Covering the States’ COVID-19 Vaccine Distribution Plans

FASKIANOS: Good afternoon and welcome to the Council on Foreign Relations Local Journalists Initiative Webinar. Today we will discuss reporting on state distribution plans for the COVID-19 vaccine with Susan Dentzer and Carla Anne Robbins. I'm Irina Faskianos, vice president for the National Program and Outreach here at CFR.

CFR, as you may know, is an independent and nonpartisan organization and think tank focusing on U.S. foreign policy. This webinar is part of CFR’s Local Journalists Initiative, created to help you connect the local issues you cover in your communities to global dynamics. Our programming puts you in touch with CFR resources and expertise on international issues, and provides a forum for sharing best practices. So thank you all for being with us today. I want to remind everybody that today's webinar is on the record and the video and transcript will be posted on our website after the fact at CFR.org/localjournalists.

We shared our speaker and host’s bios prior to this webinar, but I'll just give you a few highlights. Susan Dentzer is a leading expert on American healthcare and policy and frequent commentator on news outlets, including PBS and NPR. She is currently a senior policy fellow at the Duke Margulies Center for Health Policy in Washington, DC, and held roles as the on air health correspondent for the PBS NewsHour and editor-in-chief of the policy journal Health Affairs, and she's a member the Council on Foreign Relations.

Carla Anna Robbins is an adjunct senior fellow at CFR. She is faculty director of the master of international affairs program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously, she was deputy editorial page editor at the New York Times, and chief diplomatic correspondent at the Wall Street Journal.  So Susan and Carla,, thanks very much for being with us. I'm going to turn the conversation now over to you, Carla, before we open it up to the group for questions.

ROBBINS: Great, thank you so much, Irina, and thank you everybody for joining us. And Susan, it is great to have you with us and happy two days after your birthday. You look incredibly young as ever. So I am going to start out with a big question knowing that you will edit it for me, as you always do. So this week, the first 5.9 million doses of the coronavirus vaccine, enough to vaccinate some three plus million people are making their way across the country. And while we all got to watch the trucks roll and the first shots administered, I must admit that you know­—and I'm a pretty well read person—I'm really not sure I fully understand a lot about this. You know, how and where the decisions are going to be made, about how many doses go and where they go, who gets them in what order? And most important for this group and for us is, how we as journalists can cover those decisions and assess both their equity and their effectiveness in this decision making. I saw this list of plan, USA Today had an entire list of state by state plans. And I started clicking on them. And I thought to myself, you know what the states, you know, each one of the states have the right to set up their own plans for the pandemic and they didn't do a very good job with that patchwork. So how do we know and how do we assess how well they're going to do on this one?

DENTZER: Well, great question, Carla. And thanks very much for having me. It's terrific to be here. I think what I'll do is try to share some slides now to walk through some answers to that question, that very important question. So let me go ahead and do that. (slide presentation appears) Okay, so it's a very complicated area, as you said, and there is a lot of, frankly, good reporting on this and some erroneous reporting. I mean, just starting with the fact that, actually, although there was a lot of hoo-ha about the fact that the first vaccines were being shipped last week, actually, many vaccines had already been shipped to major health centers, on the expectation that there would be EUA (Emergency Use Authorization) approval of the Pfizer vaccine. So Duke Health, for example, already had its Pfizer vaccine before the EUA was issued. So, this is an evolving story but it is true that with the EUA, more vaccines began to be shipped just over the weekend, as a matter of fact. (next slide)

This was a feature in the New York Times a couple of weeks ago that caused a big stir. And you will note that it was couched as opinion, and that was a good thing because it was an opinion, “Find your place in the vaccine line.” I had a lot of friends who did this and then called me up shrieking, that they weren't going to be 200 or 250 million people down the line. I just went in and entered my own information. And, and I got told that in for in the US I was almost 120 million people down the line, in Maryland I was in mere 2.2 million people down the line, in Montgomery county, I was 304,000 people down the line. If you didn't have a lot of the background behind this, you would have really freaked out. And the most important caveat was way, way down in this segment which said, the order outlined above is one possibility, combining proposals by the Advisory Committee on Immunization Practices, the CDC, The National Academies of Sciences. “The final order is not yet determined, and depends on successful vaccines being adequately tested for every group”, and then, “states could also set their priorities, but will most likely follow the final CDC recommendations.” Okay, so that was a lot of caveats that, frankly, contributes to why this was best couched as opinion. Of course, nobody interpreted it as opinion because it was in the New York Times, therefore, it must be so.

