Friday, May 14, 2021

This is how America gets its vaccines

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Biden just released pandemic strategy is organized around a central objective: to supervise the administration of 100 million vaccines in 100 days. To do this, he will have to fix the mess.

Some critics called his plan too ambitious; others said it’s not quite ambitious. It is guaranteed to be an uphill battle. But before we get to solutions, we need to understand how the system currently works – and what aspects of it should be abandoned, replaced, or retained.

From manufacturer to patient

At the federal level, two basic systems lie between the vaccine factories and the clinics that will administer the vaccines: Tiberius, the Ministry of Health and Social Services vaccine allocation planning system, and VTrckS, the Centers for Disease Control and Prevention’s vaccine ordering portal.

Tiberius takes data from dozens of inconsistent sources and turns it into usable information to help state and federal agencies plan for distribution. VTrckS is where states actually order and distribute the plans.

The two have been technologically separated for eons. While Palantir built Tiberius last summer using the latest technology available, VTrckS is a legacy system that has gone through several vendors in its 10 year existence. The two are largely linked by people downloading files from one and uploading them to the other.

Dozens of other private, local, state and federal systems are involved in the allocation, distribution, tracking and administration of vaccines. Here is a step by step explanation of the process.

Step one: manufacturers produce the vaccine

HHS regularly receives production updates from Pfizer and Moderna. Manufacturers communicate estimated volumes in advance to help HHS plan ahead before confirming actual production numbers, which are routed to Tiberius.

Both vaccines are made from Messenger RNA, a biotechnology that has never been produced on a large scale before, and they must be kept extremely cold until they pass through a needle: Moderna must be stored at -25 to 15 ° C, while Pfizer requires even lower temperatures of -80 to -60 ° C. By the fall, it became clear that manufacturers had overestimated how quickly they could dispense doses, according to Deacon Maddox, chief of plans, operations and Analysis of Operation Warp Speed ​​and former MIT member.

“Manufacturing, especially of an emerging biologic, is very difficult to predict,” he says. “You can try, and of course everyone wants you to try, because everyone wants to know exactly how much they’re going to win. But it is impossible. “

PFIZER

This led to some of the first stumbling blocks in the deployment. While training states in the use of Tiberius, Operation Warp Speed ​​captured these inflated estimates in a “sandbox” version of the software so that states could model different distribution strategies for planning purposes. When those numbers did not materialize, there was confusion and anger.

“At the end of December, people were like, ‘We were told we were going to get this and they reduced it.’ All because we put theoretical numbers in the exercise side, and people assumed that was what they were going to get, ”Maddox says. “The allocation numbers are very busy. People get very emotional.

Step two: the federal government sets vaccine allocations

Each week, HHS officials review production estimates and inventory numbers and decide on the “big number” – how many doses of each vaccine will be sent to states and territories in total. Lately, they’ve stuck to around 4.3 million a week, which they say “gets us through manufacturing troughs and saving on highs,” Maddox says.

That number goes to Tiberius, who distributes vaccines based on census data. HHS and media reports have sometimes described this step as using an algorithm in Tiberius. This should not be confused with any type of machine learning. These are just simple calculations based on allocation policy, says Maddox.

Until now, the policy has been to distribute vaccines based on the adult population (18 years and older) in each jurisdiction. Maddox says Tiberius’ logic could easily be updated if Biden decided to do it on another basis, such as the senior population (65+).

Once Operation Warp Speed ​​analysts confirm the official allocation numbers, Tiberius forwards the numbers to the jurisdictions in their version of the software. An HHS employee then downloads the same numbers to a file and sends them to the CDC, where a technician manually uploads it to set the order limits in VTrckS. (You can think of VTrckS as something like an online store: when health departments order vaccines, they can only add a certain number to their shopping cart.)

Even that hasn’t been an exact science. Shortly before the inauguration, in a phone call with Connecticut Gov. Ned Lamont, outgoing HHS Secretary Alex Azar promised to send the state an additional 50,000 doses as a reward for the efficient administration of vaccines. The doses arrived the following week.

The deal was representative of “the rather loose nature of the vaccine distribution process at the federal level,” Lamont’s press secretary Max Reiss told us in an email.

Step three: States and territories distribute the vaccine locally

State and territory officials learn how many vaccines they have received through their own version of Tiberius, where they can model different distribution strategies.

Tiberius allows officials to place data overlays on a map of their jurisdiction to help them plan, including census data on where the elderly and health workers are clustered; the so-called CDC social vulnerability index different postal codes, which estimates disaster preparedness based on factors such as poverty and access to transport; and data on hospitalizations and other case metrics from Palantir’s covid surveillance system, Protect HHS. They can also enter and view their own data to see where immunization clinics and ultra-cold freezers are located, how many doses different sites have requested, and where vaccines have gone before.

Once states decide how many doses of each vaccine they want to send to each site, they upload a file with addresses and dose numbers. They upload it to VTrckS, which forwards it to the CDC, which sends it to the manufacturers.

A Pfizer shipment

PFIZER

Last week, Palantir rolled out a new “market swap” feature, effectively giving states the ability to trade vaccines. Since the federal government divides the Moderna and Pfizer vaccines regardless of how many ultra-cold freezers states have, rural states may need to trade in their Pfizer allocation for Moderna vaccines from another state, says Maddox.

When thinking about the utility of the system, it’s worth noting that many healthcare departments have a shallow bank of tech-savvy staff who can easily navigate data-rich systems.

“He’s a rare person who knows the technology and the health side,” says Craig Newman, who studies interoperability of healthcare systems at the Altarum Institute. “Now you are launching large-scale epidemiology… it’s really hard to see it all from A to Z.”

Step 4: Manufacturers ship the vaccines

One way or another, shipping millions of vaccines to 64 different jurisdictions at -70 ° C is the easy part.

CDC sends state orders to Pfizer and Moderna’s distribution partner, McKesson. Pfizer ships orders directly to sites via FedEx and UPS; Moderna’s vaccines are first sent to McKesson hubs, which then hand them over to FedEx and UPS for shipment.

Tracking information is sent to Tiberius for each shipment so that HHS can keep an eye on the progress of deliveries.

Step five: local pharmacies and clinics administer the vaccine

At this point, things really start to fall apart.

With little federal advice or money, jurisdictions grapple with the most basic requirements of mass immunization, including scheduling and tracking those vaccinated.

Getting people into the clinic might seem intuitively easy, but it has been a nightmare almost everywhere. Many hospital clinics use their own systems; County and state clinics use a number of public and private options, including Salesforce and Eventbrite. Online systems have become a huge stumbling block, especially for older people. Whenever jurisdictions set up hotlines for the tech-savvy, their call centers are immediately overwhelmed.

Even within states, different vaccination sites are implementing their own hodgepodge solutions. To record who gets vaccines, many states have modernized existing systems for tracking childhood immunizations. The agencies running these systems were already overworked trying to put together messy data sources.

FedEx and UPS trucks depart from Pfizer.

PFIZER

It is not even known who is responsible for allocating doses. Maddox described incidents when state officials contacted HHS to say their caps were too low in VTrckS, only to find that someone else in their office had transferred doses to a program federal government that distributes vaccines to long-term care homes, without informing other decision-makers.

“Operation Warp Speed ​​was an incredible effort to get the vaccine to market quickly” and distribute it to all 50 states, says Hana Schank, director of strategy for public benefit technology at the New America think tank . “All of this has been done. beautifully. “But, she said, the program paid little attention to how the vaccines would actually get people.

Many doctors, frustrated with the deployment, agree with this sentiment.

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