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Letter from NC Health and Human Services explains vaccination roll-out

With so many questions around the COVID-19 vaccination, North Carolina Health and Human Services Director Dr. Mandy Cohen issued this letter to vaccine providers. The goal of this letter is to update you and provide additional, clarity on the North Carolina Department of Health and Human Services’ (NCDHHS) COVID-19 vaccination allocation and operational strategy in our current stage, where demand vastly exceeds supply.

I want to start by acknowledging the tremendous work all of our vaccine partners have undertaken to ramp up and vaccinate people as quickly as possible under difficult circumstances. We know this effort is layered on top of many months working tirelessly to slow the spread of COVID-19 and save lives. I echo Governor Cooper’s deep thanks for all you have done and will continue to do as we work together to vaccinate residents of North Carolina as quickly, equitably, and efficiently as supply allows.

We are called together in this moment – one of the most monumental efforts of our time – to once again dig deep and achieve this goal with transparency, teamwork, and proactive communication among all partners in this effort, including NCDHHS. I know that the allocation process moving into this week has caused some of you pain and frustration. That was not our intention.

As you know, we faced a new pressure when the federal government indicated that they might reduce this coming week’s allocations to states who have larger amounts of unused supply on hand. We had to make difficult allocation decisions in order to clear our backlog of first doses and provide strong proof that North Carolina can exhaust our weekly first dose allotments and give vaccinations quickly. We asked many local health departments, community health centers, hospitals, and health systems to ramp up their ability to provide high-capacity throughput vaccination to work through this backlog. While our partners worked to rapidly create this new capacity, DHHS approved several large vaccination sites to further avoid a potential reduction in federal vaccine distribution.

Providers did heroic work — they ramped up their vaccination rates to deliver 280,000 vaccines over the past 6 days. With the clearing of the backlog, the increased capacity that was built, the mega-vaccine event we committed to, and now arriving at a week with only 127,125 expected new first doses, makes supply tighter for many. Some providers are receiving smaller allocations or zero allocations for this one week. Again, compounded with the success of our providers, the decision to support a mega vaccine event did result in the reduction of available vaccine for other providers.

As we look ahead, because of the amazing work of our provider partners, our maximum capacity in NC will continue to outstrip our anticipated state allocation. Despite the drop in the coming week, I cannot emphasize enough how critical it is that we stay on pace to meet our goal of using all our first doses during the week we receive them.

Allocation Strategy
The federal government allocates and ships vaccine to North Carolina on a weekly basis without any advance certainty of supply. This creates strain on the state, vaccinating providers, and local partners. Further, vaccine arrives anytime during a 48-hour window, creating further uncertainty when planning clinics and scheduling appointments. However, the federal government has made clear that a state’s administration of vaccine must keep pace with their allocations, and that states’ future allocations may be reduced if they are unable to keep pace.

To provide as much stability as feasible within these constraints, we are committed to providing you with a more predictable and transparent allocation model, outlined below. Please keep in mind that while demand for vaccines vastly exceeds our supply, allocations to the state remain low and an individual provider’s weekly allocation is likely to be far below the capacity they have built and demonstrated over the past several weeks while we have cleared the backlog. Moreover, while federal allocations of vaccine have been stable for the past several weeks, there is no certainty that supply quantities will remain stable past January. If the federal government were to reduce overall supply, it would likely disrupt allocation stability.

Starting with this week’s allocation, North Carolina will reserve 89,550 doses of the federal government allocation for enrolled providers. Using this, NCDHHS will guarantee a minimum baseline allocation each week, for the next three weeks assuming the expectations for our providers outlined below are met and the allocation from the federal government continues to support this level.

Vaccine will be allocated to each county based on population. Further below, we explain how we will use remaining doses to make intentional on-top-of allocations to account for counties with larger aged populations and historically marginalized populations. Then, the per-county allocation will be divided among providers in that county. It’s important to note that while our weekly allocations remain incredibly small, that not every provider will get a baseline allocation. To determine allocations among providers, we look at each provider’s stated capacity, and welcome feedback from the providers on how they would like to allocate across the county’s different providers. We aim to make these allocations as precise as possible at the county level, recognizing the constraints of the currently available vaccines’ minimum ship quantities and storage requirements.

After reserving the 89,550 doses for enrolled providers, that leaves an estimated 37,575 doses (based on continuing to receive 127,125 doses per week) to prioritize for several efforts. First, we will work to provide increased allocations to counties that, over the past several weeks, have received relatively less vaccine than other counties, when controlling for population. We will also provide increased vaccine for counties to account for larger historically marginalized populations and larger populations over 65. Second, we will use this set-aside to support onboarding of new providers, so that the base allocation will remain stable for current providers for the three-week period. Finally, we will invest vaccine into projects and events that promote increased access and partnerships in the community, with particular focus on achieving racial and ethnic equitable access to vaccine. These efforts will be planned in conjunction with local partners and ensure they complement, not hinder, or impede, your overall strategies to get vaccine out quickly. While we won’t be able to accommodate all events at the same time, we will work to plan these over time. Proposals that bring to the table a wide array of partners in the region or county and demonstrate resource sharing will be prioritized. Partners that have a track-record of sharing vaccine and working together, will be prioritized. We are committed to supporting transparency in the allocation process and our goal is to be closely coordinated with all our local partners across the state.