So what so what is the reality here? There are lots of factors driving vaccine distribution. And just to state the obvious ones, first of all, the availability of the vaccine, the success in clinical trials, and the success of obtaining emergency use authorization approval in the U.S. Now we know the Pfizer vaccine got the EUA last week. But Moderna is expected to get it today or tomorrow. There's a chance of a vaccine from Johnson&Johnson, the EUA is anticipated sometime around the beginning of February. There were great expectations about an AstraZeneca vaccine, we don't know now given a bunch of issues that have cropped up with that vaccine and those trials, we don't know when that's going to become available. So, this is sort of the number one factor is when these vaccines become available. And then of course, how many vaccines have been produced, even to this date. We know because of operation warp speed, and other pre-market commitments, a lot of these vaccines have been produced and a lot more will be produced. The whole issue around how many will be produced, though, is also up in the air at this point. It's dependent, in part on production capacity, but also raw materials supplies. And if you've been following the news, Pfizer has some concern that sort of the upstream components of the vaccine aren't going to be available in enough time for it to expand its production capacity as fast as it would like. So that's a kind of an unknown. Then we have the issue of the federal allocation of vaccines to the states. And of course, that is largely being handled at the federal level. It's based on population but the federal government has not yet disclosed exactly what it is allocating to the states. It's leaving it up to the states to disclose how much they are receiving, and those amounts have are going to be updated on a weekly basis as vaccines become more available. So that's another factor. And then you've got the states making decisions further, on allocation and prioritization. And as that Times story referenced, a lot of the states are going to follow the ACIP (Advisory Committee on Immunization Practices) recommendations, but not all. Already we've seen seven or eight states not follow those recommendations.

So those are all important factors. And then you get down to implementation and execution on the local level. How many staff people are available to provide vaccines? Where are those people? Where are the vaccination sites? It's easy, relatively easy at this point, because mostly it's healthcare workers being vaccinated. But we also have the long term pharmacy partnership program taking off at this point to get vaccines out to people in nursing homes in particular. And there are issues with that. A piece in the New York Times this morning flagged some of those issues that are arriving, not the least of which is if you've got to go back to the same nursing home on a couple of occasions, to give the two doses of the Pfizer vaccine that are required, but also because different nursing home staff are going to be there on different days, how many times do you have to go back to the same place? So all of these issues come together and bear on when people are going to get the vaccine. (next slide)

As we know, the CDC made an interim prioritization set of decisions about who is most important to get the vaccine to, and you can see the color coded system of deciding what were priority populations. (next slide) The ACIP in its August meeting decided that the phase one, the most important group would be people with high risk medical conditions, as you can see here, essential workers, health care personnel, and adults sixty-five years and older. And then of course, it further refined that into the phase one, A, population, which is just a portion of this, it doesn't include the adults sixty-five and older. And it doesn't include many of the essential workers. And now, in the next couple of days, ACIP will decide who's in phase one, B, and what the priority should be there. And again, it's going to be this other group of essential workers, people with high risk medical conditions and adults sixty-five and older. So this very important one, B, group hasn't even been fully decided yet, who's going to get what. So it basically continues to underscore the fact that there's still some ambiguity and uncertainty around all this. (next slide) This is the agenda for the ACIP meeting on Saturday and Sunday. And as you can see, first they're going to take up issues around the Moderna vaccine game, this is predicated on the Moderna vaccine getting itsEUA, today or tomorrow. And then they're going to talk about phase one, B, and one C, these additional initial phases of vaccine distribution. (next slide)

Okay. So, Carla referenced the USA Today listing of the states, we put out a report a couple of weeks ago about the state distribution of vaccines. And in this report, which you can access on our website, it has links to all of the state's available vaccination plans. And I'll point out that this list was accurate when we published it, these links will still get you to the right place. But you will see if you go to the different states, they are in the process now of updating and revising their recommendations. And various states are at different stages along the way of doing that and making this information public. (next slide) Also, the states aren't always following the same typology that ACIP has used. So this is an example from Massachusetts, and Massachusetts decided not to have phase one A, one B, one C, they decided to go with phase one, phase two, phase three. And you can see in phase one, it's basically healthcare workers, people in long term care facilities etc., congregate care settings. So that's what they're calling phase one. Even though technically, some of these people are really more like one B, or one C. And then moving on to phase two and phase three. So the states are further tweaking this way of presenting to the public, what order they are going to proceed in. (next slide)

The COVID vaccine advisory group in Connecticut is going to meet tonight, again, this is on the expectation that there will be an EUA approval of the Moderna vaccine today and they will decide what order they're going to have the Moderna vaccine go out in. The Moderna vaccine, many of you will know, has to be kept cold but not as cold as the Pfizer vaccine. So most states are banking on the fact that that is the vaccine most likely to go to people in long term care facilities in the next wave next week, because it doesn't have to be kept quite as cold. The very cold Pfizer vaccines have, to date, largely been shipped to large healthcare institutions that have very cold storage capability. So this, again, is a work in progress. (next slide)

