How hospitals are prioritizing who to give COVID vaccines to first

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The first COVID vaccine has arrived.

The initial shipments of Pfizer and partner BioNTech’s COVID-19 vaccine, which received emergency authorization from the Food and Drug Administration (FDA) on Friday, are already being deployed. And the first tranches will go to those who are on the literal front lines: health care workers.

With hospitals, ICUs, and all manner of medical units overwhelmed by a surge in coronavirus cases, hospitalizations, and COVID-related deaths, the nation’s top medical experts are facing a critical question: How do we get our own workforces vaccinated?

This isn’t just a question of resource allocation—although that is a critical point. It’s a logistical conundrum the likes of which the nation hasn’t witnessed in modern times.

From safe transportation and storage to prioritization of who gets a COVID vaccine to dealing with side effects from the vaccine—which may take out an already depleted and burned-out health care workforce—to regulatory issues such as various states’ differing approaches and even keeping track of which vaccines people are getting, the coming weeks will be a titanic pull for some of the nation’s most critical workers.

Dr. Melanie Swift, one of the doctors tasked with leading the famed Mayo Clinic health system’s COVID vaccination campaign, is in the thick of things this week. And while she’s optimistic about Mayo’s plan, questions and challenges abound.

“The top concern is how you prioritize, amongst all the health care workers, who would be eligible under the CDC recommendation for who should be vaccinated, which the CDC advisory committee voted on Dec. 1,” says Swift, who focuses on occupational and internal medicine in Rochester, Minn.

COVID vaccine distribution is a game of supply chains with multiple players who have to work together. The federal government is coordinating with state governments; state governments are coordinating with local health systems; local health systems are coordinating with pharmacies like CVS and smaller local hospitals; everyone’s coordinating in some fashion with logistics companies like UPS and FedEx and, of course, companies like Pfizer, which are actually making these vaccines.

The operational chain of command is more like a spiderweb of decisions. And ultimately it will be up to individual organizations to figure out what to do with disparate advice, which is meant to build flexibility but can also be confusing.

“The CDC voted to recommend the vaccine as the first wave to all health care personnel. That was more than we were expecting,” says Swift. “We were expecting them to recommend it for a certain set of health care workers, like those who work in hospitals. So we had to determine how to fairly and equitably allocate this limited resource, knowing that health care workers want this vaccine.”

The Mayo Clinic appears to be ahead of the curve on the issue. Several physicians Fortune spoke with in the Los Angeles area, where COVID cases are skyrocketing, bluntly said they have no idea what their vaccination rollout plans will be in the coming weeks. It’s a wait-and-see game that will rely on local governments.

But Mayo, at the very least, has a plan in place. And it is, fittingly, quite clinical.

“We’ve provided a grid of different tasks and places where our people might work,” says Swift. “So the COVID-specific unit, for example, emergency departments, a COVID outpatient vaccine infusion center, etc.”

It goes deeper on an operational scale. There are nonmedical workers who must work within a hospital, and they’re critical to protect as well: the people who take out the bedpans and scrub down the ICUs. Systems have to account for them too.

“There’s about 10 or 11 of these different risks and settings. And it goes all the way down to outpatient clinics, non-direct patient contact staff, and teleworkers. So we’ve got this grid. We actually sent these lists out to the appropriate level supervisor,” says Swift.

“And over the past few days, they’ve been marking the risks box for each of their people, and sending it back in. And so then what we have is a spreadsheet with a bunch of columns, and there’s X’s in the columns,” she says. “And we’re able to then take everybody that’s got an X in the first risk group, and maybe the second and maybe the third, depending on how many we’ve got.”

But as a leader in a sprawling health system, Swift isn’t even sure how many doses of the vaccine will be delivered to various hospitals. She’s received numbers for some places—a few thousand doses here, need to figure out how many over there—but it’s essentially an ad hoc process.

She expects there will be about six or seven waves of vaccines being rolled out to staff, with priority going to personnel specifically designated to COVID-related services, emergency services, and their support staff.

She’s also planning for side effects. The Mayo Clinic has constructed a grid of which adverse events, such as a mild fever or headache or muscle aches, are associated with the vaccine versus what is clearly a symptom of active coronavirus infection.

Swift explains that symptoms such as, say, loss of a sense of smell or taste are things that don’t manifest with Pfizer’s vaccine. So with a depleted workforce, those who display only side effects directly related to the vaccine would probably still be asked to work, while being thoroughly monitored.

Mark, who asked to use only his first name, is an anesthesiologist who takes care of patients in the emergency room on a daily basis at a large New York City–area health system, and he echoes much of what Swift said with a dash of local uncertainty thrown in.

When elective procedures at hospitals were halted to divert resources to COVID treatment, Mark and his colleagues had to use their training to do a job they didn’t exactly sign up for.

“It was sort of a part of our skill set to be involved with that treatment process,” he says. “As anesthesiologists, we are called for intubations for patients, and we’ve had sort of education and simulation around doing intubation safely for COVID patients. So they’re preparing us to be able to take care of patients safely and respond safely.”

As for when Mark himself will get a vaccine? “As I understand it, the plan is to prioritize the people who are actually on a daily basis working with COVID patients or at risk, but not specifically.”

It’s a coordination issue, he says, and relates it to a pyramid distribution system. The federal government, working in conjunction with manufacturers like Pfizer and logistics companies such as UPS, will distribute the vaccines to various state facilities. State governments must then determine which health systems have the most need for COVID vaccine doses and send them their way—and then those health systems will have to prioritize various personnel for vaccination.

And then, as Swift says, larger and more capable hospital systems will have to coordinate with smaller local hospitals to act as a hub for getting their own vaccines in case they don’t have the staff or storage capacity for these delicate pharmaceuticals.

“We meet regularly with other hospitals in our region, some of which are small,” she says. “Because it’s ultracold-storage requirements, it is a burden for small hospitals. The minimum package is 975 doses. So there are hospitals that could not use that or have the ultracold freezer to store it until they do use it.” Mayo is even willing to do the storage and deliver daily shipments to other hospitals on a need-by-need basis. Swift compares the alternative option to going to Costco to buy a toothbrush. It just doesn’t make sense.

As tough as the logistics puzzle is, it’s equally important to track all the data once staff start getting vaccinated, especially after vaccines from multiple companies are available. Ruby, an informatics analyst and trainer who works with major Baltimore-area hospitals, has the critical task of wading through pandemic data management. That includes maintaining vaccine data for major health systems through electronic health record vendors like Epic.

“In terms of the nitty-gritty, our team has been involved in doing the actual Epic build of how the staff are going to distribute and actually administer the vaccine in our electronic health record,” says Ruby, who asked to use a pseudonym for privacy.

“Basically, employees will sign up online to receive the vaccine; they can schedule themselves. And we’ve done that work on the intellectual-property side, and then when they actually show up to get the administration of the vaccine, we have done the build within Epic for the actual vaccinators to be able to document this employee.”

This process also includes following up with certain employees in high-risk departments about who they may have had contact with and whether or not they have COVID symptoms.

Health care workers, medical staff, and nursing home residents are the priority groups for COVID vaccinations, and they are the first groups to pilot this daunting task. There are many timelines going around for other groups, but most public health officials seem to agree a broad rollout for getting a COVID vaccine for your average, non-sick American at a local pharmacy or hospital probably won’t happen until late spring or early summer.

There’s still much to learn about how various states will tackle this distribution dilemma, akin to the problem the U.S. faced when it came to testing at the beginning of the pandemic.

In short: It’s still a work in progress. But the bright side is that we’ll know much, much more within the next month.

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