We Must Use the Vaccination Infrastructure We Already Have
Pharmacy and primary care are dramatically underallocated with COVID-19 doses compared with influenza efforts.
Against the backdrop of the coronavirus disease 2019 (COVID-19),the Centers for Disease Control (CDC) reports that 81,230 deaths occurred from drug overdoses for the 12-month period ended May 2020, just a few months into the pandemic.
This increase of more than 18% from the 12 months prior represents the largest number of drug overdoses ever reported.1 Even more concerning are anecdotal evidence and some more recent localized data points suggesting that the drug epidemic and the pandemic and resulting economic downturn for tens of millions of Americans have created increased despair, more joblessness, and reduced social interactions.
Judicious Prescribing and Dispensing Are Now Largely in Place
Over the past decade, much effort has been made to increase opioid prescribing and dispensing stewardship. With more than a half-million dead and millions hospitalized in the United States, the COVID-19 pandemic will be seared into our collective consciousness for generations.
In fact, demographers have already determined that Americans born between 2016 and the 2030s will be named “Generation C” for the enduring and profound effects of the COVID-19 experience on their early development and, ultimately, their life outlook.
If the effects are tectonic, so must be the response.
New Path Forward
Getting out of this mess required painful, short-term decisions to reduce the spread, namely masks and social distancing, alongside one of the most ambitious medical endeavors in human history. The international scientific community, led largely by hefty investments by our federal government, prepaid for vaccines in the hundreds of millions through Operation Warp Speed and other collaborations. The attempt to shorten vaccine development, testing, and manufacturing to a 12- to 16-month process relied on the bold assumption that the vaccines would work when they entered clinical trials.
Because the federal government prepurchased the vaccines, it put itself in the position of controlling distribution, choosing McKesson as the primary distributor and putting the CDC in charge of initial allocations through
2 programs. These are the jurisdictional program (protectorates, states, and territories) and the federal pharmacy program, for which 21 pharmacy location aggregating entities signed up as network administrators for reallocating vaccine to their pharmacy locations based largely on the number they represented. Long-term care facilities were set up in a separate system specific to their populations and facility staff members.
Mass Vaccination Favored
The initial allocations for phase 1 groupings were intended to go through the jurisdictional program and focus on high-risk populations. Jurisdictions largely looked to their departments of health, which tended to look toward 2 main entities for logistical and political convenience: large health systems and local health departments (LHDs). Both favored off-site, mass vaccination approaches because hospitals did not want to clog up primary care and other traditional sites where they were desperately trying to bring back revenue on procedures, and LHDs provide only a small portion of health care services overall in generally small clinic footprints.
Yet polling reveals a stark difference in patient preference compared with the chosen approach.
Underserved and Left Behind
As of late March 2021, about a quarter of the way through the country’s initial vaccination effort, many Americans had received their vaccinations not in health care service locations but on airport runways, in music or sports venues, or in parking lots. For some in public health circles, this brought a renewed sense of empowerment to a chronically underappreciated and underfunded workforce.
But for many frontline care providers, lack of access to vaccine allocation brought frustration and panic. Many patients expected to get the vaccine from pharmacies and primary care providers in their communities, where they already receive health care services and vaccines multiple times a year.
National firm Public Policy Polling conducted a survey in February that showed doctors’ offices and pharmacies as the sites of care for 32% and 38%, respectively, of adult influenza vaccinations in 2019.1,2 Yet just 10% and 9% of patients had received their COVID-19 vaccinations from those sites of care. This represents a nearly a 4-fold decrease in access to COVID-19 vaccinations from a patient’s chosen site of care.
When asked their primary preference for COVID-19 vaccination administration site of care, 36% responded “doctor’s office,” and 24% said “pharmacy,” indicating largely the same preferences as for the influenza vaccination.
Mass vaccination sites represented 4% of primary preference but 17% of actual COVID-19 vaccinations. Hospitals represented 5% of primary preference but 20% of actual COVID-19 vaccinations.
Meanwhile, patients already receiving care from pharmacists and physicians who have low capacity are at risk of being left behind by the mass vaccination approach. For the most of January and February, both provider types were unable to meet the needs of the patients they serve who do not have a patient advocate or caregiver or surf the internet, have behavioral health limitations, or otherwise do not trust the government or large institutions.
These are patients who make health care decisions based on longstanding relationships.
As former US Speaker of the House Thomas Phillip “Tip” O’Neill Jr famously quipped, “All politics is local.”
So, it seems, is rationing of health care services. Once vaccines became available, governors and public health officials necessarily and understandably latched onto allocation as a means of demonstrating action and control over the pandemic response. With good intentions in most instances, those officials determined when and where vaccines were delivered and to whom they were given and, for the most part, successfully channeled vaccine relatively efficiently to most at-risk and socially vulnerable populations. Rates of death and hospitalizations, arguably the 2 most important metrics, dropped precipitously in February and March.
But the consequences of leaving out pharmacy and primary care from the initial push for vaccinating at-risk individuals in the community will start to show as spring emerges. As many as one-third of patients aged over 65 years remained unvaccinated as of mid-March.
This is what government-controlled health care looks like. Frontline providers must be engaged with public health officials early and often in pandemic response. Pharmacy and primary care providers must make the case now and when preparing for future emergency responses. Frontline health care providers, involved in the everyday care of vulnerable populations and rich in data and relationships, are in the best position to serve patients, during the pandemic or otherwise.
They can be the “national guard” of the health care system in emergencies.
Mass vaccination clinics are great spectacles, but the laws of human behavior and surface area, as well as simple math, suggest a better way.
Many polls and some literature suggest a strong link between vaccine hesitancy or outright resistance to government intervention and health care “experimentation.”
Existing relationships matter, and those strong bonds already exist for hundreds of millions of patients already frequenting the nearly 100,000 pharmacies care and practice sites.
There are 50,000 pharmacies enlisted to provide COVID-19 vaccinations, but only about 10,000 of those were activated in the federal program as of mid-March. If each has a reported capacity of 100 doses per day, they alone amount to more vaccine administration capacity than the government will ever supply.
The speed of mass vaccination clinics is no match for our system’s already plentiful vaccination sites of care. Pharmacy and primary care together maintain the capacity to vaccinate the entire US population in 2 months. In fact, we already attempt to do that every fall with influenza. Let’s use the system already in place next time.
L. Allen Dobson Jr, MD, FAAFP, is editor-in-chief of Medical Economics®.
Troy Trygstad, PharmD, PhD, MBA, is the vice president of pharmacy provider partnerships for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University in Des Moines, Iowa, and his PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.
- Public Policy Polling. https://www.publicpolicypolling.com/
- Hippensteele A. Survey shows Americans prefer a health care provider over a mass vaccination event to get COVID-19 vaccines. Pharmacy Times. March 11, 2021. Accessed March 29, 2021.https://www.pharmacytimes.com/view/survey-shows-americans-prefer-a-health-care-provider-over-a-mass-vaccination-event-to-get-covid-19-vaccines