I mentioned briefly the pharmacy partnership for long-term care. This is the arrangement that was struck with CVS, Walgreens, and another entity called Manage Healthcare Associates, which represents some small pharmacies around the country, to deliver the Pfizer and Moderna vaccines, in particular, to people in long-term care facilities. Again, because this was orchestrated by the CDC, but not specifically delinked from state plans for allocation. All of these things have to go through the states as well. So I talked to the head of CVS, this effort at CVS a week or so ago, and frankly, they're kind of tearing their hair out, because they're having to cope with fifty-one different state distribution ideas now, as they undertake this program to get these vaccines out to long-term care facilities. And they really wish for greater coordination at this point, and standardization, because at this point they've got to strike fifty-one different arrangements. And the states, as I say, are at varying stages of their readiness to do this. So what this all leaves is, this was supposed to be a picture of Joe Biden with a question mark. But this is now also going to fall into the lap of the incoming Biden Administration in January, because we are getting some signs that they will probably try to tighten up the federal-state coordination of the additional phases of rollout of vaccines, because at this point, it has been so variable, and there has been, relatively speaking, less coordination than desirable between the federal government and the states. But we will see over the next few weeks a lot of movement and a lot of different directions as all of this gets sorted out. So with that, Carla, did I come close to answering your question?

ROBBINS: You did. It was great. And you didn't even edit my question down. Thank you. That was great. So I'm sure that the group has lots of questions. And I have lots of questions. So maybe we'll turn into back to the group. And if not, I've got lots of questions. So Irina, do you want to open it up?

FASKIANOS: Great. Yes, so please raise your hand, if you click on the Participants icon at the bottom of the screen, you can raise your hand there. And if you're on a tablet, you can click on the More button in the upper right hand corner and click on the raise hand button there. Please tell us who you are and your news outlet to give us some context. Maria Alvarez, over to you. And please unmute yourself.

Q: Okay, I'm here. Thanks. Hi, my name is Maria Alvarez. I'm a based here in New York City, a freelancer for Newsday. But right now, primarily during the pandemic, I'm a professor of journalism at the MCC Community College in downtown Manhattan. And I am here today because I want to look at the local aspect of how people are going to be vaccinated once this comes to the general public. And I was looking for some suggestions as to what would be the important issues that should be addressed here. Of course, equity is number one in the minority neighborhoods, my students are predominantly Black and Hispanic and some are of other immigrant groups. And my instinct is to have them go into their neighborhoods and talk to people who are actually getting the vaccine. But how do you visualize this happening? You know, on the ground distribution? I'm picturing it outside, not inside.

DENTZER: Well, again, a lot of this is still unfolding, because as you can see that for the general population, it's going to be a couple of months before it gets beyond these priority groups. And most states and localities are just now coming to grips with exactly how they're going to do that. Again, if you go, depending on the locality, if you go to some of these states sites you will see that some states are a little further along in thinking about it than others. But in general, I think the basic truth is it's going to vary a lot around the country. In New York City, for example, when we think about the sort of the mass inoculation of the public, it is quite likely that the pharmacies will play a role. Again, they've been part of this long-term care partnership with the CDC. So you're going to be able to get a vaccine at CVS, for example, and at Walgreens, and Duane Reed, etc. It's also quite likely there will be community settings set aside to administer the vaccine, that the healthcare settings much along the lines of what's happened with COVID testing.

As you know, now in Manhattan, there are walk up places that some of the health care facilities are running, you can also go to make an appointment and get a test at CVS and Duane Reed and so forth. It's going to be a similar kind of dynamic that. And one imagines that there will probably be additional settings created again in public spaces, the armories, for example, or schools, but this is really still a work in progress. The other really important issue, particularly for the populations that you referenced, is going to be vaccine hesitancy. And we know that there is a lot of skepticism and concern about the vaccine in in various communities, particularly Black communities, and to some degree Latino communities. And we don't honestly know even if a lot of vaccines are made pretty broadly available, which I believe they will be, certainly by March and April, how many people are going to actually want to go take it take it up? They don't have to, people don't have to do that. I think that the level of vaccine hesitancy is going to recede as vaccines become more normalized, and as many populations get them over the next couple of months. But we honestly don't know that. So I think it'll be interesting for your students to look at both facets of that; the supply and the distribution of vaccines and also the take up of the willingness of the population to actually get the vaccine.

