The annual U.S. flu vaccine campaign has been cast into disarray by COVID-19, with people staying away from pharmacies, schools, offices, hospitals and other places where they typically get their shots. But with fears of a flu surge colliding with the coronavirus pandemic, health authorities are looking at how one vaccine effort can inform the other. 

In Denver, public-health officials are trying to increase the number of adults who get the flu vaccine this year to 65% from 45%. To do it, they’re setting up “strike teams” that can go from school to school giving vaccines, vans that can stop at construction sites and inoculate workers, and doing outreach to hard-to-reach communities.

“This whole model that we’re building can then be moved into COVID,” said Judith Shlay a physician and associate director at Denver Public Health.

In Baltimore, the city has several vans it sends out to conduct COVID-19 testing, targeting high-risk residents. It will likely use those vehicles for flu vaccines and then COVID-19, City Health Commissioner Letitia Dzirasa said in an interview.

“Our flu vaccine distribution will inform a Covid vaccine distribution,” Dzirasa said.

The federal government has helped lead development of a vaccine, issuing more than $4 billion in contracts to drugmakers. The money is meant to speed production and cut financial risk for the most promising of the dozens of inoculations in development. President Donald Trump has said a shot could be ready by November, though other experts inside his government predict it will be well into 2021 before most Americans have access to one.

So far, federal health authorities have offered little detail about their plans for administering vaccines. The U.S. has said that it will likely rely on the private sector to distribute the shots, and last week extended a contract to health-care supplier McKesson Corp potentially worth more than $300 million. But the government has said almost nothing about who will get the shots first, where they’ll be given, and how to make sure they get to hard-to-reach and vulnerable communities.

At least 170,000 people in the U.S. have died of the virus, many of them as a new surge of cases has expanded outside the Northeast to other parts of the country. While new cases have fallen from last month’s daily high of almost 80,000, new outbreaks are being reported in schools and colleges as students return, forcing some to shut days or weeks after opening. 

This week, the U.S. Centers for Disease Control and Prevention plans a call with health-care providers to discuss flu vaccination, along with guidance for delivering vaccines during the pandemic and operating “large vaccination clinics held in satellite, temporary, or off-site locations.”

In the meantime, local authorities are still awaiting clarity. “We have not heard anything yet,” Baltimore’s Dzirasa said. 

The U.S. has been consulting with experts and medical ethicists on COVID-19 vaccine allocation plans. The government plans to work with the existing medical-distribution network to get shots to the public, said a senior Trump administration official, with possible help from the Defense Department.

Never Done Before

There is no single national U.S. flu vaccination campaign, per se. American and global health authorities pick the flu strains to target, drugmakers manufacture the shots, and they’re given by workplaces, schools, drugstores, local public-health departments, physicians and hospitals.

The federal government typically plays a role in financing and promoting the vaccines, but not in physically distributing them. This year, the Centers for Disease Control and Prevention has purchased 9 million doses of the adult flu vaccine, compared with 500,000 in a normal year.

The scale of the vaccination campaign needed for COVID-19 will be a daunting logistical challenge, said Howard Markel, a physician and historian of medicine at the University of Michigan School of Public Health. Past efforts to vaccinate against pandemic threats have fallen short.

“We’ve never vaccinated an entire American population,” he said in an interview.

In 1976, after an outbreak of swine flu at Fort Dix in New Jersey, the Gerald Ford administration planned a mass vaccination program to prevent a pandemic. “They were held in large gymnasiums and public meeting places,” said Markel, who recalled getting the shot when he was 16. “It was really very much an assembly line.”

The vaccination drive was dismantled after several cases of Guillen-Barre syndrome were identified in people who got the shots. A U.S. review of the campaign in 2003 confirmed the increase in cases of the disease, which can cause a form of muscle weakness or temporary paralysis, though the exact biological link between the vaccine and the condition wasn’t established.  

In 2009, the H1N1 flu pandemic prompted another effort to quickly produce vaccines. Ultimately, only about 20% of the population got the shot, Markel said.

“It is an enormous task, no question about it,” Markel said.

Public-health officials will also have to overcome reluctance by some Americans to get a shot. An Aug. 7 Gallup poll found that one-third of people would not get a COVID-19 vaccine when it’s ready, even if it was free. And some Americans have rejected basic public health measures like wearing masks or social distancing, raising more questions about how willing they are to participate in a vaccine campaign.

Some vaccine infrastructure already exists. A surge in demand for COVID-19 tests had drugstore chains, states and cities set up sites where people could line up or drive through. And the H1N1 flu pandemic also provided a roadmap for mass vaccination, said CVS Health Corp. Chief Executive Officer Larry Merlo.

“That was really the spark plug,” Merlo said in an interview this month. The company is in planning sessions with officials for an eventual coronavirus vaccine, Merlo said.

A spokesperson for Walgreens, the next-largest U.S. pharmacy chain behind CVS, said both existing testing and immunization infrastructure will support the future delivery of Covid vaccines.

Sanofi, the French drugmaker that’s working with GlaxoSmithKline Plc on a coronavirus vaccine, said it’s been in touch with CVS and other drugstores about vaccination plans.

“I would suspect that some of the blueprint that we’ve developed for flu immunization will also hopefully be a blueprint for COVID-19 vaccination,” said Elaine O’Hara, Sanofi’s head of vaccines for North America.

Denver Plan

At Denver’s public health department, Shlay said she began thinking about how to deliver COVID-19 vaccines back in June.  

She knew childhood immunizations had dropped sharply since March, when COVID shut things down, and she thought her agency could build a model to get a COVID-19 vaccine to people who need it.

Under a $1 million grant from the CARES Act, the federal stimulus law to respond to the pandemic, her team has begun working on alternative flu vaccination strategies. The strike teams they are developing will be targeted at 84 schools where vaccination rates have slipped. And the agency is working with leaders from the Black, Hispanic, Asian and Native American communities to bring flu-shot sites into neighborhoods.

Particular outreach will focus on uninsured and unemployed adults — some of the same people are more likely to be hospitalized if they get sick — along with essential workers and people who are homeless.

“We are going to try to reach that group that people don’t always think about,” Shlay said.

There will be challenges making the switch to COVID-19. Early vaccines are expected to require two shots weeks apart, compared with a single flu dose. Health officials will have to keep careful registries of who has received which shots when, and make sure to reach people when their second doses are due. They’ll also have to handle the logistics of keeping vaccines refrigerated at the proper temperature.

“A two-dose COVID vaccine will be much more complicated,” Shlay said. That’s part of the reason Denver health officials are planning now. “COVID has made us do things quicker than we’ve ever done before, and so we figure it out and we do it.”