San Diego Public Health Leaders Detail How They'll Roll Out The COVID-19 Vaccine
There has been a series of promising announcements from COVID-19 vaccine manufacturers. Pfizer has already requested emergency use authorization, and if granted, vaccines could ship as early as Dec. 12. Another company, Moderna announced on Monday it was also applying for emergency approval in the U.S.
So how would a COVID-19 vaccine get to San Diego and who will receive it?
Health Reporter Tarryn Mento asked the architects of San Diego County’s vaccine rollout plan: Health and Human Services Agency Director Nick Macchione and Public Health Officer Dr. Wilma Wooten.
Click on a question to reveal their responses:
Dr. Wilma Wooten: Our staff, per guidance from the Centers for Disease Control and Prevention, signs up providers with their requested allocation and then the vaccines are shipped directly to providers. That's the way it is being done all across the nation, and this is via guidance from the Centers for Disease Control and Prevention.
Director Nick Macchione: Yes, there's clear requirements on the temperature on the storage for the vaccine. The way it's even shipped: It's coming in a special kind of cooling storage to what we have prepared here at the county, to our providers who have this type of specialized freezing and then — happy to talk more what we have done proactively to buy additional of these specialized cooling units, freezing units for the vaccine as we think about the distribution across with our health care providers throughout San Diego.
Wooten: Providers submitting their application and identifying what allocations they want, they have to provide evidence that they have the capability to store the vaccines appropriately — and particularly the Pfizer, it is the sub-cooling or sub-freezing — so they have to have the capacity to manage and store the vaccines appropriately. And if they don't, then they can't get at least that particular vaccine. We know that there are others coming down the pike — signing up and distribution will be done the same, but they also have to document their vaccine handling process.
Wooten: We don't do the approving. We just help providers fill out the information that the CDC requires and that information goes directly to the CDC and then they will approve the process, the application or the submission.
Macchione: We're basically the extension of the California Department of Public Health at the local level, with Dr. Wooten as our public health officer. So we're collecting the information from hospitals, from clinics, from medical group practices, etcetera. But it's being submitted up to the state. As Dr. Wooten said, there's review processes to make sure they have the capability, the bandwidth, the capacity, the security and so forth on the storage of the unit. There's other factors of the ability to administer the vaccine and we'll get into that. And that's, you know, regulated by how many people are they looking to vaccinate, they're capable of doing, and that's how much they get the vaccine.
Macchione: It goes without saying not a single dose of vaccine could go to waste here, and so there is tremendous amount of scrutiny and planning to ensure that we are being extremely diligent about where the vaccine goes and that it — and we'll talk about how it's phased and released, according to the CDC, and then carried through the California Department of Public Health, CDPH, that we then locally administer out to some of the providers who get it. Some will get it directly from the state, some will get it from the federal government, CDC, some will get it from us. So it is variant based on the providers, based on what they do, the type of service, for example, and then the relationship they have with local public health. And also we are a vaccinator ourselves, our public health clinics. So we're not only going to be a distributor locally for some of the health care providers, but will be administering the vaccine as well.
Macchione: We have to submit a plan. The requirements is kind of rigorous requirements that are being put together right now. We don't have that yet completed. That will be submitted up to CDPH. And that's exactly what they're looking for as what your provider community is. Before to answer that question, Tarryn, we have to get into that priority setting there is by, per CDC, and I'll let Dr. Wooten explain this. There is real clear guidance of who gets the vaccine and that would determine also at what point do we administer it. So that'll be clear in a second.