FASKIANOS: Thank you. Let's go to Raul Galvan next.

Q: Thank you, Irina. Susan, first of all, I would like to congratulate you on the thought that you have given to your to your zoom lighting and you're set, it's probably the best I have seen for a long, long time if at all. I don't know if you're a betting woman. But I'm wondering if you had to, to put an estimate out on when some of these populations are going to get the vaccines. I'm calling from Milwaukee PBS in Wisconsin. So I know that they vary from state to state, but when would you say that the normal people will be getting will be getting their vaccines. I spoke to Walgreens representative today and he told me that he would he would see in February, doing some independent living folks.

DENTZER: Yeah. Well, again, if you take this partnership, the long-term care partnership that was forged between Walgreens and CVS and MHA and the CDC. Depending on how you're classifying long term care, mean, those folks are going to start getting the vaccine next week. A lot of them in nursing homes, for example, and assisted living facilities. So independent living is a different category from assisted living. But very often independent living places are contiguous to assisted living places. So it's possibly going to be the case that even some independent living people will get the vaccine next week if they are closely proximate to assisted living places, right? That this is how kind of ambiguous all of this is at this point. So if you think about people in independent living, and I'm distinguishing this from community living, right, I mean, the rest of us live in communities, we're not an official independent living category as you would consider a person, an older person who's in a specifically designated independent living facility.

If the question is the community, when did the people in the community access the vaccine, that's going to tie back to a lot of the factors that I talked about in my first couple of slides, which is, you know, tell me that we know for sure when, for example, that Janssen vaccine, the Johnson & Johnson vaccine is going to be available. And that's important because the Johnson & Johnson vaccine, first of all, is a one dose vaccine, not a two dose vaccine. It doesn't have to be kept as cold as either the Moderna or the Pfizer vaccines, it's going to be much more easily distributed. It's an older vaccine platform. So there's some question until we see the final clinical trial results about just how effective it is, but it looks like it's going to be fairly effective. And since it's going to be easier to administer, and a lot of it has already been produced, we imagine that that's going to roll out fairly quickly. So if that does get EUA authorization in February, you could see a lot of that vaccine rolling out in February and March. This is why I think, you know, we're going to have to play this by ear and see when that becomes available. But I'm guessing a lot of Americans who don't think of themselves as necessarily being at very high risk of COVID will be able to start getting the vaccine in March and April. And then if you ask how long does it take to get it out to everybody in the country who wants it? I'm personally just taking a scientific wild ass guess now I'm guessing that that's June. But we'll see because again, it ties back to all those factors that I talked about in my slides.

FASKIANOS: Thank you. Next question goes to Katie Coyne.

Q: Hi, my name is Katie Coyne. I am a health reporter at the Charleston Gazette Mail in Charleston, West Virginia. Our state has been, at least in my perspective, pretty proactive and putting out their plan for distribution. They have two phases split into tiers, there's one A, one B, one C, one D, and then general population, same thing. One thing that they've put out, though we're starting with health care workers, they've already gone into long-term care facilities and started vaccinations there. But when we get into the general population phase, after we get to the health care workers, teachers, educators, and public officials are in there. One thing that they're prioritizing is by age and preexisting conditions, but the way that they're doing that is for the preexisting conditions. In order to be placed in a higher tier for the vaccine, then someone like me who doesn't have a preexisting condition, you need a doctor's note, a physician's note. And on its face for a state like us where we already historically and systemically have so many people that are disengaged from health care infrastructure, who made who don't trust doctors, because they live out in hollers were an incredibly rural state. Some places you have to drive two hours to get to the closest clinic. And in those places too, are home to the people that have the most preexisting conditions that are perhaps the most vulnerable and the end and the elderly. So I'm wondering, from your all's perspective, does that does that raise any flags to you and enroll out there? And what could that look like moving forward with those populations? Yeah.

DENTZER: Well, it’s part of the reason that I said just a few moments ago that, you know, guessing as to when the vaccine is, reaches everyone who wants it. In this country, it's going to be June, but you're putting on the table, a couple of other important issues, which is, what about people who don't even who don't want it? Or don't think they want it, or don't even know much about it, or have heard about and are very, very leery and hesitant about it? And we know that that's the case, particularly in black communities, how, how does the vaccine get out to all of those people? And as you identified, so many of them are going to be in rural areas. That's the piece that It's referred to as the last mile, or sometimes the last inch of vaccine distribution. And there are very, very few states that have gotten their arms totally around the notion of that last mile, what that last mile and last inch looks like particularly in the areas that you designated. So is it potentially a problem? Very much so because those populations could still be affected. And we all we have to do is look at the recent surge, which has largely affected very rural areas of the country, to a much greater degree than most public health people thought was going to be what's going to happen.

