SD Plan to Ration Coronavirus Vaccine: 23,171 Health Care Workers First

So far, the inattentive White House is leaving distribution and rationing of the coming coronavirus vaccines to the states, and Congress has appropriated only $200 million out of the $8.4 billion that state public health officials say they need to responsibly vaccinate the public.

Instead of doing the hard work (those six words are the unifying theme of the Trump Administration) of looking at different risk factors in different states, the White House is simply the amount of vaccine they predict will soon be available—6.4 million shots—and dividing them up in proportion to states’ populations. By 2019 Census estimates, South Dakota’s 885,000 people will get about 17,000 shots. That’s 1.9 percent of our population getting the first round of coronavirus vaccines.

So, to whom will we ration this health care?

The South Dakota Department of Health’s 64-page vaccination plan (version 3.0 as of November 18, as updated by Angela Jackley) says that the “critical population groups” who will be moved to the head of the line for coronavirus vaccines during the initial phase include the following:

• long-term care facility residents;
• people with underlying medical conditions;
• people 65 or older;
• people from racial and ethnic minority groups;
• people from tribal communities;
• people who are incarcerated/detained in correctional facilities;
• health care personnel;
• other essential personnel;
• people experiencing homelessness/living in shelters;
• people attending schools/colleges/universities;
• people living and working in other congregate settings;
• people living in rural communities;
• people with disabilities;
• people who are under- or uninsured.

That list is not in order of priority, but it will need prioritization. Consider underlying medical conditions, which in this plan include hear disease, asthma, previous stroke, diabetes, hypertension, kidney disease, and obesity. According to the DOH, more than 50% of the population of all but two of South Dakota’s counties (Brookings and Clay) have underlying conditions.

According to DOH’s population numbers*, Brown County alone has over 17,000 people with underlying medical conditions warranting priority for the first phase of coronavirus vaccinations. That’s the entire supply South Dakota would be receiving, just for that subgroup in one county. Lincoln, Pennington, and Minnehaha counties together have more than nine times as many people with underlying medical conditions than the number of vaccines coming in the first phase.

The Department of Health thus plans to ration the first vaccines even more strictly, according to criteria developed by the National Academies of Science, Engineering, and Medicine in its Framework for Equitable Allocation of Covid-19 Vaccine:

• Risk of acquiring infection
• Risk of severe outcome due to infection
• Risk of negative societal impact
• Risk of transmitting infection to others.

Under those criteria, first in line for coronavirus vaccines are high-risk health care personnel (doctors, nurses, and support staff) working in emergency departments, intensive care unites, and dedicated coronavirus units. In hospitals that don’t have dedicated coronavirus units, “frontline staff providing care to covid-19 patients on general wards” are included in this top-priority group. Emergency medical service first responders also qualify for the absolute first vaccines.

But even that group of “Phase 1a” vaccine recipients numbers 23,171:

Once we vaccinate that 23,171 corps of health care providers, DOH says we will turn to “Phase 1b,” which will get shots to people of all ages with two or more of the medical conditions that the CDC says increase their risk of severe coronavirus: cancer, chronic kidney disease, COPD, heart conditions (e.g., heart failure, coronary artery disease, cardiomyopathy), immunocompromised state from solid organ transplant, obesity, sickle cell disease, and type 2 diabetes mellitus. (Note that the first map above shows residents of each county with one or more underlying conditions, so that map is not limited to the Phase 1b recipients.)

Phase 1b will also target anyone 65 or older in long-term care facilities “or other congregate settings” and law enforcement first responders.

The Department of Health plans to restrict vaccines in the first phase by conducting closed vaccination clinics—i.e., the public can’t just walk in and ask for a coronavirus shot. DOH will also allocate vaccine based on (p. 17) target populations in each area, the amount of vaccine and the number of vaccinators available, spread of coronavirus infection in the state, and second-dose requirements. DOH will secondarily consider regional coronavirus spread, equitable geographic distribution, county incidence rates, and the size of priority populations. So it’s possible that if coronavirus is surging in your county and not other counties, the DOH may send more vaccines your way, but local rates are only one criterion out of many.

The need for two doses will complicate matters. Remember, you’re going to need two shots maybe a couple-three weeks apart—DOH says three-four—and the second shot apparently is a doozy for side effects. One potential problem in the DOH’s vaccine plan pops up in one line on page 38: “Vaccine providers will administer all allocated doses. For example, they will not withhold half of their allocated doses to be used as second doses in 21–28 days.” On the one hand, I can see the sense of that statement: if there are 100 people at a clinic eligible for the vaccine, we’re not going to shoot only 50 of them; we’re going to give all 100 the first dose so twice as many people will be ready for the second dose and full protection. But the sensibility of that approach depends on the vaccine supply not flagging. If we vaccinate all 100 takers on January 1, and then blizzards and breakdowns prevent the shipment of more vaccine, we’d better be ready to scramble to get 100 second doses out to that site so those 100 first doses aren’t wasted.

Once vaccine supply rises to meet demand, DOH says we will enter Phase 2, in which we will start to see open vaccination clinics. At that point, DOH appears to depend on distribution practices for rationing to the remaining higher-risk populations. For instance, it will be reasonably easy to set aside vaccines just for students by working with the K-12 schools and the Board or Regents to hold vaccination clinics on campus just for students (although shouldn’t we include teachers in that group as well?). But while the DOH plan refers to reporting requirements from the vaccine sites, I don’t see a clear explanation of how we will ration shots at the points of delivery to higher-risk patients and turn away shot-seekers who don’t meet the criteria for early vaccination.

We are about to embark on an enormously important and enormously difficult exercise in rationing health care. There is no way that the free market could effectively or equitably distribute the coronavirus vaccine. We need both our state government and the federal government to develop and execute robust plans to ensure the optimal use of the vital vaccines coming our way. Doing vaccines right will require elected officials to focus on doing their jobs, not on campaign fundraising or running for reëlection.

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*Data note: When I add up the number of people DOH says have underlying medical conditions in each county, I get 381,307. When I divide the number given for each county by the percentage reported for underlying conditions, I get a total statewide population of 667,273, far below the current Census estimate of 885,000.