Macchione: I will say, yes, not only are we looking to store the vaccine ourselves, and typically they will be in our public health centers because we are in communities where we need to give the vaccine. We are the safety net provider. Public health is that safety net provider. Let me put it in perspective. When you look at the seasonal flu — and we hope we could talk about that because that's an important segue to COVID vaccines — but when you look at seasonal flu, the county public health does about 1% because the health care provider community is really where you have that relationship with your physician at the clinic or administering that seasonal flu, including the retail pharmacies. So in some respects, this will be the same with COVID vaccinations. But we are the safety net, ensuring that there isn't a group of populations of people that are somehow not getting it. Even with the best FQHC community we have, we're ensuring that there’s no barriers in people not getting their vaccinations, be it seasonal flu, as it will for COVID vaccine. We can get into a little further about what does that ecosystem look like and our strategy, and I'm happy to go into that. But maybe very importantly, let me let Dr. Wooten explain at a macro level, very importantly thus far, what CDC and CDPH has laid out.
Wooten: Can I just say we store it in the same place we are all of our other vaccines. There's no secret location. It is stored — we have a vaccine scene warehouse that's where we store all of our other vaccines. We might be, we'll be working with partners early on until we get our freezers. But once we get our freezers in, it will be in our vaccine warehouse location.
Macchione: Here in San Diego.
Wooten: But we're not going to tell you where that is.
Macchione: It's not secretive, but it is a secure environment with all the requirements that we have to have for vaccines.
Macchione: Yeah, but let me say, there is a stratification, Tarryn, in even those groups you mentioned, and so I think it'd be important to kind of make sure we're clear, at least from I know what CDC is saying at this level. But remember, we also work with California Department of Public Health that's working closely with CDC and what those groups and phases are, and then we could talk about how we're going to get to those groups. So Dr. Wooten.
Wooten: Yeah, there's a lot we don't know yet. We are signing up just like all of the providers, we're helping providers in the community sign up on the CDC's website for the allocations. But if you have those four phases, I can tell you that phase 1A and 1B is 75% of our San Diego population, so we will have to prioritize the prioritized guidelines. And that's what all counties across California and across the nation, that's what everyone's doing right now, is looking at their population. And we've met with our local health care providers and we, you know, provide that information, but they know that that they will have to do that so this is not going to be news to them.
Wooten: But the front line individuals, health care workers that are in the EDs, in the hospitals as — so doctors and nurses and then first responders and then also nursing home workers, that's phase 1A. 1B is actually individuals that have at least two or more underlying medical conditions. And as I stated before, that's pretty much over half, it’s almost probably two-thirds, if not more, over 75 percent with 1A and 1B, of the entire San Diego population. So we will have to determine what within that group what's going to be prioritized, again, individuals with two or more underlying medical conditions. And CDC recognizes this, too. So we are continuously asking the state and CDC for more granular guidance so that everyone is doing the same thing. And so we're going through that process now.
Macchione: Well, first, we start with the medical homes because that's where the relationship is. So the medical homes of the physicians or health care providers will know their patients, right because you have patient confidentiality. So they'll know those folks that need to be, you know, prioritized, if you will, their conditions, number one. So that relationship will be with the provider community. So the clinics, the medical groups, the IPAs and so forth play a key role. The hospitals, obviously, because the hospitalized patients, it's they're there too They're a captive audience and they would know who to prioritize within the hospital.
Macchione: Managed care, and so I’m glad you mentioned that. So we have approaching almost 900,000 Medicaid lives. The Medicaid plans know their covered lives and so they will also have that data of who needs to be — and based on the accordance of being prioritized — communicating to: this is you need to come in and get your COVID vaccine. Then the issue about where they go that we can get into that discussion. But we're fortunate in California, we're fortunate in San Diego having a huge segment of our population that is tied to a medical home. That's the great work our state has done and the coverage, you know, of 26 years of age and having people access to medical homes.
Macchione: Clearly there are some that still don't and that's the population and we'll talk about how we're communicating with that population that does not have a medical home, kind of like we've been doing with T-3, about how do we get to those folks for testing and so forth or what we've been doing with seasonal flu already. We're not waiting for the COVID vaccination. The efforts are happening right now with getting people with their seasonal flu shot, which, by the way, is going fairly well, approaching nearly a million already, which looks like we'll surpass last year.