I’ll give you the example of North Dakota, for for instance, or South Dakota. So this is going to be a real challenge. And it will depend on a lot of factors, including the robustness of the public health outreach program in in various states. And it's largely going to be public health agencies that end up getting the vaccine to those people that you described. And so I guess, important questions to ask would be, you know, what has the state appropriated for this effort, this last mile effort? Many of you will know that in the current COVID relief package that is being negotiated on Capitol Hill, at the moment there is, fill in the number, looked like it was going to be eight to nine billion to the states precisely for these kinds of efforts. It's not clear what the final number is going to be. But the states have repeatedly said that if they don't get more federal assistance, they're not going to be able to undertake these last mile activities that we've just been talking about. So watch that space to see whether that those dollars materialize. Watch what happens when they get to your state, in your case, South Carolina, and then watch what plans are developed to really get this to people in that last mile, last ditch effort.

ROBBINS: Okay, I'm sorry, Katie, were you asking whether there was an equity issue here that the state was requiring proof for people who didn't have even if they wanted it, people who didn't necessarily have easy access to that sort of, it's almost like a voter id issue?

Q: Yeah, so they would need a physician's note that outlines what their preexisting condition is, and how it would make them more susceptible to COVID or worse infection. And in the state, to be to be transparent, did say they would come out with further guidelines for this, when we get closer to that point, they're estimating that that won't hit until probably about February, because again, it's the first phase of our general population. But yeah, my worry is too, you know, if you don't have a physician, if you don't have a doctor, you can't get to it. How do you get that note, when you're still at risk in your community? Susan, but thank you, I haven't heard last mile so that that's something I'm definitely gonna keep an eye on.

DENTZER: Yep. Yeah. And I think, you know, again, a lot of this is dependent. A lot of plans are being set now in contexts where we don't know what the supply is going to be. Right. So that's why the state is saying the status trying clearly to husband enough vaccine as possible. So it doesn't, it wants to make sure it's getting while there's limited supply, it wants to get it to priority populations. I think you're going to see those kinds of things relax as more supply becomes available, right. So it's why I was saying, Let's watch what happens with the Janssen vaccine, the one dose vaccine, when if there's a lot of that vaccine, a lot of supply, some of these requirements, I think are going to be eased a bit. So I would say watch it. You're right to identify the potential there, but let's see how it really plays out.

ROBBINS: So is the equity issue more or less the question of, you know, being unfair in which they assign particularly if it's an expanding pie, and more the effort to push it down to reach into communities to raise awareness to go into the communities on the last mile issues that your primary concern on equity issues?

Q: It is? Yeah, I mean, we don't have the infrastructure to do, I think widespread public outreach in those areas for public health. And it's something that I mean, we've seen this fail time and time again in West Virginia with HIV, with hepatitis. They know that these are the populations that are listed as being most at risk for these outbreaks. And there's very little proactively done to get buy in from communities in you know, participate in this get tested for hepatitis do this and I worry, watching that over the last few years seeing it repeat with a COVID vaccine that also has you know, this other hesitancy on top of it too, right, the cultural aspect too.

ROBBINS: And Susan, what do you worry about inequity issues?

DENTZER: You know, frankly, at the moment, the biggest equity issue that we face is the vaccine hesitancy in the black community. And that's a legacy of the historic, you know, the Tuskegee experiment, all of the mistreatment and health disparities, healthcare disparities, etc. And what I worry about is that not enough people who are highly at risk of bad outcomes from COVID, including death, will not take up the vaccine because of their fears of the vaccine. And that's a really horrible, perverse equity issue, but it's a real equity issue. I'm less concerned that people who genuinely want the vaccine and who think that they have good reason to be classified in a priority group will not get it, I think that most people will be able to get it. And again, as these as these vaccines become, and we think about the locations where the vaccines will be available, I mentioned obviously, the commercial pharmacies, physician's offices will start to have them. Community health centers and federally qualified health centers will start to have them. I think, as long as the supply is bit continues to build and as broadly distributed, I do think anybody who's in a high risk group is going to get fairly timely access to the vaccine.

FASKIANOS: Susan, what is the percentage of the population that needs to take the vaccine in order for it to be effective?

