Decisions still being made in Missouri's COVID-19 vaccine plan

This undated electron microscope image made available by the U.S. National Institutes of Health in February 2020 shows the Novel Coronavirus SARS-CoV-2. Also known as 2019-nCoV, the virus causes COVID-19. The sample was isolated from a patient in the U.S. (NIAID-RML via AP)
This undated electron microscope image made available by the U.S. National Institutes of Health in February 2020 shows the Novel Coronavirus SARS-CoV-2. Also known as 2019-nCoV, the virus causes COVID-19. The sample was isolated from a patient in the U.S. (NIAID-RML via AP)

There is not yet an approved vaccine to fight COVID-19, and there are details of Missouri's plan for eventual vaccine distribution that still need to be worked out.

Gov. Mike Parson and state health Director Dr. Randall Williams unveiled the state's vaccine distribution plan Oct. 15 - the same date the plan was submitted to the Centers for Disease Control and Prevention for review.

Williams said that day there are four candidates for a vaccine in development, and he hoped a vaccine will be available by late November or early December, with general availability for the public by April.

Pfizer Inc. and the CDC announced "we should have the vaccine here in Missouri by the end of this calendar year," he added last week, and Missouri's distribution plan was sent to all 50 states by the White House as a model plan.

Once it arrives, the limited amounts of vaccine expected to be on hand early would be administered in phases and reserved for critical and high-risk groups of people: health care and long-term care facility workers; people older than 65 or who have underlying chronic health conditions; first responders; prison workers; child care providers; teachers; workers who keep electrical, water, manufacturing and food production systems running, along with other employees deemed to be essential; racial and ethnic minority groups; housing-insecure individuals; and people living and working in congregate settings.

The state's plan estimates there are approximately 3.3 million people in groups such as those listed above who are prioritized to receive a vaccine ahead of the general public.

There are still questions about who is or is not included in priority groups, however, along with what distribution itself may actually look like.

For example, it's not immediately clear whether or where some other particularly important workers are included in the distribution plan: state lawmakers and their staff; county-level officials including judges and prosecutors; public defenders; Missouri National Guard soldiers, if not already covered by any federal plans; and state Department of Transportation employees who maintain critical infrastructure.

It's also not immediately clear how employers would get approval for essential employees to be vaccinated among priority groups or whether there would be any prioritization between state departments' workforces.

Lisa Cox, Department of Health and Senior Services spokeswoman, told the News Tribune, "These types of decisions, more specific prioritizations, are still being made."

Williams said the vaccine will not be available for children or pregnant women, at least initially, because final clinical trials for those groups have not been done, and children are not as vulnerable to COVID-19 as senior citizens.

Williams said his sense is that the state would get through the health care worker vaccination phase "pretty quickly."

"After that, once we get into January, February and March, those numbers get pretty big," in terms of people in prioritized groups, and "we will just move through them sequentially. I can't give any exact number."

The trigger for moving from one phase to the next will be based on the amount of vaccine available, he added.

"At this point, we have not ranked those other groups (after the elderly and people with underlying conditions), until we see how much vaccine we get," Williams said.

He did say people living in congregate settings - part of the second phase of distribution - does include incarcerated people, though he reiterated that the group has not yet been prioritized of where they would fall sequentially among the other groups in that phase.

In terms of cost of receiving the vaccine, Williams said, "providers are allowed to charge an administrative fee," perhaps $20.

However, the state's distribution plan for the general public - phase three - notes there will be a "focus on making sure every Missourian who qualifies and needs or wants a COVID-19 vaccine receives the requested vaccine at no cost."

The plan notes while providers may request a vaccine recipient to pay an administrative fee, "a provider may not mandate payment. Per the terms of the Provider Agreement, a provider must administer the COVID-19 vaccine regardless of the vaccine recipient's ability to pay an administration fee."

The plan also notes under the federal Coronavirus Aid, Relief and Economic Security Act, "health insurance providers are required to cover, without cost-sharing, any qualifying coronavirus preventative service," and that includes "an immunization that is intended to prevent or mitigate COVID-19" that has gotten federal regulatory approval.

Therefore, insurance may be billed for the administrative fee, and if a vaccine recipient does not pay and does not have health insurance, there are funds available to reimburse providers.

Williams added there will be mass vaccination events at places such as gymnasiums and drive-thru settings.

"I do not anticipate cost being a barrier to getting vaccinated," he said.

The state's sequential vaccine distribution plan does rely on at least eventual availability of a vaccine that does not require "ultra-cold" storage temperatures that would require more complicated logistics: "Extended availability of only ultra-cold vaccine could undermine the tiered sequencing currently planned to guarantee equitable vaccine distribution across rural and urban populations."

The state is counting on having a less logistically restrictive vaccine that can be given out in many locations at once. According to the current distribution plan as released, "vaccination capacity modeling demonstrates it would take a minimum of 331 days of gymnasium events to vaccinate all Tier 1A health care workers statewide. This model's apparent failure demonstrates the crucial role of concurrent efforts across Missouri and the importance of decentralized execution."

The plan assumes one person in a doctor's office could provide up to 10 doses an hour, with an average of 48 doses given in an eight-hour day.

Seven people working a drive-thru location full-time could give 12 doses an hour, with an average of 94 doses given in eight hours.

Fifty people working a vaccination event full-time in a 94-foot-by-50-foot basketball court that allows for 16 lanes of 6-foot socially-distanced vaccination could give 160 doses an hour, for an average of 1,280 doses in eight hours. "The limiting factor is likely to be parking availability and safely keeping social distancing outside the facility's controlled area."

Some current vaccine candidates require only one dose, but others require two.

In terms of any role of the Missouri National Guard in distribution, the plan states: "As of the time of writing, there are no intentions to utilize the resources of the National Guard, including its soldiers, to support the logistical needs of the vaccination plan," because involvement of the Guard "is entirely fact dependent based on the specific task or project sought to be accomplished by the National Guard. As such it is not possible without specific details to determine whether it is permissible to utilize National Guard soldiers in support of COVID-19 vaccination."

The plan also recommends using only local law enforcement to provide frontline security at vaccination sites, not the National Guard.