Previous Vaccine Distribution Efforts (2009 H1N1 Pandemic)

The challenge of effective vaccine distribution amidst health crises is not a new one, as evidenced with the H1N1 Influenza vaccine in 2009. The execution of an effective distribution plan in 2009 was too delayed to effectively limit the spread of the virus. ^{Reference Escuyer, Fuschino and St George3} In the 2009 pandemic, the US government distributed antiviral medications and vaccines through the Strategic National Stockpile (SNS). ^{Reference Dimitrov, Goll and Hupert4} The simple SNS distribution plans, such as releasing a fixed quantity each month from the stockpile to states, proportional to each states’ population size, were optimal for mitigating the spread and effects of the virus. ^{Reference Escuyer, Fuschino and St George3} However, this is most likely attributed to the influenza’s mild contagious effect, whereas more contagious strains, such as COVID-19, require increased supply from the Federal SNS and more optimal policies to include greater-quantity early releases. ^{Reference Dimitrov, Goll and Hupert4}

Pre-existing distribution plans, such as those seen in 2009, have generally followed the following framework: the federal government allocates vaccines to states based on population size, and then states develop their own distribution plans. ⁵ In 2009, vaccines were shipped directly to vaccination provider sites (public and private) from the central distributor. ^{Reference Dimitrov, Goll and Hupert4} States then deployed various types of distribution plans by means of a combination of state and local public health authorities, private health-care providers, and pharmacies. ⁵ While some states relied on local health departments for distribution, some states received all of their vaccine supply and coordinated the physical distribution to vaccine provider sites without partnerships with additional agencies. ⁵ The heterogeneity in distribution plans was reported to have caused communication challenges, especially in the states in which each local health department deployed a unique distribution plan. ⁵

The 2009 CDC H1N1 Vaccine Pharmacy Initiative proved to play an imperative role in the vaccination efforts. In conjunction with the Association of State and Territorial Health Officials (ASTHO), the CDC distributed vaccines directly to pharmacies to assist in the state vaccination campaigns. ^{Reference Koonin, Beauvais and Shimabukuro6} Approximately 10% of adults who received a vaccine during the 2009 pandemic reported getting vaccinated at a pharmacy. ^{Reference Koonin, Beauvais and Shimabukuro6}

Current COVID-19 Vaccine Distribution Approach and Pharmacy Partnerships

The accessibility of community pharmacies makes them a popular location for health-related visits and pharmacists are often the first encounter with a health-care professional for many Americans seeking care. It has been reported that 9 in 10 Americans live within 5 miles of a community pharmacy. ⁷ Pharmacies have, therefore, played a beneficial role in the vaccination of hundreds of thousands of Americans. Using pharmacies increases the accessibility of vaccines at a community level, and their contribution to national, regional, and local storage and distribution can be of use with large scale administration of vaccines, which has contributed significantly in the effort to achieve herd immunity against COVID-19 in a timely manner.

The Federal Retail Pharmacy Program has been structured to aid the COVID-19 vaccination program and will directly supply vaccines to nearly 40,000 pharmacy locations across the 50 states. ⁷ The use of community pharmacies in the distribution of vaccines provides greater availability in convenient and familiar locations. ^{Reference Strand, Bratberg and Eukel8} Several European countries have reported that distribution models that effectively involve pharmacists result in increased vaccination coverage and assist in achieving herd immunity, both extremely beneficial in diminishing infectious diseases. ^{Reference Czech, Balcerzak and Antczak9} Pharmacy participation is particularly important in the circumstance of another rise in COVID-19 cases in which a shortage of medical staff and depleted infrastructure is already a concern. Currently, select pharmacy partners listed as participating in the COVID-19 Vaccine Program represent upward of 50% of total pharmacy industry market share by prescription drug dispensing revenue (Table 1). ^{10,Reference Fein11}

Table 1.

COVID-19 vaccination program select pharmacy partners

^a Determined from company websites.

^b Based on the 2020 Economic Report on US Pharmacies and Pharmacy Benefit Managers (Drug Channels Institute, 2020); https://drugchannelsinstitute.com/products/industry_report/pharmacy/.

