Illinois will have to vaccinate 10 million people against COVID. What could go wrong?

Illinois is gearing up for an unprecedented logistical challenge in the midst of a public health crisis.

The goal is simple: vaccinate 80 percent of the population against COVID-19. But getting the shots from manufacturers to people’s arms will require precise coordination among numerous public and private entities, as well as an airtight supply chain—not to mention a safe and effective COVID-19 vaccine.

The complexity, urgency and scope of such a vaccination campaign make this an effort unlike any other in history.

Illinois needs to vaccinate at least 10 million people as quickly as possible—a scale and pace far greater than other vaccination campaigns.

The state must monitor and enforce compliance with a strict priority regime for the initial rollout, in which health care workers, residents and staff at long-term care and assisted-living facilities, and other essential workers get vaccinated before a general population clamoring for shots. Cold storage and handling requirements add another layer of complexity, with some COVID-19 vaccine candidates stored between minus 76 and minus 112 degrees Fahrenheit, compared with a range of 36 to 46 degrees Fahrenheit for the flu vaccine.

And with many vaccines requiring two doses administered at least three weeks apart, Illinois must track who got which shot when. On top of it all, the state will continue managing COVID-19, which has infected about 400,000 Illinoisans. “All of that together makes for an unprecedented set of challenges for our health care system,” says Katherine Baicker, dean of the University of Chicago Harris School of Public Policy.

A successful vaccination campaign would significantly slow the spread of the virus, allowing normal activities to resume and the economy to recover. Failure would allow the virus and its social and economic consequences to continue unchecked. Illinois recently unveiled a draft of its COVID-19 vaccination plan, as required by the federal government.

At this point, state officials don’t know which vaccines will be distributed, or when they’ll be available. Vaccines from Pfizer and Moderna are expected to have the safety and efficacy data needed to ask the U.S. Food & Drug Administration for emergency use authorization this year. But experts doubt authorization will come before January.

“Vaccination will take place over many months and may unfold in phases, as more vaccine becomes available,” Illinois’ draft plan reads. “Demand for the pandemic vaccine will be high throughout the response.” There are many unknowns and potential bottlenecks that could derail the effort.

For starters, without an authorized COVID-19 vaccine and details from the federal government around production and distribution, Illinois and Chicago won’t know how many doses they can expect to get during the initial phase of the rollout. Without knowing “what that viable vaccine is going to be, and what manufacturer is going to distribute that first vaccine, it’s really challenging to align a specific process,” says Jeff Thiel, assistant vice president of pharmacy services at NorthShore University HealthSystem.

“There are a lot of hypotheticals,” he says.

Illinois intends to allocate doses to each public health jurisdiction across the state based on population size, while factoring in hot spots and health equity. For example, if the state gets 200,000 doses, Cook County would get approximately 56,000, or 28 percent, since it’s home to 28 percent of Illinois’ population, the draft plan says.

“Initially, when we anticipate supplies will be limited, the federal government will actually allocate doses to the different states and certain local jurisdictions, so we will not be requesting a number,” says Dr. Candice Robinson, medical director at the Chicago Department of Public Health. “They will just say, ‘You have this many doses.’ ”

During the first phase, health care workers will get priority, followed by residents and staff at long-term care and assisted-living facilities. The next group in line would be critical workforce members.

The vaccines will be allocated based on the state’s mapping of priority populations. In its plan, the state says public health departments should coordinate with local health care providers, emergency management and other partners to develop a list of entities serving priority groups and determine whether to set up closed vaccination sites.

The city says it eventually plans to use large indoor spaces at City Colleges, the largest community college system in Illinois, to vaccinate large numbers of people while maintaining social distancing.

But before the vaccine can be administered, a complex supply chain orchestration must occur.

Big questions will need to be addressed: “Do we have the syringes and the vials necessary to deliver these vaccines?” says Tarek Abdallah, an assistant professor of operations at Northwestern University’s Kellogg School of Management. “It becomes about the supporting kits. That’s not trivial, making sure we have those numbers in place.”

Vaccines and ancillary supplies—such as needles, syringes and alcohol prep pads—will be shipped directly to health care providers. Orders will either come from medical and pharmaceutical supplies company McKesson, the federal government’s main COVID-19 vaccine distributor, or directly from vaccine manufacturers. It will be up to health care providers to procure their own sharps disposal containers, bandages and additional personal protective equipment.

Making this particular endeavor even more challenging is the fact that storage and handling requirements will vary, with some vaccines needing to be refrigerated or frozen and others requiring ultracold temperatures.

“Already our supply chains are strained because of COVID, and now we need to use a subset of a subset of our supply chain,” Abdallah says. “It’s a very complicated supply chain, and you need a lot of things to work together for this to happen at a large scale.”

Ultracold freezers aren’t common outside large health systems and academic medical centers that use them for research purposes. While the city of Chicago does have its own ultracold storage capacity, with the ability to house around 100,000 doses, Robinson says it’ll work closely with health care providers to secure capacity. The CDC has advised jurisdictions against purchasing ultracold storage equipment at this time.

“Knowing that the first wave of vaccines will be fairly limited, we definitely have the ability to store those on hand,” Thiel says. Still, NorthShore is among health systems looking to buy additional ultracold freezers to expand storage capacity. Many ultralow medical freezers that are about the size of an average refrigerator cost at least $10,000.

Manufacturers plan to ship vaccines in coolers packed with dry ice. The coolers should be repacked with dry ice within 24 hours of receipt and repacked again within five days, according to the CDC.

Some of the biggest uncertainties include how to supply rural areas that don’t expect to vaccinate thousands of people at a time, and what to do if people don’t show up.

“Let’s say we build the supply chain and people don’t buy in—they don’t want to take the vaccine or they don’t trust the vaccine that’s being delivered,” Abdallah says. “It’s incredibly important in terms of efficiencies to the supply chain to limit the amount of vaccines that get disposed.”

Beyond a possible supply shortages and missing links in the cold chain, industry observers say bad weather could stall the vaccine rollout if shipments don’t get to providers within the optimal timeframe.

In the case of a transportation or security issue, the state says it’s prepared to call on the Illinois Department of Corrections, which maintains refrigerated fleet vehicles to transport biologics, and the Illinois National Guard, as well as the Illinois Trucking Association.

With some vaccines requiring two doses roughly three weeks apart, timing will be crucial.

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