Macchione: But there's multiple avenues we're using of how do we connect to those people that need to come in, before we get to then, Tarryn, you know, the last group, which is the general population and that there's a lot of social media that will be building up to that. So we're working with those establishments that have the connection with the people. It's going to be easier, obviously, in 1A and even in parts of 1B because of those connections. When you get to essential workers, then it's the nature of their job, so they'll be identified that way. And then when you get into the age stratification of those below 30 or younger, I believe, you know, it's based on their age, if they haven't already got one. And then it’s the general population. So I think it has been well thought out. As the rollout on this, it's going to be the implementation to your point of how we connect with people. And and I'm happy to get into what are those things we're doing to get that connection, trust and confidence, because that's a big deal here, as you know, nationally and what we're doing here locally to address that. But Dr. Wooten is there anything you want to add to that?
Wooten: This is not the first time we've had to deal with this type of situation in terms of prioritizing vaccinations. As you may recall, during H1N1 pandemic, it was actually probably even worse in terms of there was a small amount of vaccine that was initially rolled out and then there was prioritization of the priorities. And that information, the guidance comes from CDC and we pushed that out at every opportunity during our press conferences, during our news stories. (Macchione: CAHAN) And for our providers through our CAHAN, so that's the way — we will use the same strategies that we use in general for pushing out information about out vaccination efforts.
Macchione: We're blessed, literally blessed in San Diego having one of the best immunization registries in the state. The San Diego Immunization Registry, SDIR, has been established for a long period of time. It is a very intelligent system that for vaccinations — and it's mainly children, for kids we register into the SDIR. For COVID, it's mandatory. And so we're going to have an advantage in the sense that people will be registered and when they get their first dose, not only be given physical reminder cards, but having a system that will be able to follow up with them in addition to their provider community, their medical home. So you're right that we have to be very proactive, not even in the first dose, but in that second dose as well. So we'll be in some cases, right, giving second doses as we're giving — depending on the availability of vaccine — our first doses of the different populations we're rolling out. And that's why, you know, this is going to have to be done in a very broad scale with all of our health care partners that have been fantastically at the table, to Dr. Wooten’s point, willing and stepping up with us in doing that. They do that now.
Macchione: You're right. You know, we still have to get them to take the first dose and you gotta get that second dose. And all the polls are showing that only what 60% of people are willing to do the first dose. So that's going to be a big lift and it's going to be the ongoing consciousness raising, public awareness, the media, the outreach and education groups that we've established, the faith community. It's going to have to be a saturation approach of all places, trusted messengers of reminding not only the first dose, but that second dose, and then obviously having the type of technology and sophistication to know what vaccine they took. Because that's the other thing. If you took Pfizer, your dose, the second dose has to be Pfizer. So now we're dealing with potentially multiple vaccines and those requirements. So that complicates things. And that's why we're going to have to have really stringent reporting to make sure folks get their second dose, but get the right second dose of the vaccination.
Wooten: We have a lot of experience with two-dose series vaccinations First, hepatitis A outbreak, and then our meningococcal group B outbreak at San Diego State. And so our San Diego Immunization Registry provides us with the opportunity and the ability to track vaccinations. Obviously, systems are only as good as the data that goes in. But when we administer the vaccinations, like if we are doing it out in the field to vulnerable populations, staff takes an iPad out with them and they can do it then. But they document it — if they don't do that — and then when they come back to the home base, then they put all that information in. So the San Diego Immunization Registry provides us with an opportunity to know who's getting vaccinated. So after the first vaccination, when it's put into SDIR before giving the second vaccination, SDIR is checked and that person is searched for and then it can tell whoever is giving, providing that second dose, they know what the first dose was. So that provides us the opportunity to make sure that everyone is getting the appropriate doses.
Wooten: And then we have, if you take a look at our San Diego immunization, not the registry, but our flu watch: it has a table there that shows for influenza, it tracks the influenza vaccinations that have been administered across the county. And we will have a similar graphic for COVID-19 as well. But again, I just want to point out, we have a lot of experience working with two dose vaccinations for two big outbreaks in the past. So this will not be a foreign process for us.
