to donate 8,000 COVID-19 vaccine doses to the District of Columbia.

Esther Krofah, executive director of FasterCures, part of the Milken Institute, said the COVID-19 vaccine is "a massive undertaking that demands simplicity in the execution."

A distribution formula based on the number of high-priority residents in each state would have made things more difficult, Krofah said. “You want to get the vaccine out as smoothly as possible and as efficiently as possible.” 

Tom Bollyky, director of the global health program at the Council on Foreign Relations, said the population-based formula is “politically and logistically expedient.” 

It gives the Trump administration a clear, politically neutral approach. But it doesn’t make medical or ethical sense, Bollyky said, and it puts states in the position of figuring out who to vaccinate first.

Speed vs. risk 

When announcing the distribution plan in November, Azar suggested that inequities caused by a per capita formula would be temporary. 

"Once we pass through these initial tranches where we're in much more of a scarcity situation, we're eventually going to get to the point where it would need to be per capita,” he said, “and so instead of having multiple methodologies, we thought it best to keep it simple.” 

That allowed Warp Speed to avoid an emerging controversy in bioethics: the complaint that traditional vaccination campaigns unfairly leave out disadvantaged groups, especially people of color who are among those suffering most from the coronavirus. 

Opinion contributor:Trump team COVID vaccine plan will fail people of color. Fast does not mean equitable.

Tuesday, an Operation Warp Speed spokesman reiterated Azar's rationale for distributing the vaccine based on the number of adults in each state. 

“In addition to ensuring fair and equitable distribution to each jurisdiction due to effectively nationwide spread of the virus, it would also prevent the need from switching the formula mid-vaccination effort," said Michael Pratt, chief communications officer for Operation Warp Speed. "The governors supported that from the feedback they provided.”

James Nash, spokesman for the National Governors Association, said the group wasn’t consulted on the decision and declined to comment on its potential impacts. 

Peter Pitts, president of the Center for Medicine in the Public Interest and a former associate commissioner at the Food and Drug Administration, said Operation Warp Speed’s development and production of vaccines has been “brilliant,” which makes the distribution plan all the more puzzling.

“I’m shocked that Warp Speed didn’t do those calculations” to determine how many at-risk residents are in each state, he said. “It’s not rocket science to know what that looks like on a state-by-state basis. It’s student intern work. ... I just think somebody did not have their eye on the ball.” 

Patsy Stinchfield, a nurse practitioner at Children’s Minnesota and president-elect of the National Foundation for Infectious Diseases, said the population-based allocation “won the day” because Operation Warp Speed faced a “time crunch.” 

Stinchfield, a liaison to the CDC’s Advisory Committee on Immunization Practices, said developing a formula based on vulnerable groups and disease control would have required research plus a balancing of science, ethics and logistics.  

Instead, the Trump administration adopted a system based on simplicity rather than science or ethics. “I would not say it is an equitable process,” Stinchfield said. 

The federal government also took a per capita approach when distributing a vaccine for the H1N1 virus in 2009 and 2010.  

A study at the Massachusetts Institute of Technology by researchers Richard C. Larson and Anna Teytelman found that the CDC’s per-person allocation for H1N1 overlooked not just the difference in at-risk populations from state to state but the way a virus spreads. During an outbreak, they found, doling out doses based on population “may not be the best in terms of averting nationally the maximum possible numbers of infections.” 

Such inequities could have impacts beyond the health care workers and nursing home residents in Phase 1a, said Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit coalition of organizations that advocates for elderly and disabled people in nursing homes. 

“It is truly unfortunate that we cannot do this in a more thoughtful manner,” he said. “It, of course, goes well beyond nursing homes, but even there, think about the family members who could get access to the vaccine – and hence their loved one – sooner if distribution was done more intelligently.”