SciLine interviewed: Dr. Julie Swann, the department head of industrial and systems engineering at North Carolina State University. Her research focuses on improving the operations of health and humanitarian systems, and during the pandemic she has been analyzing the public health impacts of COVID-19 and creating models to help state officials make policy decisions.
What are the largest supply chain issues the country faces in distributing COVID-19 vaccines?
JULIE SWANN: So one of them is the gap between the doses that have been distributed and the doses that have been administered. I like to remind people that it’s not always comparing apples and apples because distributed means that it shipped out from a distribution center. But it may not have arrived at states yet. And administered means that it’s recorded in the administrative system. But sometimes it takes a couple of days to get it recorded. One of the other big challenges is that we are trying to reach priority groups so we can reduce mortality or deaths, reduce morbidity or hospitalizations, make sure that society can keep functioning and address some of the inequities that we’ve seen in the burden of COVID-19. Another challenge is that we have a lot of demand right now and, really, not enough supply. So what’s happening is that people are really eager to get it. And they’re making lots of phone calls and making appointments. And it’s turned into a little bit of a “Hunger Games” competition for a vaccine. Finally, one of the other challenges that we’re addressing in the supply chain are some of these inequities. And we’re already starting to see that in some of the distribution, we’re finding that groups that have more resources are better able to access the vaccine and have much higher uptake.
Why are issues occurring in the COVID-19 vaccine supply chain?
JULIE SWANN: Some of the key things that are driving the challenges that we’re seeing in the supply chain are uncertainties. So for example, the state health departments in other jurisdictions don’t have a really good sense of what the demand is going to be at any particular location. So when they send a shipment of vaccine, let’s say Pfizer, that has a minimum of almost a thousand doses in the box, they don’t fully know whether that demand is going to be sufficient at that location to use of that particular supply. Another factor that’s really driving the challenges is that supply is not what we want it to be. We want it to be much bigger. And it’s also been variable over time without a whole lot of knowledge about what’s coming down the pipeline in the supply chain. The more stable that we can make that supply and the more knowledge that health jurisdictions have about what’s coming, then the better that they and the providers are going to be able to plan the administration of doses. Another factor that is driving some of the issues is that reaching priority groups does take some time. You can identify them sometimes and send vaccine to particular locations. But it does take some time to get people vaccinated. It’s faster to run a mass vaccination clinic and let anyone have access to the vaccine. But that would not reduce mortality and morbidity as much as we would if we’re focused on priority groups. Finally, one of the other factors that’s driving things in the system is that people have different resources. And access across the system is not the same. So we know that there are some places that have pharmacies and doctors’ offices. And some places are medically underserved. We also know that some populations have more access to technology, which is helping them get appointments for this limited vaccine, and other groups or populations may not. So that is one of the other factors that’s driving the things we’re seeing in the supply chain.
What can federal and state governments do to deliver vaccines more efficiently?
JULIE SWANN: The first thing is to get that supply up. We definitely want to see that increase. If we had two or three or five times as much supply, then we could meet more of this demand quickly. I am hopeful that our supply is going to be increasing. Secondly, we’d like some stability and foreknowledge about what’s coming down the pipeline of the supply chain. I think we’re starting to get that now. And I hope that that will continue, especially as more vaccines may come onto the market. A third thing that’s really important is information across the whole system. We know that some states have better information systems than others built up over years and years of investment in public health. And information flows at lots of different places in the supply chain. We have it on the top side coming from the supply to the states who are making their allocation and distribution decisions. But we also have it on the other end, where after a dose is administered, we have to get that record into the system. The more that we can do to make sure that those systems are automated, standardized, et cetera, the better off we’ll be. Another thing that we can make sure that we’re doing with our health jurisdictions is making sure that there are ways to access vaccine and access appointments to vaccine that do not depend on someone having technology at home. Some organizations are also using waiting lists, where they may have people join by phone. And this can be a good thing. But you really have to manage it well to make sure that, you know, people are not really getting frustrated by that.
What distribution approaches could help get vaccines to rural areas and older people?
JULIE SWANN: Health jurisdictions are figuring out ways to get vaccine to every corner of the United States. This includes rural areas, where they may be using mobile vans to help deliver that vaccine and meet people where they are. In some cases, they’re going door to door and knocking on doors to make sure that people know about the vaccine and have access to the vaccine. Some states are standing up websites where people can determine what eligibility group they’re in and help them find vaccine across the state. We do see some continued concerns about some people who have less access to technology, so states should also make sure that they have ways to reach those people, which can include phone lines and call centers, as well as neighborhood and community outreach. One other population that a lot of health jurisdictions are focusing on – and we really need to – is communities of color. So populations like African Americans, Hispanics, Native Americans, each of these different communities across the U.S. may have their own challenges, including accessing vaccine geographically – how far they might need to travel – accessing vaccine in terms of what technology might be needed to get an appointment and get a shot, as well as addressing any concerns that they might have in the vaccine hesitancy and reducing that.
Are there other special populations that would be helped by distribution approaches tailored to their needs?
JULIE SWANN: Health jurisdictions have identified a lot of priority groups that are more than just what we see defined at a national level. For example, I know one health jurisdiction has an initiative for the homeless to make sure that they have access to vaccine. You can imagine the access for someone who is homeless looks very different than that for someone living in a house in a suburb. So they are partnering with community groups. They are using trusted messengers to get the word out. They are going to be taking vaccine from place to place. That will take time. I’d like to encourage people to try to remain patient and give health jurisdictions time to work through all of these challenges in this really complex system.
What have previous mass vaccination efforts taught us about how to deliver vaccines efficiently?
JULIE SWANN: So I was on loan to the Centers for Disease Control and Prevention back in 2009 and 2010. I was a science adviser looking at vaccine distribution, and I especially studied what state and local health departments were doing. So, you know, there are a number of factors that were associated with increased immunization uptake. One of those is lead time. In that case, it was the lead time from receiving an allocation of vaccine to really ordering that and determining where that would go. A second factor is making sure that there is broad access to vaccine – not only in doctor’s offices, but in other locations like pharmacies, community care clinics, mass vaccination events and potentially even events at employer sites or schools and things like that. Those are really important, and we know that those work. Education and messaging is also very important. And keeping people safe while they’re getting their vaccine administered – we know from past events that that’s important as well. We’ve learned a lot over the last years, but there are still things that we need to do, and some of these take time to put into place.
State and local systems had months to prepare for COVID-19 vaccine distribution, so why are they still encountering problems?
JULIE SWANN: There are several factors that are contributing to that. One is that state and local health departments didn’t really have the resources to really develop full systems. There were some resources, a limited amount, that were put aside for things like hiring staff to help administer vaccine, but to really make this supply chain efficient and effective and equitable, we really need underlying infrastructure, like information systems and data. And if you look at some of the states that are performing better with others, it’s partly as a result of investments over a longer period of time in their public health infrastructure and in their information and technology systems.
What changes do you see coming up in the continued COVID-19 vaccination campaign?
JULIE SWANN: What we have in the next coming weeks is that things are getting more complex. Health jurisdictions are starting to use more and more providers. And now they’re allocating both the first doses and the second doses. We’re also starting to see some of these mass vaccination events, and some people may come back for their second dose to that kind of event, where some may go to a different location for their second dose. As we continue to expand to additional priority groups, it’s also going to continue to get more complex, as we’re focused perhaps on reaching employers in essential industries, people with high-risk medical conditions, et cetera. So, you know, I ask that people, you know, try to be patient and realize that this is going to take a while and that everybody is doing what they can to make sure that things go efficiently and effectively and equitably.