San Antonio Express-News (Sunday)
Uphill rollout for the vaccine
‘Nightmare from Day 1’ for officials
Years before COVID-19 emerged as a worldwide threat, the San Antonio Metropolitan Health District developed a plan to handle exactly such a catastrophic public health scenario.
Metro Health’s “Operational Pandemic Flu Plan” drew lessons from the H1N1 influenza pandemic of 2009. The 115-page document’s stated goal was to “minimize serious illness, hospitalizations and death; to preserve critical infrastructure; and to minimize social disruption” in the region.
The plan was developed after the federal government poured millions of dollars into state and local governments to help them prepare as outbreaks of avian and swine flu viruses erupted across the globe.
Now that the pandemic nightmare has occurred — one triggered not by a new influenza virus, but a new coronavirus — those plans have streamlined some elements of the local response, most notably the rapid creation of four mass vaccination sites.
But a shortage of vaccine across the country, as well as lag
ging distribution, has made it impossible for health providers to enact the city's plan in full.
Public health experts have placed the blame largely on the federal government, which stopped planning the vaccine rollout once shipments arrived in states.
“It's been a nightmare from Day 1,” said Assistant City Manager Colleen Bridger, San Antonio's coronavirus czar. “People don't understand, they don't know whether it's the federal government or the state government or the local government. And I don't blame them. I don't expect them to understand that. They see that government isn't responding to their needs.
“And it's a really difficult position to be in right now to have zero control over what you're trying to do, and yet be the boots on the ground who everybody looks to and asks, ‘Why isn't this better?'”
The Trump administration had pledged to vaccinate 20 million Americans by the end of 2020. But instead of rolling out a nationwide distribution plan to guide the states, it left them on their own to decide who should get vaccines — and when doses would arrive.
Almost six weeks into vaccine distribution, about 16 million people had received at least one dose of the vaccine, U.S. Centers for Disease Control data indicated Friday.
President Joe Biden has vowed a more robust vaccination campaign than his predecessor. Shortly after his inauguration last week, he signed a flurry of executive orders meant to boost the nation's COVID-19 response on a range of fronts.
To speed vaccinations, the president directed the Federal Emergency Management Agency to set up 100 vaccination centers in a month, and he authorized agencies to use the Cold War-era Defense Production Act to compel private industry to produce needed supplies.
“The federal government from the very beginning should have recognized that their role doesn't stop at giving vaccines to states,” said Dr. Leana Wen, an emergency physician and public health professor at George Washington University. “Because of the chronic under-funding of state and local health departments, there was no way that state and local health departments could've done all this work on their own.”
In Texas, that process so far has been marred with confusion and delays. The state reserved the first vaccines for health care workers on the front lines of the pandemic, but then abruptly opened up eligibility to the next tier of recipients — anyone 65 and older or with a chronic health condition.
More than 1 million San Antonians suddenly were eligible. Residents flooded phone lines and crashed websites to sign up for appointments at the city's few mass vaccination sites, spurring fear among some public health professionals that the most vulnerable residents without access to that technology would be left out.
“That kind of free-for-all fits those who have privilege. Who is able to call a phone hot line 500 times?” Wen said. “That's not the way it should be, and we know with a system like that, those who don't have access to the same resources are going to be left behind.”
Because vaccine supplies have been limited, Metro Health officials say they haven't been able to set up immunization events at schools, community centers and mobile clinics to meet residents where they live — let alone vaccinate as many residents as they'd planned at mass sites.
Metro Health's pandemic plan calls for “initially” vaccinating 4,000 people a day at each site. But the short supply of vaccine has forced the agency to limit vaccinations at its Alamodome clinic to half that — about 2,000 doses a day, even as a winter surge continues to infect thousands of San Antonians every day.
Constricted by the shortage, health providers at the city's three additional sites — Wonderland of the Americas mall on the Northwest Side, the Elvira Cisneros Senior Community Center on the South Side and the Alicia Treviño Lopez Senior Center on the far West Side — are vaccinating only about 1,500 people a day.
“Every single one of our mass vaccination sites could double the number of vaccinations they give every day, tomorrow, if we had more vaccine,” Bridger said.
University Health, Bexar County's public hospital system, could more than triple its daily numbers at the Wonderland mall by early February, vaccinating about 5,000 people a day, if more doses become available, officials said.
But so far, shipments of vaccine have been unpredictable and often contain fewer doses than health providers anticipate, Bridger said.
As of Friday, the state reported that it had “allocated” a total of some 235,000 doses to Bexar County since December, but it's unclear how many doses it actually has distributed. That number could be significantly lower: Fewer than 121,000 doses had been administered as of Friday.
“I don't think that plan anticipated the shortness of supply that we're dealing with,” Bridger said. “That's really the biggest challenge that we have right now, is we don't know when we're going to get doses, and we know that the doses we get are not nearly enough to do what everybody needs us to do.”
