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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.

South Dakota Department of Health, Covid-19 Vaccination Plan, Appendix 4: Underlying Medical Conditions by County, updated 2020.11.18.
South Dakota Department of Health, Covid-19 Vaccination Plan, Appendix 4: Underlying Medical Conditions by County, updated 2020.11.18.

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:

SDDOH, "Estimated number of first responders, frontline hospital staff, and nursing home staff by county, 2020.11.18.
SDDOH, Covid-19 Vaccination Plan, “Estimated number of first responders, frontline hospital staff, and nursing home staff by county, 2020.11.18.

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.


*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.


  1. jerry 2020-11-29 14:41

    This is cowboy country. Those 23,171 doses will just rot here. Here, there is freedom, so who would want to be herded into a corral? Next thing they would want to bangs and preg test you while they line them buckaroos up to castrate. Nope, let the cowboys ride.

    Let the vaccine be for folks like myself. Those who will appreciate them, while they wash their damn hands, wear a mask and practice social distancing. Let the non cowboys ride… yippee tie one on.

  2. jerry 2020-11-29 14:52

    We don’t need no GNOem, we will be alright without her stank.

    “The coronavirus vaccine is expected to become widely available for the general US population in early 2021.
    One place where you’ll be able to get the COVID-19 vaccine for free is at any location of the Rite Aid drugstore chain.
    Rite Aid has sent out a letter to customers saying it will provide COVID-19 vaccine shots at no cost.
    Dr. Peter Hotez, co-director of the Center for Vaccine Development at Texas Children’s Hospital, said in an interview this week with NPR that after certain populations started to get vaccinated for COVID-19 in December, a broader vaccination program will follow quickly once 2021 gets underway.

    Indeed, the expectation is that a “significant percentage” of the US population will be able to receive the coronavirus vaccine early next year — which the doctor says is the reason why he’s asked one question pretty regularly. It’s “‘Hey, doc, which vaccine are you waiting for?’ And the answer is… I’m going to take any of those vaccines that are made available to me once they’re authorized by the US Food and Drug Administration. Don’t overthink it. Don’t wait. Get what vaccine you can.’”

    “Welcome Rite Aid Pharmacy Patients

    Welcome to Walgreens. Over the next few months, many Rite Aid locations — especially in the Northeast and Southern parts of the U.S. will be joining the Walgreens family. Taking care of patients, customers and our local communities is our top priority, and we look forward to having the opportunity to continue serving you.

    As a first step, select Rite Aid locations will transfer to Walgreens ownership over the next few months. When this happens, the pharmacies in these stores will be managed by Walgreens. Over the next approximately 18 months, the majority of these locations will convert to full Walgreens locations with the products, services and great prices found at other Walgreens stores nationwide.”

  3. grudznick 2020-11-29 16:17

    Mr. jerry, are you already drunk and ranting at this early hour? grudznick, who is in a number of those classes of high-risk, will gladly give you my spot in line so you can quit lashing about and urging the ultimate civil unrest which will no doubt come outside the Walmart pharmacy over by Lacrosse street when the masses start to riot about their position in line.

    Calm down. Be kind and nice to others, and you can have grudznick’s doses.

  4. mike from iowa 2020-11-29 16:47

    Better get at it….

    drumpf/noem bodacious body count for a busier than normal Sunday….

    United States
    Coronavirus Cases:

  5. jerry 2020-11-29 17:55

    While GNOem death panels rations the vaccine, Walgreen’s/Rite Aid, will give it to you and it will be done. She and her crackpot legislators can take their death panel rationing and stick where the sun don’t shine.

  6. Mark Anderson 2020-11-29 18:09

    Ahh, I remember my Ford swine flu shot in 76 in the Hyde County courthouse. It didn’t work, South Dakota has become filled with swine ever since.

  7. ds 2020-11-29 20:43

    Now I’m warning you, don’t besmirch Kristi…she has control of the coronavirus vaccine and she can put you at the end of the receiving line….

  8. grudznick 2020-11-29 20:52

    If we had the Walgreens of the world in charge, we would have a lot more groceries and hair care products, of that there is no doubt. Make no bones, we need private industry in charge of this herd immunity agenda and not the governments. You pick Walgreens, I pick Hooters and the Campbell Street Cafe, but golly somebody needs to be in charge besides the government.

  9. Cory Allen Heidelberger Post author | 2020-11-30 05:51

    DS, your comment gets back to a main point I’m wondering about how the rationing will work. The DOH is overseeing distribution to the points of delivery—clinics, pharmacies, etc.—but after delivery, the points of delivery appear to determine who gets a shot and who doesn’t. Theoretically, the Governor could create a do-not-vaccinate list of enemies, but she’d have to distribute such a list to multiple vaccinators around the state… and I’d like to think at least one health care worker would see such a list as an abuse of power and post it to Facebook.

  10. Dicta 2020-11-30 08:43

    Seems like a rational plan. For once, the administration is actually doing something to stem the tide.

  11. ds 2020-11-30 09:26

    CAH yea, you are correct that it would be unlikely that Kristi would retaliate against mask supporters…Guess i was confusing her with that vindictive dtrump.

  12. Tim Higgins 2020-11-30 12:34

    Cory, I thought you didn’t subscribe to conspiracy theories.

  13. mike from iowa 2020-11-30 13:52

    Pharmacysts can use their sincerely held religious beliefs to deny people they don’t like vaccinations, similar to those that won’t fill birth control or morning after pills.

  14. jerry 2020-11-30 14:04

    In China, they have vaccinating for a month or so, maybe even longer. Chinese capitalism at work.

    “Waves of Chinese students and businesspeople are flocking overseas, apparently undaunted by the rampaging coronavirus. But first, many of them are making a beeline for Yiwu, a bourgeoning trading hub in eastern Zhejiang province.

    They are not there for its consumer goods, but for the first batches of Chinese Covid-19 vaccines. Since October, Yiwu has quietly rolled out what may be the world’s first mass inoculation.” Asia Times 11.27.20

  15. Cory Allen Heidelberger Post author | 2020-12-03 06:57

    Update from SDPB’s Jackie Hendry: the SDDOH expects to receive 7,800 doses of the Pfizer vaccine by December 15. DOH will distribute those shots to 7,800 health care workers in Sioux Falls, Rapid City, Watertown, and Mobridge. Note that we’ll need to bank on getting another 7,800 Pfizer doses to give those first health care workers their second shots.

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