COVID-19 Vaccination Plans: North Carolina, North Dakota, Ohio

Even though the US is still in the midst of the COVID-19 pandemic, plans are already underway to create and distribute a safe and effective vaccine for the virus. What is evident is that once the vaccine is ready, there will be challenges in its swift and equitable distribution across the country. The large-scale vaccination distribution effort is set to ensure that as soon as the vaccine becomes available, citizens will begin to receive it through their state, territorial, and local governments. These findings discuss the distribution efforts in North Carolina, North Dakota, and Ohio.

COVID-19 Plans for North Carolina

Distribution

• Providers serving open-priority groups will receive additional sub-allocations of the vaccine.
• Amounts allocated to individual providers will be loaded from NCIR to VTrckS.

• As soon as an order is approved by CDC, distribution will begin. Vaccines will be shipped from the manufacturer in ultra-cold storage coolers packed with dry ice, so jurisdictions do not have to purchase ultra-cold storage equipment just yet.
•  Ancillary supply kits and their diluents will be shipped separately from the vaccines but to arrive at the same time or before the vaccine.
• Vaccines will be distributed mainly to commercial, private section partners, and the public sector as required. The CDC will oversee distribution contracts. The state and its contract distributors will ensure that the vaccine reaches providers in a timely manner.

Storage

• Vaccine providers and coordinating state agencies, including IB, PHP&R, HPP, and NCEM will coordinate and implement supply and storage requirements.
•  Storage will coordinate with allocation and distribution.
• PHP&R, as well as the Immunization Branch, will provide expertise and technical support.
• The state will monitor CDC guidance to determine storage requirements from the time it is received until delivery to citizens.
• The Industrial Hygiene Unit within PHP&R will provide guidelines on safe storage of the vaccine. Each provider’s storage capacity will be examined. They will be educated on supply chain and storage operations.
• The state will be expected to make storage available based on CDC guidance.
• The state will maintain an inventory system to track vaccines using a QR code.
• In case of need, orders for 100-1,000 vials might be repackaged for smaller providers.
•  Ultra-low temperature shipping containers are supposed to be returned to CDC designated locations.
• PHP&R will monitor ordering trends and manage the vaccination sites as necessary.
• Once the vaccination process is complete, vaccination sites will be closed and all storage equipment will be returned to the relevant partners.

Prioritization

• The authorities have already indicated that all North Carolinians will have equal access to the vaccines.
• North Carolina will follow guidelines from the CDC’s Advisory Committee on Immunization Practices (ACIP), the National Academy of Medicine, John Hopkins University, and the World Health Organization.
• The state has considered prioritizing itself to release limited quantities of a vaccine requiring ultra-cold chain storage, release more significant quantities of a vaccine requiring standard storage, or release both vaccines at the same time.
• The state has examined further the prioritization possibility of releasing a vaccine that requires ultra-cold chain storage and which caters for 100-1000 doses per facility. However, the state’s advisory committee notes that this prioritization scenario can be adapted to the other two scenarios if necessary.
• Priority will be given to healthcare workers and medical first responders (approximately 161,000 individuals), followed by residents in long-term care settings (approximately 951,000 individuals).
• Next will be those at risk of high exposure and transmission to others (up to 1.57 million people), workers in critical industries (at least 767,000 people), followed by the remaining population.

Data & Reporting

• The state has indicated that data will be used to ensure that there is equity, to help in the decision-making process, and to track the progress of the vaccination effort.
• Data will be collected and tracked through an end-to-end system and federally-supported web-based systems to ensure efficacy. Data dashboards will be used for analysis and to ensure transparent reporting on vaccine distribution. All vaccination data will be reported to stakeholders such as state and federal agencies.
• Providers will use VAMS to enter data related to the vaccine.
•  VAMS will send data to IZ Clearinghouse and then to the IIS (NCIR) through the IZ Gateway to report storage and use procedures.
•  The Information Technology Division (ITD) will maintain oversight of public dashboards and maintain data connections between IZ Data Lake and dashboards.
• The G.S. 130A-153 grants the NC Commission for Public Health to grant additional access to immunization information. The state is however now required to send information to CDC, so the state must re-evaluate its existing rules to be able to comply with CDC’s requirements.
• Information will be available on the public Vaccine Finder website when a vaccine is available for more people in the general population. In this case, providers will be expected to provide information about their available supplies on this website.
• A public dashboard will be made available to provide information on the dosages already administered, the demographics of recipients, and vaccine coverage. The state will continuously monitor the data dashboard to determine progress.

