WASHINGTON — With just a month before a Nov. 1 Trump administration deadline for states to be ready to potentially distribute any upcoming COVID-19 vaccines, states are just starting to get their share of $200 million in preparation funds as Congress deliberates over whether to provide more.
Public health officials cite the relatively small amount of funding and tight time frame as examples of the many challenges they face in distributing any vaccines that potentially could change the course of COVID-19's impact in the United States.
Local public health officials say they need billions more to stand up vaccination sites and improve software to track when individuals receive one vaccine dose or two and monitor side effects. They also want money to contract with health care providers to administer shots, buy medical deep freezers to store vaccines and encourage Americans to take vaccines amid unprecedented hesitancy.
"States are going to spend that money fast," Marcus Plescia, chief medical officer at the group representing state public health officials, the Association of State and Territorial Health Officials, said in an interview.
The Centers for Disease Control and Prevention announced on Sept. 23 that it would send out the $200 million, which is divided among 64 states, territories and major cities, so that each will receive just a few million dollars or less as the nation faces a rise in cases and flu season begins. Together, the twin threats of COVID-19 and influenza are likely to cause a new wave of hospitalizations and deaths.
The money is needed right away, according to the group representing public health officials at the local level.
"It's really hard to build out infrastructure, hire personnel, etc., to be ready to go and hit the ground running when a vaccine is available," said Adriane Casalotti, an advocate with the National Association of County and City Health Officials. "Most local public health departments are tapped."
The two groups say they want Congress to give states another $8.4 billion for distributing any eventual vaccines. Much of the distribution planning ultimately falls to states, with the CDC relying on jurisdictions to develop their own "microplans."
CDC Director Robert Redfield told Congress earlier this month that $6 billion is needed, but negotiations on a new coronavirus relief bill have been facing difficulties on Capitol Hill. One sticking point has been allocating more money to states, which Speaker Nancy Pelosi sought but Senate Majority Leader Mitch McConnell balked at.
Some Republicans say they want to be cautious about offering more money, considering how much Congress has already provided for the COVID-19 pandemic response this year. For instance, a CDC official pointed to an agency spreadsheet showing that the agency has distributed $12 billion this year for coronavirus-related needs from two March laws. Some of that funding is dedicated to increasing lab capacity or influenza, but other tranches could be leveraged for COVID-19 vaccination.
State and local government officials note that they face plummeting revenues this year amid the economic collapse. And advocates say public health funding was neglected for years before the pandemic.
"I'm not quite sure how Congress can assume that our states can run on a flat-line budget for a decade ... and deal with this crisis. A vaccine is due in a handful of months and we're just getting some money now," said Amy Pisani, director of Vaccinate Your Family, a vaccine awareness nonprofit.
Fourteen states, the District of Columbia and seven territories are receiving less than $1 million from the $200 million to prepare for distribution.
Public health departments began sounding the alarm this spring that the funding wouldn't be enough.
"Back in May we were just trying to warn everybody: 'We don't want to build a plane while we're flying it, so let's get moving,'" said Casalotti. "Since then, there's been no movement."
The concerns are complicated further by mixed federal messages.
Sandra Ford, the health director in DeKalb County, Georgia, said she heard from state leaders that there would be 100 million vaccines by year's end, in keeping with President Donald Trump's statements, but a few days later learned from watching television that Redfield had testified to Congress that that was actually unlikely.
"It came from the state, maybe a week or two ago, that the goal was to have 100 million doses by the end of the year," Ford said. "I was watching the news and Redfield said it would be a while. ... So we're in sort of a holding pattern."
Some experts worry that Trump's promise of millions of vaccines this year has more to do with his reelection campaign than reality.
"In the heat of a presidential election, the people in the White House don't care about the delivery of a vaccine; it just has to arrive at the front door. Once it's at the front door, they can declare victory," said Vanderbilt University professor William Schaffner, a nonvoting member of CDC's vaccine advisory committee.
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States also are concerned about White House interference with the CDC and the Food and Drug Administration. Some want funding to independently verify FDA's authorization of any vaccine, a highly unusual step.
Another resource-intensive challenge will be to reassure people that a vaccine is safe, once experts agree.
"It's going to require a lot of marketing and media to promote the safety profile," said Ford. "We don't really have the money right now with what we have to support that level of effort."
States, localities and health care providers are being asked to answer many of the most vexing policy and logistical questions ahead, although CDC and other federal officials released a "playbook" for states this month.
"The challenge we're facing is we're trying to put together a 1,000-piece puzzle and we are still missing about 90% of those puzzle pieces," said Soumi Saha of Premier Inc., which advises health care providers.
All the tasks falling on state and local health officials are "going to be a very big effort. This is going to be unlike anything we've ever done," said Mark Ghaly, secretary of California's public health department.
One major expense could be storing Pfizer's vaccine candidates, which are reported to spoil at temperatures above minus 94 degrees. Medical deep freezers — which cost $10,000 to $15,000 each — are not commonly available at the clinics and pharmacies where people usually get vaccinated.
States and hospitals are holding off on purchasing them until they have more federal guidance and funding.
"Without knowing if you are going to be a vaccination site, why would you invest in a freezer?" said Saha.
That could create a bottleneck when it's time to distribute a vaccine.
Another concern is a shortage of staff. Missouri, Oklahoma and Oregon indicated that they expect to pull workers from other state projects to work on COVID-19 immunization.
Shortages of nurses, already in high demand, are especially concerning.
"Think about how long it takes to hire somebody," Schaffner said.
Nursing staffing agencies can be used but are more expensive on an hourly basis than a nurse on staff, Ford said.
Plescia said the overall staff shortages mirror challenges with contact tracing, which has been spotty because of a lack of dedicated funding.
"We had people geared up for contact tracing, but it took a while for the funding to come from the administration, and people are reluctant to spend money they don't have yet," he said.
The delays in funding could generate the kind of chaos that characterized the distribution of personal protective equipment and the reopening of schools and businesses.
"As we learned in the early stages of this pandemic, a fragmented approach leads to competition rather than coordination," Saha said.
Frustration is mounting among experts.
Since public health departments have been seeking more relief since March, Pisani joked, politicians can't be considered "essential" workers and should wait for a vaccine.
"I don't consider Congress to be essential when they can't even agree on something as critical as public health funding," Pisani said.
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