The existing national vaccine distribution plan provides support to States’ DOHs by both increasing vaccine supply and enabling equitable vaccine distribution and administration through additional funding. ^{Reference Rapfogel12} Previously, state governments had to develop their own systems to distribute limited vaccine doses, raising concerns of access and equity. ^{Reference Rapfogel12} In the first month of US vaccinations, available data demonstrated that 5.4% of vaccine recipients were Black and 11.5% were Hispanic, despite those ethnic groups being 12.2% and 18.5% of the US population, respectively. ^{Reference Painter, Ussery and Patel13} The Federal Retail Pharmacy Program is based on pharmacy partners using the Social Vulnerability Index (SVI) to inform decisions on additional locations and vaccination sites. ⁷ Additionally, the Biden administration is organizing partnerships with federally qualified health centers (FQHCs), which tend to serve low-income individuals and people of color. ^{Reference Rapfogel12} Initial results indicate that such efforts are indeed alleviating inequities, with 45% of Federal Retail Pharmacy Program sites being located in zip codes with high social vulnerability scores, and over 65% of the federal doses allocated to community health centers being administered to people of color. ¹⁴

Federal government investment in State DOHs is essential for supporting functions, such as workforce funding, data reporting systems, and communication efforts. ^{Reference Blumenthal, McClellan and Tewarson15} Apart from infrastructural support, states have had difficulty developing comprehensive plans that determine priority populations, set up immunization registries, and meet CDC time requirements for reporting measures. ^{Reference Michaud, Kates and Dolan16} Lack of state preparedness does not appear to be a COVID-specific issue, as it has been reported that multiple states that had lower than a 40% immunization rate against influenza in 2019 are the same states among the highest in COVID-19 infection rates currently. ^{Reference Blumenthal, McClellan and Tewarson15} While state governments are essential partners in implementation of vaccination distribution, the federal government can provide additional operational support, such as the Federal Emergency Management Agency (FEMA) assisting in developing federally run community vaccination centers and mass vaccination sites. ^{Reference Rapfogel12} Furthermore, the federal government can coordinate targeted partnerships, such as a recent initiative between the CDC and Administration for Community Living (ACL), in which the federal government provided nearly $100 million in grants to aging and disability networks in every state and territory, along with funding for national hotlines to connect older adults and people with disabilities to resources that assist in vaccine registration and support. ¹⁷

Policy Recommendations

An effective Federal Retail Pharmacy Program is crucial in accelerating the current vaccine distribution rate to the general American population, with nearly all Americans now eligible to receive the vaccine. Based on learnings from these recent developments and historical context in considering federal and state governments’ vaccine distribution plans, we propose the following recommendations that may drive future policy development:

• Use federal government capabilities and resources to ensure equity in vaccine distribution and adequate access to vaccinations. While state governments know their populations the best, federal government resources have been and should continue to be used to focus specifically on equity and access to COVID-19 vaccination. A potential next step includes involving rural health centers and pharmacies that are not currently engaged in the federal pharmacy partnership strategy.

• Continue to prioritize high-risk and vulnerable populations. From the outset of this pandemic, nursing home residents have been disproportionately affected. The Pharmacy Partnership for Long-Term Care (LTC) Program has been set up between the CDC and partners like CVS, Walgreens, and Managed Healthcare Associates to provide on-site COVID-19 vaccination services for nursing home residents. ¹⁸ There are over 63,000 LTC facilities enrolled in the program, but opportunity exists for continued expansion. ⁷

• Invest additional resources in information and awareness campaigns. In the past, such as with the H1N1 pandemic, local variations in vaccine allocation led to confusion about public eligibility for vaccination. ^{Reference Weintraub, Subramanian and Karlage19} Therefore, it is necessary to educate the public about when and where they will be able to receive COVID-19 vaccination, as well as continue to build public trust in the vaccines’ safety and efficacy. Recent events, such as the CDC recommendation to pause use of the Johnson & Johnson vaccine, require additional investment in public messaging and communication.

• Allow for flexibility in distribution models. Pharmacy partnerships should allow for flexibility such that resources and vaccines can be reallocated quickly to areas in which supply is needed, especially given varying COVID-19 positivity rates across the country and the presence of multiple virus strains. This can occur through initiatives such as the Pharmacy Transfer Program, which allows states to transfer their allocated vaccine doses to federal pharmacy partners in other locales. ⁷

Taken together, strong emphasis on equity, pharmacy partnerships, and federal support increases the likelihood of more efficient COVID-19 vaccine distribution and improved societal health outcomes.