DENTZER: Well, there's a lot of discussion about getting to what is known as herd immunity, which is the notion that so many people have immunity to the virus that it stopped spreading as quickly as it has over the last ten and eleven months. Most public health experts think that herd immunity is at around 70% of the population. So that would say, we've got to get it. You know, we think we've already had ballpark 60 million infections in this country. So since we're a country of roughly speaking, 330 million people, right, we've got to go from 60 million, up to about 210 million people. But again, this is ballpark, with immunity to have herd immunity. So that means at least 150 million people have got to get vaccinated and possibly more because again, these are just sort of ballpark numbers. The one unknown, however, is we don't know how long immunity lasts. We don't know how long immunity lasts from natural infection and in fact, some of the recent studies seem to suggest relatively low presence of antibodies to the virus in the body, even among people who have had active infections. So does immunity last three months? Does it last six months? Does it last longer? We don't know. We also don't know how long immunity from the vaccine will endure? Is it going to be three months? Is it going to be six months? Is it going to be a year? We don't honestly know. A lot of people think we will probably have to be giving booster shots of the vaccine to continue just the same way of it slightly different way. We know we get annual flu vaccines. That's because the flu virus evolves, right? The SARS COV-2 virus is evolving, and it may continue to evolve and we may need to give booster shots for that reason. We also may just find that the immune response doesn't last as long as we thought it did. So I think it's a reasonable bet that even people have been vaccinated once this year. We'll end up getting vaccinated again next year or even later this year, depending on what we find out.

FASKIANOS: Thank you. So I'm going to raise two questions from the chat and then we'll go to Amy Green, who is has her hand raised. So Maria Alvarez had a follow up comment or question about New York Governor Cuomo’s comments today that no one will have to pay a penny for the vaccine here in New York. Is that realistic? And how is that is that going to be it's going to be free across the country? And Stacey Josh Barton, who's at the Leader News in Central City, Kentucky, a rural weekly newspaper with 6,000 circulation says, what about the hesitancy in the rural community due to misinformation and political pressures?

DENTZER: Yeah, yeah. So I think, as many people will know that there embedded in some of the earlier COVID relief packages was the stipulation that there would be no out of pocket costs for COVID testing. And that has largely held true. It doesn't mean they're free, somebody could have paid for those tests. But individuals have not had to pay out of pocket tests, except in limited circumstances where screw ups have occurred, let's just I’ll be brief and just put it under that heading. I think similar thing is going to happen with COVID vaccines have been that the government has purchased all of these COVID vaccines through operation warp speed, so they are bought and paid for. So most of the vaccines that are being distributed, now nobody's paying a penny for. CVS and Walgreens are getting paid by the government now to distribute these vaccines to long-term care facilities. So there's still money changing hands to support the delivery of vaccines, but it's not coming out of the pockets of individuals. So I think Governor Cuomo was absolutely right. There's not bloody likely anybody is going to pay a dime out of pocket to get any of the vaccines that are going to be available soon, because most of them have been the subject of advanced purchase agreements by the government. So they are paid for, they are paid for.

Now, as to the question about, let's say, it was its vaccine hesitancy in rural communities, particularly because of misinformation and disinformation? Absolutely. It's a terrible, terrible problem. There's a lot of sort of casual misinformation floating around. There's the preexisting fear that many people have, as I mentioned earlier, you know, blacks who know about Tuskegee, get really leery at the notion of a vaccine, that that hasn't been on the horizon until very recently. And there's also been some concern, I think, fanned largely by people who don't really understand the process by people who worry that these vaccines got developed so quickly and have been approved so quickly. And maybe that they weren't tested as thoroughly as they ought to have been. So there's some unease about that process as well. And then finally, we have the very deliberate over anti-vax movement, that has been a feature of the landscape now for about a decade or more, starting with concerns that vaccines caused autism going back fifteen years ago, and now morphing into a very deliberate, very orchestrated campaign, including of funded by bad actors like Russia. There has been active disinformation and misinformation fomented on social media sites, and it's only been in the last year so that Facebook and others have started taking down that information. So you sort of roll all that together and people who are not that well educated or not that sophisticated and are in rural communities and are picking up any of the little shreds of any of that. There is this sad but real vaccine hesitancy phenomenon playing out.

FASKIANOS: Amy, it looks like you lowered your hand. But I don't I want to give you the opportunity to great if you want to accept.

Q: Yeah, there was mentioned about eight states that had veered off the recommendations for plans and I was just curious, what was there anything interesting you saw in how they had decided to do differentiate from the recommendations.

