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We must use the vaccination infrastructure we already have

March 31, 2021

L. Allen Dobson Jr., MD, FAAFP
Troy Trygstad, PharmD, PhD, MBA

Article

Pharmacy and Primary Care have been dramatically under-allocated COVID-19 vaccinations when compared to influenza distribution and administration.

With over a half million dead, millions more hospitalized, the COVID-19 pandemic will be seared into our collective consciousness for generations. In fact, demographers have already determined that Americans born between 2016-2030s will be “Generation C” for the profound and enduring 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.

A new path forward

Getting us out of this mess required short term and painful decisions regarding the reduction of spread, namely masks and 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 — pre-paid 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.

Since the federal government pre-purchased the vaccines, it put them in the position of controlling distribution. They chose McKesson as their primary distributor and put the Centers for Disease Control in charge of initial allocations through two programs. The Jurisdictional Program (states, territories, and protectorates) and the Federal Pharmacy Program, for which 21 different pharmacy location aggregating entities signed up as Network Administrators for reallocating vaccine to their pharmacy locations based largely on the number of pharmacies they represented. Long-term care facilities were set up in a separate system specific to their populations and facility staffers.

Mass Vaccination Favored Over Community-Based Administration

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, who tended to look towards two main entities for both logistical and political convenience – namely Local Health Departments (LHDs) and large health systems. Both favored off-site, mass vaccination approaches since LHDs provide only a small portion of health care services overall in generally small clinic footprints and hospitals did not want to clog up primary care and other traditional sites where they were desperately trying to bring back revenue on procedures.

“Primary care and pharmacy together maintain the capacity vaccinate the entire U.S. population in two months. In fact, we already attempt to do that every fall with influenza. Please use the system we already have next time.”

Yet polling reveals a stark difference in in patient preference compared to the chosen approach.

Underserved and left behind

As of late March 2021, roughly a quarter of the way through the country’s initial vaccination effort, most Americans have received their vaccination not from a health care service location but rather parking lots, airport runways and music or sports venues. For some in public health circles, this brought a nostalgia and a renewed sense of empowerment to a chronically underfunded and underappreciated workforce.

Yet, for many frontline care providers, lack of access to vaccine allocation brought panic and frustration. Many patients expected to get the vaccine from their primary care and pharmacy providers in their communities, where they already receive vaccines and health care services multiple times a year.

National polling firm Public Policy Polling conducted a survey in February that revealed pharmacies and doctors’ offices as the sites of care for 38% and 32%, respectively, of adult influenza vaccinations in 2019. Yet only 9% and 10% had received their COVID-19 vaccination from those sites of care. This represents a nearly a four-fold decrease in access to COVID-19 vaccinations from a patient’s chosen site of care.

When asked what 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 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 are being left behind by the mass vaccination approach. For the greater part of January and February, both provider types were left in a lurch for the patients they serve who don’t surf the internet, have a patient advocate or caretaker, have behavioral health limitations, or otherwise don’t trust the government or large institutions. These are patients who make health care decisions based on longstanding relationships.

As former Speaker of the House Tip O’Neal 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 to who, when and where vaccines were delivered, 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 two most important metrics — dropped precipitously February and beyond.

Yet, 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 much as one-third of patients over the age of 65 remained unvaccinated as of mid-March.

This is what government-controlled healthcare looks like. Frontline providers need to be engaged with public health officials early and often in pandemic response. Pharmacy and primary care need to make the case both now and when preparing for future emergency responses. Frontline healthcare providers, rich in data and relationships and involved in the everyday care of vulnerable populations, are in the best position to serve their patients, pandemic or otherwise. They can be the “national guard” of the health care system in emergencies.

A better way

Mass vaccination clinics are great spectacles, but simple math and the laws of surface area and human behavior 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 our nearly one-hundred thousand pharmacies and primary care practice sites. Pharmacy alone has 50,000 pharmacies enlisted to provide COVID-19 vaccinations, of which only about 10,000 are 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. Primary care and pharmacy together maintain the capacity vaccinate the entire US population in two months. In fact, we already attempt to do that every fall with influenza. Please use the system we already have next time.

L. Allen Dobson Jr., M.D., is the Editor-in-Chief of Medical Economics. He is the former president and chief executive officer of Community Care of North Carolina.

Troy Trygstad, PharmD, PhD, MBA, is the Editor-in-Chief of Pharmacy Times and vice president of Pharmacy and Provider Partnerships for Community Care of North Carolina.