Allocation Timing
NCDHHS typically receives the state’s weekly allocation on Tuesday afternoon, and we aim to provide weekly allocations to our vaccine providers on Thursday evening. Providers must accept or decline their allocation in whole or in part no later than noon on Friday, each week, recommitting to the expectations outlined below. First doses of vaccine outlined in that allocation will arrive at the provider’s location on Tuesday or Wednesday of the following week, approximately 5 days after receiving notice of the allocation.

Providers must be ready to follow these expectations when accepting the allocation:
• All first doses of vaccine that arrive on Tuesday or Wednesday must be administered and entered the COVID-19 Vaccine Management System (CVMS) by Monday evening of the following week.
• CVMS remains the state’s system of record as well as the federal government’s reference point when making allocations. At this time, providers should fully enter vaccine administrations into CVMS within 24 hours as often as possible. Providers should plan capacity for real-time or simultaneous data entry during vaccine efforts and identify local support or request help with staffing or centralized data entry immediately if they are not certain they can get the data entered within the timeframe.
• Vaccine cannot be restricted based on county or state of residency.
• For high volume vaccination events intentionally created to increase speed of vaccination and increase access to vaccine, efforts should be made to create access for individuals in the community in addition to serving the provider’s patients-of-record. We recognize while supply remains incredibly limited, vaccination happening in smaller vaccination efforts, for example in outpatient provider offices, will likely only be delivered to patients-of-record.
• The percentage of vaccine administered to historically marginalized and minority populations should meet or exceed the population estimates of these communities in their county and region.

Please see the specific operational considerations below to ensure you are deploying best practices to meet this expectation. Providers should engage in partnerships, targeted outreach and vaccine events to vaccinate historically marginalized populations and meet this goal.

If providers cannot meet these expectations, NCDHHS will not be able to continue allocating supply to the provider and will not guarantee the minimum baseline allocation over the full three weeks.

Operational Considerations
We recognize that the expectations outlined – in particular, the weekly use of all vaccine – creates little room for advance planning and outreach efforts when we are provided with little advance notice of allocations. Over the past several weeks, we’ve learned from many of you about the strategies you’ve put into practice at hundreds of vaccine clinics across the state.

Here is a selection of those best practices that may be helpful:
• Wait to schedule appointments for the coming vaccine week until you have received the allocation. Use a waitlist to allow individuals to know they are “in line” and pull appointments from that waitlist for the following week as soon as you receive the allocation. In most cases, this will still provide people at least 6 days’ notice before their appointment.
• While vaccine supply remains very low, attempt to complete your first-dose administrations on Thursday, Friday, Saturday, and Sunday. Reserve Monday for using up vaccine that is left from no-shows or cancellations and to confirm that all administration data is entered into CVMS. You can call individuals from your waitlist Sunday night to finish up the small clinic.
• Avoid scheduling first-dose administration or planning first-dose events on Tuesday and Wednesday, because of the variability in shipping from the federal government.
• Open a set-aside block of appointments first to community health workers, care managers, churches or other community partners that will fill slots with underserved community members.
• Reserve a portion of your appointments specifically for members of historically marginalized populations. Utilize extended hours beyond 9am-5pm and weekend appointments.
• Locate the vaccination event in highly accessible locations for historically marginalized populations – such as churches, schools, community centers and others.
• Have an on-call list of people in the current priority groups who can be called to come to a vaccination event if doses remain at the end of the event due to no-shows, last-minute cancellations, or unforeseen additional doses from available vials (e.g., consistently getting 6 doses per vial of Pfizer).
• There are staffing resources available to assist for both clinical and clerical needs – please submit those requests through your county emergency managers into the WebEOC system

The federal allocation system is designed such that providers will always receive second doses to match the first dose allocation they received 2 or 3 weeks prior, depending on vaccine manufacturer, and in enough time to ensure availability for administration. It is important to remember that second doses do not arrive on the same day as first doses. For example, if you receive the allocation notice via email on Thursday night, the second doses outlined in that email will arrive at your site on that same day or the next day, Friday. Again, the first dose allocations indicated in that email will not arrive until Tuesday or Wednesday of the following week. While we are very focused on exhausting first doses, it is critical to ensure your operational planning includes necessary capacity to accommodate future second doses. In 3 to 4 weeks, once the backlog of first doses is cleared, North Carolina will reach the point where each provider should be exhausting all first and second doses every week.

Given the different ship dates of second doses, consider the following strategies, which we have learned from many of you:
• Schedule second-dose appointments at the same time that you schedule first-dose appointments. Or schedule second-dose appointments when the recipient completes their first-dose appointment.
• Create a priority phone number for second-dose scheduling or appointment changes to reduce confusion and increase likelihood of vaccine series completion.
• Hold second-dose appointments on Saturday, Sunday, Monday, Tuesday, or Wednesday. Monday, Tuesday, or Wednesday second-dose appointments may smooth out vaccine administrations if they complement the days you hold first-dose clinics.
• Consider how you will handle second doses when planning one-time events or via mobile vaccine sites. This could be by repeating the event or returning to the community in 3 or 4 weeks.
• Use auto-dialers, text messages, email, staff outreach, or other means to remind individuals of appointments.

NCDHHS is committed to continuing to improve our own operational response and helping you address any challenges you face in your local vaccination efforts. This is truly a shared effort that requires each of us to do our part and work in good faith with one another. I am confident that we can and will succeed together, and all North Carolinians will get a spot to take their shot.

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