‘Underprepared’
As the avian flu spread across the globe in 2005, President George W. Bush asked Congress for $7.1 billion in emergency funding to help the nation prepare for a pandemic. Lawmakers approved $3.8 billion, $350 million of which was earmarked to improve state and local preparedness.
The funding set off efforts to craft pandemic response plans, ensuring health officials in cities and states would know what to do if patients flooded hospitals and they needed to open mass vaccination sites capable of immunizing thousands of people per day.
“Any community that fails to prepare, with the expectation the federal government will come to the rescue, will be tragically wrong,” Michael Leavitt, thensecretary of the U.S. Department of Health and Human Services, cautioned Texas government leaders and public health officials in 2006 at the state's Pandemic Influenza Summit.
“When it comes to a pandemic, we're overdue and underprepared,” Leavitt said.
The city's pandemic plan, most recently updated in 2014, predicted “a pandemic outbreak in any given community will last about six to eight weeks for each wave of the pandemic.” The document warned that “multiple waves … of illness could occur with each wave lasting two to three months.”
Metro Health seemed to anticipate receiving the bulk of available vaccine. Its plan called for providing vaccine to any organization with the medical ability to use it, and prioritized inoculating first responders and key government officials to “maintain continuity of government operations.”
San Antonio epidemiologist Cherise Rohr-Allegrini oversaw pandemic flu planning for Metro Health during that era. She and other officials knew it wasn't a matter of if a pandemic would arrive — but when. She said they also knew from the beginning that when that happened, the nation would face a severe shortage of vaccine while production and distribution slowly geared up.
“The federal control on the vaccine rollout has been hugely problematic, but we knew in 2006 even that it was going to be problematic with any pandemic,” Rohr-Allegrini. “As a local entity … we may not be able to decide when we're going to get it and how much we're going to get it, but we can decide how we're going to distribute it, and we have control over that working with those partners.”
What Rohr-Allegrini hadn't expected was that the federal government would provide so little guidance on vaccine distribution — and then the state of Texas would limit cities from deciding how to provide the vaccine in their communities.
Operation Warp Speed, the federal government's program to accelerate the development and distribution of vaccines, had anticipated using the military to distribute the shots but ultimately thrust that responsibility onto the states.
In its first weeks of allocating vaccine doses in December, the state disregarded the readiness of health authorities such as Metro Health to set up mass vaccination sites swiftly, instead distributing its stockpile to hundreds of registered health providers in Texas that included hospitals, pharmacies and physician's offices.
It wasn't until almost a month into distribution that Texas pivoted to a model that focuses more on mass vaccination sites.
But some public health experts worry the mass vaccination sites that are open to entire communities will miss Texans who are most at risk of becoming severely ill and adding to the strain on hospitals.
“If the 65-year-old diabetic in poor condition, living in a crowded house with 10 people gets COVID, they're likely to have severe illness, they're likely to go to the hospital, and their whole household is likely to get it because they can't isolate,” Rohr-Allegrini said. “Probably a few more of them are going to go into the hospital, which means a drain on hospital resources — that means those are three beds that are not going to be available to a heart attack victim or a stroke victim.”
Rohr-Allegrini is among public health officials who want the hardest-hit neighborhoods in cities to be first in line for vaccines. Dallas and Tarrant counties, for example, recently considered plans to prioritize vaccines to residents in the most vulnerable ZIP codes.
But the state put a stop to Dallas' plan last week, threatening it would stop sending the county vaccines if it didn't reserve a “significant proportion” of doses for eligible people across the city.
“That is negligence,” Rohr-Allegrini said of the state's actions. “That is horrifying to me because we know, and there's a number of stories now showing in different cities, the people that have been vaccinated already are the wealthiest people with the lowest risk and we're not getting it into the populations that need it.”
Chris Van Deusen, a spokesman for the state health department, said the state has directed providers to ensure they're vaccinating people in the hardest hit neighborhoods, but “they cannot do that to the exclusion of literally everyone else and still remain a hub provider.”
It has meant San Antonio health officials have had to walk a fine line to ensure they reach residents who need the vaccine the most — and meet state requirements.
Knocking on doors
Metro Health's pandemic plan calls for focusing on vaccinating “hard to reach populations,” such as people who lack health insurance and transportation and have lower incomes.
To help meet that goal, the city sends its community health workers into high-risk parts of San Antonio every day to register 300 people for vaccinations at the Alamodome, Bridger said.
“We're not limiting,” she said. “We're targeting. So 1,400 appointments a day are gone in five minutes through the system, and that's open to anybody who lives anywhere.”
Bridger is hoping for expanded access in the near future.
“God willing, there is going to be more vaccine supply available to us,” she said. “When that happens, we are going to go to mobile vaccination shots, we are going to go to a much easier opportunity for people to sign up. There will be vaccine at your local pharmacy. The problem right now is, there's 25,000 doses a week in Bexar County, and we have 1 million people who are eligible, and each of those people need two doses.”
“The problem is we're trying to squeeze 1 million people through a hole designed to serve 9,000 a week,” Bridger continued. “There's no way to do that.”