A Blog by Jonathan Low


Jan 27, 2021

The Case For Vaccination Mega-Sites

Scale. It's faster, more efficient and probably safer than a hodge-podge of  pharmacies, supermarkets, clinics and government offices. JL

Maryn McKenna reports in Wired:

Mass sites could put the most shots into the most arms in the shortest period of time. There are ways in which it is less complicated—in dose allocation, transportation, and other logistics—than by distributing doses through hospitals, pharmacy chains, and supermarkets. “If we want speed, then the best way to do that is to stand up mass vaccination clinics, 10 or 20 in a state, instead of the hundreds of  doctors’ offices and hospitals and health departments. It’s slower to roll vaccine out to priority populations than it is to mass-vaccinate a lot of people.”

THE ROLLOUT OF the Covid-19 vaccine is going badly. Delivering more doses faster is central to the 200-page White House Covid-19 plan, which was released last week, one day after President Joe Biden took office. The plan, which promises to vaccinate 100 million people in the new administration’s first 100 days, lays out a raft of initiatives for revving up delivery: releasing almost all doses, loosening eligibility criteria, tuning up distribution, and developing new packaging to preserve temperature-sensitive products for transport to rural areas.

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All of that’s good, but none of it will be sufficient unless those better-packaged, faster-delivered doses can be given to more people in a timely way. The plan addresses that too: It says the administration will create mobile vaccination vans, recruit pharmacy workers to give shots, and increase support for state clinics and the federally qualified health centers that cover underserved areas. The most critical provision is a promise to create 100 new vaccination sites, backed by the Department of Defense and the Federal Emergency Management Agency. They’ll be staffed by what the plan calls “thousands of clinical and non-clinical staff and contractors,” including federal agency and Public Health Service personnel.


What the plan doesn’t say, explicitly, is where—or when, or how big—those federally supported sites are going to be. Outside the new government, experts are starting to talk about whether it will be possible to create mass vaccination clinics, where thousands of doses can be delivered each day.

There’s no question mass sites could put the most shots into the most arms in the shortest period of time. But depending on where they are sited and how they are operated, they may inadvertently exclude the people who need protection the most. Choosing whether to do mass vaccination is effectively a proxy for deciding national priorities: whether to reach herd immunity quickly, by vaccinating as widely as possible in order to suppress infections, or whether to focus on protecting the most vulnerable, by targeting the first doses in order to reduce severe illness, hospitalizations, and deaths.

But while that conversation is urgent, it may also be moot—because there may not be enough health care personnel to staff mass sites and keep them open, for as many hours in the day, and days in the coming months, as we need.

Conducting mass vaccination is a formidable challenge, but there are ways in which it is less complicated—in dose allocation, transportation, and other logistics—than what much of the US is doing right now by distributing doses through hospitals, pharmacy chains, and supermarkets. “If we want speed, then the best way to do that is to stand up mass vaccination clinics—let’s say 10 or 20 in a state, instead of the hundreds of locations that you have when you send vaccine doses to individual doctors’ offices and hospitals and health departments,” says Julie Swann, a professor and department chair of industrial and systems engineering at North Carolina State University. “It’s slower to roll vaccine out to priority populations than it is to mass-vaccinate a lot of people.”

Which is not to say that mass vaccination is easy to organize or quick. A glimpse of what will be required, Swann said, can be found in plans for mass flu shot clinics that the Centers for Disease Control and Prevention compiled during the 2009 H1N1 swine influenza pandemic. Having licensed health care workers present to administer injections is just part of the puzzle. “You need people handling forms, people doing orientation or giving instructions on the way out, and people handling data entry or medical records,” she says. “Supply managers, security, potentially translators, some emergency personnel, IT support.”

In 2009 the CDC forecast that a single clinic housing four “vaccination stations,” open for 16 hours a day—that is, two concurrent eight-hour shifts—could administer 120 vaccines per hour, or about 1,900 per day. It would require 58 workers per day to keep it running. Only eight of them would actually be administering vaccines; the rest would be managing the site and its supplies, screening recipients for preexisting conditions that might cause a reaction, checking them afterward, and handling medical records. And that estimate didn’t even include translators, paramedics, or tech workers, who were assumed to be off-site but on call.

The throughput for a single Covid-19 vaccination site would inevitably be slower, because recipients must be monitored for at least 15 minutes after the shot to guard against rare allergic reactions, and then issued a card, linked to the state’s vaccine registry, that records the dose’s manufacturer and lot number.