DENTZER: Do things or not do things? Yeah, there was a write up about this in the Kaiser Family Foundation put out a report of, I think earlier this week, noting that there were 45 states that had follow the ACIP one a recommendations to prioritize health care workers and long term care residents. And within that group, some of the states started vaccinating those people together, I mean, not in the same room, obviously. But this groups at the same time, some went for the long-term care people first before the health care workers Believe it or not. So there was a little bit of variability there. And then there was a total of seven states that did, for example, D.C. and Utah, put health care workers in phase one A but long term care residents and phase one B. So they essentially went with, we're going to get health care workers first and then the long term care folks in D.C. And then Massachusetts also decided to vaccinate people who are incarcerated and people in homeless shelters in that first group. So that was another sort of slight variability. There was a group of about twenty states that further segmented healthcare workers into very high risk, health care workers, high risk, etc.

And I know that's playing out informally in other places as well. I talked to a friend of mine yesterday, who's a radiation oncologist in Florida, who got her vaccine yesterday. But then I talked to another friend of mine who's an anesthesiologist at Yale New Haven Hospital and he, he's probably not going to get his for a couple weeks. Because what this gets down to the real arcane of all of this, but essentially, there, there is some concern that people will have a reaction to these vaccines, one in particular is just as your immune system kicks in, people can develop fevers, they can feel a lot of soreness around the injection site. So there is some concern that some health care workers are going to need to take a day off the day after they get their vaccine. So Yale New Haven didn't want to be without all of its anesthesiologists. So it's not vaccinating all of them at the same time, it's doing them alphabetically on different days. So since my friend's last name begins with an S, he's not going to get his vaccine for a couple of weeks. So you're seeing that kind of additional variation play out again, as various entities along the way decide how they're going to execute on even something as simple as vaccinating, quote unquote, health care workers.

ROBBINS: I also read that there's a variation and among states about who's an essential worker like Arkansas has been talking about, including people from their poultry industry in Colorado was going to apparently include ski industry workers, particularly people who live in large housing units. There seems to be variable. Those don't seem to be totally wacko, though. I mean, are you seeing? I mean, not that I, you know, I'm just sort of I feel a certain amount of skepticism about certain states, you raise South Dakota in particular, not that I want to pick on South Dakota, but given their refusal to have masks and when you look at the death rate right now in South Dakota, iit does, shall we say, make one begin to question the competence of the government there. Are you seeing any of the plans that make you nervous, first of all, and second of all, what numbers what data should we be looking for? You said in particular, that the federal government isn't even telling us the number of doses that they're shipping out that we have to rely on the states for those numbers? What should we be asking our states to fess up about so that we can monitor what they're doing?

DENTZER: How much vaccine Are you getting on a week by week basis? Because the shipments will vary week by week. You know, are you confident that you're getting, you know, an appropriate supply or not? Do you have any doubt that the state is any somehow being disadvantaged? Now, keep in mind overall, these are being allocated according to population. The government's been quite straightforward about that. But you know, what does that mean week by week, right is going to matter. Particularly if we do see production Issues crop continue to crop up and delay more production of the Pfizer vaccine. I think that's going to be alleviated now that there's a lot of Moderna vaccine that's been produced already, about 100 million doses right? But, you know, so you've got, again, back to that first couple of slides. So you've got all of these different factors that are going to feed into what actually shows up in a state. Right. So I, and I think that's part of the reason now, there's so much uncertainty around, you know, who's in what category? And when? It's because it's all predicated on we don't have unlimited supply at the moment?

ROBBINS: And should I be also looking at, I mean, expecting states to be clearly defining who's in what group and the speed of implementation, what percentage they've been doing each week? Or what other data should we be asking for?

DENTZER: I think, assuming that the state has put out a fully articulated plan, right? Which is truly who's in what group? And what is the priority, asking for the numbers. Now, an issue with that is, as we know, the states have variable levels of reporting systems here. And particularly around public health data. It's a lot of the public health data during the course of the whole pandemic has only come in with a lag. So I think, we're almost certainly going to see lagged data coming in about vaccine reports. But if it's going to be aggregated any place at all, it's going to be at the state public health department. There are about seven different vaccine surveillance systems that are in existence that are eventually going to get all of these data about who got a vaccine, and when, partly for the purposes of continuing to monitor vaccine safety. But that data is all going to be lagged, that just is. So but starting with the state and asking tough questions of the state health entities, you know, what do you know, and then and to some degree, the county and cities, so because I mean, for example, New York City, the public health department, you know, is going to have probably the best handle on everything that's going on in the immediate New York City area. So but just asking them, what data do you have? And, you know, what are we achieving? The allocation and distribution that you've set forth? And also, how is that being affected by increasing supply? Because it will be, things will change with more supply.

FASKIANOS: We have no further questions. So I know, Carla, you have many questions. We have about five more minutes. So if anybody wants to raise her hand, please do so. But Carla, I'm turning it back to you.

