Vaccine Demographics and Demand

I have received several online and offline questions related to vaccine distribution. From these interactions I perceive two widely shared concerns, one substantive and the other “political”.

The substantive concern relates to meaningful demand identification, motivation, and sequencing. Those who have contacted me are not especially concerned about so-called Phase 1 vaccine distribution. There is considerable confidence that effective channels are in place to serve health-care providers. It will be a scramble in the midst of the current surge in hospitalizations and year-end holidays, but most of you perceive that healthcare providers are motivated, the target population is concentrated in well-known places, and there is an existing infrastructure to serve the population in those places. (Some of you make an important distinction between vaccinating residents of long-term-care facilities and vaccinating LTC staff, but most of you perceive that LTC staff are also motivated, place-specific, and preexisting infrastructures are being intentionally — urgently — enhanced) (more and more). (More on the December 1 ACIP meeting)

Many of you are not confident about Phase 2 distribution. Some of you are losing sleep trying to anticipate Phase 3.  You are not alone.  According to a November 18 analysis by the Kaiser Family Foundation:

Less than half (19 of 47, or 40%) of state plans reviewed include a numerical estimate of the number of individuals in different priority populations; the majority of states report they are still developing their data sources and methodology to calculate the number in their priority groups.

A majority of states (25 of 47, or 53%) have at least one mention of incorporating racial and/or ethnic minorities or health equity considerations in their targeting of priority populations. Some states expect to make racial and ethnic minorities an explicit priority population group, while others report using more general or indirect methods to do so, such as through use of the social vulnerability index (as was recommended by the NAM) and/or a Health Equity Team or Framework, as in the case of Arizona, California, Georgia, Louisiana, New Jersey, Ohio, and Vermont.

Phase 1 vaccines are being pushed directly to places where motivated “consumers” regularly congregate and who are accustomed to the processes and infrastructure that vaccine distribution requires. In  subsequent phases none of this is true.  Many targeted — even priority — consumers are not motivated or even resistant.  These sources of demand are in many different places: fire stations, food banks, grocery stores, food processing plants, distribution centers, homeless shelters, truck stops, and otherwise scattered. Perhaps of most concern, instead of vaccines being pushed to demand, the target populations are being expected to move to the vaccines. Many are skeptical that this will achieve the desired vaccination rates. (Others are also concerned.)

I got a bunch of emails after the decision to ship vaccines on a “population basis” was announced at a November 24 HHS/OWS briefing.(more and more).  As I hear the decision, this was not intended to supersede more targeted demand strategies. State governors are still able — and will be encouraged by expert advice — to recognize differentiated demand and the probability of variable demand in developing and executing state and local distribution strategies.  Rather, the initial releases announced last week are as much a network-test, even akin to a full-functional exercise, as an expression of long-term strategic intent.  Again and again, the same message is being repeated: “While Operation Warp Speed will deliver vaccine shipments as directed by the jurisdictions, it will be up to the states, territories and major metropolitan areas to further define where the doses ultimately go.”

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