En español | With the country's first coronavirus vaccine now authorized for emergency use, many in America's hard-hit long-term care community are turning their attention toward logistics. How do they actually get the vaccine?
Inoculating residents and staff in nursing homes and other long-term care facilities, which have seen more than 106,000 COVID-19 deaths — or some 40 percent of the nation's entire coronavirus death toll — will be no easy feat. A federal initiative, the Pharmacy Partnership for Long-Term Care program, has contracted with the drugstore chains CVS and Walgreens to provide and administer the coronavirus vaccines at no cost to long-term care residents and staff at their facilities. But key details are still being determined, including exactly how many vaccines each state and territory will allocate to the program in the initial distribution phases, whether long-term care staff are included in those allocations and whether rural facilities can be served.
And all of this will play out as the crisis in long-term care intensifies in the coming winter, with cases and deaths soaring like never before. “This is a massive undertaking that's never been done before,” says Jennifer Kates, senior vice president and director of global health and HIV policy at the Henry J. Kaiser Family Foundation. “It provides a really good platform for reaching this population ... but it doesn't mean there won't be challenges.”
"The trial run,” she adds, “is going to be the actual run.”
Who gets what, and when?
Pfizer's COVID-19 vaccine, which was found to be 95 percent effective in a late-stage study in November, is the first vaccine to be granted emergency use authorization by the Food & Drug Administration. This week, 6.4 million doses are being pushed out nationwide in the first round of distribution.
The Centers for Disease Control and Prevention (CDC) has recommended that long-term care residents and health care personnel — workers in long-term care facilities, hospitals, outpatient clinics, home health care, pharmacies, emergency services and other public health settings — be the first to receive the vaccine. But there are not enough doses in the first batch to go around. The U.S. has roughly 3 million long-term care residents: 1.3 million in skilled nursing facilities, 800,000 in assisted living and 900,000 in other forms of residential care. And there are roughly 21 million health care professionals.
Precisely who among them receives the first doses varies from state to state. While the federal government has divided up the initial 6.4 million doses among all states and territories, based on how many adults live in each, it was left to the governors and local leaders to determine exactly who gets their first allotted vaccines.
In Texas, its first 224,250 doses are being sent to hospitals to vaccinate health care workers. Although long-term care residents and staff feature in the state’s first-priority group for vaccination, it appears they will have to wait for the next round of vaccines. Ohio, on the other hand, has allocated 88,725 doses from its first batch to Walgreens and CVS to vaccinate residents and staff of nursing homes. Just 9,750 doses are going to hospital sites for health care workers. Both health care workers and long-term care residents and staff are listed in Ohio’s first-priority group, too.
While thrilled that the long-term care residents and staff have been categorized as a first-priority group in Iowa, Glen Lewis, executive director of the Edgewater senior living community in West Des Moines, wonders what that really means for his facility, which offers multiple types of eldercare.
"We don't know a lot yet on what types of priorities will be given around vaccinations for a community like us, because we're not considered a 100 percent long-term care community,” he says. “Sections of our buildings [constitute long-term care] — our health care settings as well as assisted living and memory-care environments do, but I don't know where our people on the independent living side of things are going to fall yet.”
After the initial shipment of COVID-19 vaccines, batches will continue to be distributed each week. Nationwide, 40 million doses, enough to vaccinate 20 million (since two doses are required), are predicted to be shipped by year's end if both Pfizer's and Moderna's vaccines are granted emergency use authorization. Moderna's vaccine, which was found to be 94.5 percent effective in a late-stage study in November, is scheduled for its emergency use authorization review on Dec. 17.
Practiced pharmacies prepare for unprecedented plan
Of the roughly 50,000 skilled nursing and assisted living communities in the U.S., CVS and Walgreens say that more than 48,000 have signed up with one of the chains to administer the vaccines through the federal partnership. Uptake was particularly strong among skilled nursing facilities, with 99 percent registering nationwide and 100 percent of facilities in 20 states signing up, according to the federal government. Both CVS and Walgreens have the capability to vaccinate residents and staff, but whom it vaccinates, and when, will depend on state plans, which are continually being updated.
For operators who didn't register with the program, the vaccination process may take longer. “It's important to recognize that we believe that this plan will be the quickest and easiest way to be able to provide vaccines to long-term care facility residents,” Paul Mango, deputy chief of staff for policy at the Department of Health and Human Services (HHS), said at an October press conference launching the federal partnership.
Once vaccines are allocated to the program, facilities will work with their local CVS or Walgreens to coordinate vaccinations. The pharmacies are responsible for ordering the vaccines and associated supplies, like syringes, needles and personal protective equipment (PPE). Pharmacies are also tasked with scheduling and coordinating on-site clinic dates at each facility; ensuring that the vaccines are stored at the correct temperatures (minus 70 degrees Celsius for Pfizer's vaccine, minus 20 degrees Celsius for Moderna's); delivering the vaccines; and reporting required data to the government. The CDC expects the program to run for around two months, after which each facility can choose to continue working with CVS or Walgreens or go with another pharmacy.
"We all have to be prepared for some bumps,” cautions Kaiser's Kates, who likes the overall plan, which she believes beats a patchwork of different state-by-state distribution plans. “This program does provide some uniformity and does build on the CVS and Walgreens infrastructure that exists in the United States, which is pretty extensive,” she says. “This is going to get things off to a much better start than they would have otherwise.”
Rick Gates, Walgreens’ senior vice president of pharmacy and health care, is confident his staff can vaccinate the 23,000-plus long-term care communities that have signed up with his chain. “We have deep experience administering immunizations in long-term care facilities, having conducted 150,000-plus clinics since 2015,” he said in an email. “While the vaccine may be new, the model and our experience are not.”
Whether the program can reach rural communities is a major concern, though. CVS and Walgreens only committed to serving long-term care facilities within a 75-mile radius of one of their stores, and the CDC recommended that more remote facilities look to state health departments and local pharmacies for vaccination options. “We're prepared to address one of the major hurdles … rural and underserved communities,” Gates said in his email. “We're prepared to leverage different models of delivery to reach [them], including mobile clinics and different methods for transporting vaccines.”
Are we returning to normal?
For nursing homes and other facilities that have limited visits from loved ones, cut communal activities and struggled to contain the coronavirus, vaccination can't come fast enough. Lewis has begun thinking about how Edgewater will reopen communal dining, reintroduce excursions and welcome families back into the residence. But he's conscious that the road back to normal will likely be long.
"The vaccine seems to be the miracle answer, and I think there's a certain level of truth to that, but at the same time, it's going to be a slow rollout,” he says. “If it's determined the entire building falls under long-term care and can get vaccinated, we will certainly start to reopen and bring back that sense of normal, but it's going to be a very cautious approach.”
In the meantime, Lewis says his focus must also be on rigorous infection-control practices. “Certainly, we've had our eye on [the vaccine]. I have communicated to our residents and team that there's light at the end of the tunnel … but we also have to make sure that between now and that point, we continue to keep doing everything we've been doing to keep everybody safe.”
Bill Sweeney, senior vice president of government affairs at AARP, agrees, noting that testing, proper PPE use, sufficient staffing and virtual visitations must continue. “It's very exciting that we're hearing good news about the vaccines, but this virus is still with us, and it's still killing thousands of people every day,” he says. “We cannot get complacent.”