ROBBINS: So there were adverse reactions and, and more significant than just soreness or the day of chills and fever among couples health workers. And there has been criticism about the press coverage of this. So and concern that this was going to lead to further vaccine hesitancy. How do we at the same time, if there's a problem, you know, it's a responsibility of journalists who raised concerns about this, and it's a big country, and it's, you know, it's disparate out there. So A, what do you think of the coverage yesterday of the adverse reactions and B, how do you think we should be covering this?

DENTZER: Well, it's complicated, for obvious reasons. I mean, what we saw last week, when the vaccine was administered in the UK, was what people would have expected, which is, you know, there’s how vaccines are administered in the context of clinical trials, where the one thing you don't do in a clinical trial is say, let's put in a bunch of people who have severe allergic reactions to vaccines and test our vaccines on it, right? You don't do that. You rule out those people, you exclude them from clinical trials for good reasons. But when you move into the general population, you're inevitably going to administer it to people who will have severe allergic reactions. Now you can screen those people out ahead of time and say, we advise you not to get this. It's why everybody knows you go get a flu vaccine, you get asked over and over again. You know, are you allergic to eggs, you know, do you have you have a history of adverse reactions to vaccines, right? That's important information to have. There was some criticism of the UK regulators for putting out recommendations that seemed to be, you know, very frightening to people to steer clear of this if they had any fear about an allergic reaction, as opposed to saying no, we really want to target people who have, who have a history of severe allergic reactions. Right. So that's an ambiguity that sometimes the news media doesn't negotiate any better than some of the regulators do.

The other reality though, is, you know, lots of stuff happens every day in healthcare that is good. I mean, people have strokes out of the blue, right? People have heart attacks out of the blue. What a lot of people are concerned about is that somebody is going to get a COVID vaccine, and then have a stroke the next day, or a heart attack the next day or two days later, we have to be able to say that to basically disentangle cause and effect, right, and say, this person did not have a stroke, because of this vaccine. They had a stroke, independent of the vaccine. And so how we all collectively work our way through that. I am sure we're going to see stories of people dying. And somebody's going to say, well, they just had the vaccine just the same way we saw, well, my kid had got autism, and it was diagnosed right after they got a vaccine, right? We saw that phenomenon play out, we will see it again. It's just going to be we're all going to be beholden to step back and say okay, let us look at the facts here. And let us not try to lump everything in and assume after which because of which, right, that fundamental error, error of logic, right? It's, what we're going to have to do is basically take a breath and say, we really have to study this in, in a in big populations, with a lot of surveillance, to understand what real safety issues are going to crop up from the vaccines.

ROBBINS: So, I mean, I don't maybe I'm wrong in the numbers, but Pfizer tested with what, 30,000 people? So when will we know in a big population that are including people who have a potential for severe reaction? When will we know that this is genuinely safe or safe within the notion of an acceptable notion like a flu vaccine? And when will we know in the country?

DENTZER: I think we know a lot now that it is generally pretty safe. That's not the same thing as saying that we're 100% confident that nobody's going to have an adverse effect, right? And it's all a numbers game, because you can get really tiny effects that don't show up, manifest themselves in in a huge general population for a year. I mean, this is a different modality. But some people will remember the drug Vioxx that got pulled off the market years ago, in the clinical trials, there was a tiny little signal that some people had adverse cardiac issues because of the drug, it was a little statistical signal that might be an issue. But then that drug went on the market. And it was several years before there were enough people dying of heart attacks so that it showed up in the data. And then it took another couple years, for people to say this is a big enough problem that we need to pull the drug off the market. I think that all of that dynamic will be accelerated because there's so much attention on these vaccines. And there are these seven different surveillance systems now, trying to capture these data and analyze them in real time. So I think it's going to be faster, I think we'll know a whole lot more a year from now than we know today about all of the vaccines. But when would you say you know, we're confident that these are 99.9999% safe for the global population? Going to be a couple of years.

ROBBINS: Susan, this has been great. Thank you so much. This has really been fabulous. Thank you, everybody. Irina back to you.

FASKIANOS: Thank you. I echo that, Susan, this is been fantastic. We really appreciate you taking time out of your busy schedule to be with us and I hope that you will all follow Susan at @SusanDentzer on Twitter. You can follow Carla @RobbinsCarla and we will send out after this webinar the link to the recording as well as the link to Susan's report that she shared so that you can get to your state's data and look at the sources. As the year draws to a close, I thank you for participating in this new Local Journalists Webinar series from CFR. Your work couldn't be more important than we know how hard it is. Please continue to share your suggestions for future webinars by sending an email to [email protected]. So thank you all again wishing you safe and healthy holiday season.

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