Governance

• The North Carolina DHHS Vaccination Planning Team is in charge of the vaccination plan and strategies. This will involve the distribution, maintenance, and updates on the plan.
• The North Carolina Office of Emergency Medical Services Healthcare Preparedness Program (OEMS HPP) will work with existing partners and seek new ones to ensure the vaccine plan works effectively.
• Regional healthcare groups will provide technical assistance, facilitate connections between healthcare providers, and facilitate communications between stakeholders.

Technology Infrastructure

• Data and reporting will require integration into North Carolina’s vaccine IT systems.
• The systems used will include the immunization information systems (IIS), the CDC’s Vaccine Administration Management System (VAMS) modules, the Immunization (IZ) Gateway, Vaccine Tracking System (VTrckS), and a potential alternative system.
• Providers will be expected to collaborate with VAMS to manage the vaccine, schedule patients, and administer dosages.
• The state will evaluate CDC recommendations on the use of cloud data hosting and storage to make sure that the capacity for data storage is sufficient.

Security

• The vaccine will be tracked using a QR code based on an effective Vaccine Tracking Platform.
• The state will ensure that there are Data Use Agreements (DUAs) to ensure effective ordering, visibility of available vaccines, and the protection of shared data.
• The Immunization (IZ) Gateway will be securely hosted on Amazon Web Services (AWS) and will not save information centrally.
• All security risks will be evaluated and mitigated as they occur.

COVID-19 Plans for North Dakota

Distribution

•  Distribution is expected to be fair across the state based on the access which providers will have to prioritized populations.
• Vaccines will be distributed to providers based on their population estimates for the target populations, the dosages allocate to the state, package quantities, and ability to accept the minimum shipment.
• Orders in 100 dose increments or 1,000 dose increments for ultra-low cold chain vaccines will be ordered and sent to CDC’s ordering system and then distribute through McKesson.
• Vaccines not sent in 100 dose increments will be ordered through CDC’s ordering system and then delivered to the NDDoH Emergency Preparedness warehouse for distribution.
• Vaccines allocated to providers will be tracked cumulatively, and allocations will be base on administered and inventoried dosages.
• The NDDoH Division of Immunization (Mass Immunization Group) will try to provide the same vaccine to providers at all times.
• Distribution will be done based on a three-phase system. Phase 1 will include mass clinics for outreach to eligible groups. Phase 2 will involve distribution to large urban areas once the vaccine becomes widely available. Phase 3 will focus on private health care providers and pharmacies as demand for the vaccine declines.
• Routes will not be longer than 12 hours to ensure the vaccines stay cold.

Storage

• Ultra-cold vaccines will be shipped directly from the vaccine manufacturer.
• CDC is expected to authorize the shipment of full 100-1,000 dose increments to providers in the state.
• The state will most likely have to repackage some vaccines in order to meet the needs of rural areas and Tribes.
• State storage facilities will be set aside and will consist of coolers, freezers, and ultra-cold freezers. Local vaccine storage might however be limited if storage spaces are expected to contain both COVID-19 and influenza vaccines.

Prioritization

• The first people to receive the vaccine will be critical-infrastructure employees such as healthcare personnel and other essential employees.
• Next will be people at higher risk of COVID-19 infection such as long-term care residents, individuals with underlying medical conditions, and those aged above 65 years.
• Next, those at increased risk of transmitting COVID-19 will be vaccinated. These include people from racial minority groups, tribal communities, those in correctional facilities, the homeless, students and their teachers, and those living in congregate settings.
• People who have limited access to vaccination services will be next, followed by the rest of the population.

Data & Reporting

• Data estimates on priority groups will be obtained from statewide data sources and from healthcare facilities when they enroll for the vaccine. The estimates will be vetted based on county census data and known sources of data.
• The state will use the Tiberius platform to collect this data in order to make effective allocation decisions.
• Provider information will be manually updated in NDIIS in the vaccine module. When changes are made to the module, they will be automatically uploaded to the CDC ordering system called Vaccine Tracking System (VTrckS).
• Facilities will be expected to post the availability of the vaccine on vaccinefinder.org or a similar vaccine locator website once the vaccine is publicly available.

Governance

• The overall vaccination plan will be managed by the Unified Command Planning Team. This section will however hand over the planning and management plans to the Operations Section, within the Disease Control Branch in the Mass Immunization Group.
• The Joint Information System will handle all communication issues.
• The state warehouse will be controlled by Logistics.
• The Unified Command will meet weekly to discuss progress, and the Internal COVID-19 Vaccination Planning Team has already been meeting regularly.
• An Internal/External COVID-19 Vaccination Planning Committee is already established, and it consists of major external stakeholders in the state.
• The state was selected as one of the five sites to enhance microplanning for the vaccination in conjunction with CDC and other federal partners.