Last week, three public health scholars published a rough estimate of what a national effort would look like, scaled up. Biden’s goal of 100 million shots—for simplicity, 1 million per day for 100 days—would require at least 400 vaccination sites, each with 10 vaccination stations running 12 hours per day. It would demand up to 184,000 people, 17,000 of them health care workers, comprising a staff of up to 220 at each clinic.

The experts were skeptical that this personnel goal could be met. “The workforce is a staggering need,” says Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, who derived the estimate along with Thomas J. Bollyky of the Council on Foreign Relations and Prasith Baccam of the security consultancy IEM. They based the estimate on CDC planning documents and strategic exercises that several states had conducted for bioterror planning—though in a separate study published last year, Nuzzo found that most states had never planned for conducting rapid mass vaccinations against acts of bioterrorism, only for dispensing pills (such as antibiotics to treat anthrax) if needed.

States were expected to plan for the Trump administration’s never-filled promise of 40 million Covid-19 vaccinations before the end of 2020, though they received the appropriation to fund that work only on December 27—leaving them short of money to solve the personnel problem. “A number of states that we spoke to that had been thinking about mass vaccination, when we asked them where they would get staff, would say things like, 'We have a partnership with a visiting nurse service,’” Nuzzo says. “Well, those are employees that have other jobs. Right now they’re really busy taking care of Covid patients.”

To be fair, a few mass vaccination sites already exist in the US: for instance, in several boroughs of New York City, six cities in New Jersey, and the San Diego Padres’ Petco Park. And since vaccines began to be sent out on December 14, there have been several days on which the US has topped more than 1 million shots a day. But those shot records share an underlying reality. The recipients were not only highly motivated to be vaccinated but were already present at the vaccination location; many of the earliest shots went to health care personnel at their workplaces.

It’s possible that mass vaccination sites won’t actually serve the purpose of vaccinating the most vulnerable. The elderly and chronically ill may not be able to stand in long lines or drive to a queue in a parking lot. Essential workers outside of health care—refinery workers, firefighters, supermarket cashiers—may not be able to take hours away from their jobs.

What this may demand, instead, is a different model of mass vaccination: not devised in the US for fighting the flu or bioterrorism, but practiced in other parts of the world for countering polio, measles, and tropical disease. The ongoing polio campaign, for instance, relies on mass immunization days in which families bring children to designated locations—but it follows those with “mop-up” days in which teams of vaccinators trek through neighborhoods, going house to house, to track down any children who were missed.

For decades, members of the business fraternal organization Rotary International have been the main ground troops against polio, and they have amassed a fund of knowledge about how to administer vaccines successfully at scale: not only pushing out information and building enthusiasm, but also being sensitive to how far people are being asked to travel to get their doses. A vaccination site “has to be in the immediate neighborhood,” says Deepak Kapur, who has chaired Rotary's India National PolioPlus Committee since 2002. “We cannot expect a family, if they’re on foot, to walk 15 miles to the nearest center and then walk back, maybe in the hot sun or maybe shivering in the wind.”

The mop-up days, which require armies of volunteers, are only possible because each jurisdiction has mapped out every neighborhood, including precisely where every child lives—a particular challenge in areas that may not have paved roads or predictable house numbers. Rotary is applying that knowledge now to India’s Covid vaccination effort, lending its army of volunteers to whipping up enthusiasm and managing crowds at clinics. The same kind of effort might be necessary to get Covid-19 vaccination done in the US.

“We need to proactively figure out who are the people who fit the eligibility criteria at a given moment, based on the supply available, and then implement multiple ways to get it to them,” says Ranu Dhillon, a physician and faculty member at Harvard Medical School who studies the health systems of low-income countries. “And really plan out how that's going to happen, down to a local level.”

What that might mean, he says, isn’t the kind of mega-site that fills up a county fairground, but a macro effort of micro sites: barber shops, produce markets, pop-ups—preceded, as the polio campaigns are, with promotion by volunteer neighbors to answer questions and allay concerns.

That kind of mass distribution might not move doses as fast as the White House’s planned 100-day sprint, but it could solve the problems such a sprint poses, of equity and access for the least mobile and most underserved. And, similar to the polio campaign in India, there’s a US model for how that kind of door-to-door action can be run: the US Census. “I work nights at the hospital. The census came to my house three, four times before they found me at home,” Dhillon says. “Why can’t that happen for the vaccine?”


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