Sometimes in the the next few months – before the end of the year, depending on optimistic, or more likely at the beginning 2021—The United States will have a vaccine against Covid-19. We don’t know which formula will be first at the finish line. We do not know whether this vaccine will be distributed as part of an emergency use authorization or a new standard drug approval. We don’t even know how many doses will be available. But one thing is certain: State governments and health departments are responsible for shooting. And since every state is different – in terms of geography, density, income, and the trust its people have (or not) in their rulers – every state is going to have to design its own plan.

Our attempt to control the coronavirus, in other words, will not be a war. There will be at least 50 separate battles – maybe 56, if you count Washington, DC, Puerto Rico, and the other U.S. territories – fought over different terrains and under different time frames, with varying supply lines and no not yet know who will pay for all the staff.

It could be complicated.

State and local health departments, and the organizations that advocate for them, are trying to be cheerful in the task, but officials are clearly concerned. “This is unlike any other effort we’ve had to make in about 100 years – maybe never,” says Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. “The closest we have ever made was the H1N1 flu, and in terms of vaccination, that was not the scale of Covid-19. So it’s a whole new planning process. And it’s really hard to plan when you don’t have all the information you need. “

The planning process has already started. The Centers for Disease Control and Prevention released a 57-page document “provisional playbookIn mid-September which details what states should do now: create committees, identify vaccination sites, develop orders and storage, create systems to track who receives vaccines and build the workforce. work to manage all these Tasks. The work specified in the playbook is not optional; States must run it to show authorities that they are ready to receive the vaccine once it is approved.

And this is a rapidly evolving process. States’ first submission to the CDC – the first iteration of their comprehensive plan to recruit vaccinators, receive the vaccine, and motivate their citizens to take it – is due today, October 16, exactly one month after the manual was published. Yet states must submit these plans without having access to crucial information: not just when the vaccine will arrive, but how many doses they will receive in the first round, how many will follow thereafter, and when those subsequent releases will begin.

“States do not know how much of the first supply they will be allocated,” says Marcus Plescia, a medical officer who is the chief medical officer of the Association of State and Territory Health Workers, and who has led an appeal with state health department last. the week. “Because it hasn’t been determined, they don’t know how to prioritize distribution.”

Two realities, little publicized until now, underlie this decision-making. The first is that once a vaccine is approved, it is likely to arrive not all at once, but in installments; a state’s initial allocation may be as little as a few thousand doses. The second is that one of the formulas is almost certain to require two injections, spaced 21 to 28 days apart, to be effective. So no matter how many doses received in that first delivery, they can probably only be used to protect half of that number – meaning the number of people allowed to come to the front line in n any state can be quite weak.

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