Technology Infrastructure

• The state has obtained written SAS code that adheres to CDC standards for data recording. Also, the NDIIS will use a datamart to enable immunization staff to extract data directly from the NDIIS database.
•  The PrepMod website will allow citizens interested in getting the vaccine to preregister for it.
• The Unified Command Joint Information System will be expected to continue swiftly and regularly disseminating messages through social media and media list serves.
•  Data from electronic health records (EHRs) will also be automatically used to document the vaccine record in NDIIS in real-time.

Security

• All vaccines being transferred from one provider to another must be inventoried and approved by the NDDoH Division of Immunization (Mass Immunization Group) before the transfer.
• North Dakota will comply with the data use agreement (DUA) for documenting and using patient-level data.

COVID-19 Plans for Ohio

Distribution

• The CDC’s Social Vulnerability Index will be used to assess vaccine administration during and after distribution.
• The state will ensure that the vaccine is distributed equitably to all people, especially to racial and ethnic minorities.
• Registered providers will receive direct shipment of the vaccine. Contracted transportation vendors will deliver the vaccine.
• All vaccine-ordering and distribution processes will be transparent, ensuring that the total incoming shipment is appropriately distributed to providers based on estimated target population, health equity, social vulnerability, the current epidemiological landscape, and the current level of immunity.
• Every dosage received will be accounted for, ensuring minimal loss or expiry. To achieve this, all providers will be expected to demonstrate the availability of cold-chain storage.
• Allocation for the vaccine will be done through a central VPO allocation algorithm and the state will order on behalf of providers whose information will be in VTrckS.

Storage

• Any satellite, off-site, or temporary setting which will store the vaccine must be verified and registered with the pandemic registration system.
• The state will receive vaccine allotments at the RSS warehouse to repackage and further break down the product in order to make sure that priority areas receive the vaccine first, particularly in the early days when the vaccine will still be limited.
• The RSS warehouse is currently setting up additional cold storage to ensure that all vaccines are safely stored. Further, there is backup power in case of electricity failures.
• The state has inventoried available containers and also plans to purchase additional ones in preparation for the vaccine’s arrival.

Prioritization

• The first beneficiaries of the vaccine in Phase 1 will be high-risk healthcare workers and first responders.
• Next will be the older adults living in crowded settings as well as those with underlying health conditions.
•  Phase 2 will cater to critical risk workers, teachers and school staff, all older adults not included in Phase 1, people living in homeless shelters and group homes, people and staff in jails and prisons, and people of all ages with underlying conditions.
•  In Phase 3, all children young adults, and workers in critical industries will be vaccinated.
• In the final phase, all other people living in Ohio who did not have access to the vaccine in previous phases will be catered to.

Data & Reporting

• The state will use the Immunization (IZ) Gateway to share data and information. It will also use the Connect and Share functions of the Gateway to disseminate information.
• The state will ensure that all healthcare systems and hospitals are digitalized to ensure effective vaccine registration.
• Providers will be responsible for reporting to Ohio’s ImpactSIIS and they will be expected to send data every 24 hours. On its part, the Ohio Department of Health Immunization Program and ImpactSIIS team will check for updates from providers on a daily basis.
• The state will provide required data reports to CDC and the federal government.

Governance

• The state has a dedicated organizational structure for vaccine readiness activities. It consists of a Vaccine Preparedness Office, a Local Coordination Committee, and external stakeholders and outreach groups.
• The Vaccine Preparedness Office (VPO) will plan and ensure the vaccine is available across the state.

Technology Infrastructure

• The state has already prepared a vaccine deployment analytical tool that will help the team to select critical population groups and then to filter and allocate them based on need.
• The state will use the current IIS system (ImpactSIIS) and use it to connect to the IZ Gateway via Connect and Share. This will ensure that the vaccine is distributed effectively and based on priority, particularly in the early days when vaccine availability will still be limited.
• Ohio is considering using VAMS to increase patient registration and scheduling.
• Providers will receive administration and IT training, and the state will facilitate CDC, VTrckS, and ImpactSIIS enrollment to avoid delays.

Security

• Currently, Ohio does not have a Data Use Agreement (DUA) in place with the organization that hosts the Immunization Gateway. However, plans are in place to get this agreement, and the state has already signed a memorandum of understanding (MOU) with other states.
• All provider registration forms and agreements will be accessed after authentication with accounting details to demonstrate ownership.
• Additionally, electronic signatures will be used to ease the process for providers.