Macchione: We're not reinventing the wheel. We're using our current infrastructure with really you think about the 30- plus primary care clinics, FQHCs, the hundreds of doctors’ offices we have, our hospitals, the SNFs and and, you know — the ecosystem. We're using our ecosystem on top of that, yes, we are using our public health clinics and above and beyond that, Tarryn, we've done what's called those pods one-day kind of events that we've done for seasonal flu. We'll be looking at that when we go into areas that we have to do more in-reach. But excitingly — and I'm going to ask you a second part: how are they going to verify?— I think the part that we're also innovating with and been testing already out in East County with Cal Fire with T3 — our testing.
Macchione: When you think about where we've come from April to where we are today, today reporting over 20,00 tests is our seven-day average, we've built real great inroads in communities. Working with community partners we built trust. And this is well before the Thanksgiving rush for testing. You know, this is we have been increasing that now for months. So we're in right locations. You know, we have 52 different locations in the month of November throughout the county, so covered every aspect of our vast, diverse community. We have been testing now at our testing sites, piloting seasonal flu vaccinations. Now there's real rigor in how you do that because you don't want to have people coming in for a vaccine that are ill. They can't, they don't qualify for it. So we've been looking, though at sites where the community is familiar, is comfortable, has gone. And so we're seeing some really great results around people coming in for their — some cases, getting their covid tests and and being with no symptoms, getting the vaccine, seasonal flu and others coming there just for their seasonal flu. We are looking to that model and applying that now to, for example, Tubman Chavez, where we worked with the community in that southeastern San Diego that have Dr. Hood and the Health Equity Task Force and have really been champions of promoting testing. It's not the county, it's our partners, aringing the ability to do COVID vaccinations there, as an example, as well as other sites in South Bay. Again, we've made inroads. And so we're going to have even these additional sites in addition to the primary care settings that we have and even the ambulatory care settings where vaccinations are going to be taking place. I think the challenge for us will be the roll out of the vaccine: How much? And that's, you know, we don't know. And that's going to come in flows, and that will be then told to us, and then we have that strategy, the implementation. But if a fair amount of that came, we have that infrastructure and workforce that we've built up with our partners to do large numbers and for the right population.
Macchione: You ask, though, how do we know which population? Meaning it's clear with the 1A of health care, I think maybe you're referring to possibly the 1B: people with two or more chronic health conditions, right. So those are going to be the referrals that we're going to get. And if you remember, for testing, when we had to prioritize testing, Dr. Wooten did, we stratified of who should be getting tests and I would say for the most part San Diego followed them. (Wooten: Yeah.) And so I would see the same here when we do and prioritize those that will come to those sites that are not their doctor's office for example on that. So a lot of these details are still being worked out to your point with our provider community, but that's just the thinking of how we're going to roll out the vaccine.
Following flu shot rollout
Wooten: We will be building upon the strategies that we currently use for influenza vaccinations. So the pods, when we stand up the pods, that's one strategy. Public health centers, as Nick said, and then working with partners that can administer the vaccines to the populations that are identified. That's what we do now with influenza. And we will utilize those same strategies and expand to testing sites where we now conduct COVID tests. We will identify locations that are throughout the the the county. But I want to make the point, you were asking about knowing who's gotten the vaccines. When we do our pods, we take the computers to those locations. When you get a vaccination, you have to first go to a desk and you are you are looked up on SDIR. If you're not there, then they put you in. I've actually personally done this when we've had our pods and take-offs previously. So that is how we ensure that we know who's getting vaccinated, that information is being downloaded or input into computers that are on-site to access SDIR.
Wooten: Well, for me as a health officer, my biggest fear is: will people take the vaccine? Because we can have our vaccine that we get from the federal government, but if we can't get that vaccine into people's arms, we're not going to see a turnaround in businesses being able to open back up. But I have confidence that, again, we will build on the strategies that we've used before, working with our community partners, conducting outreach and education of the general public so that they understand and that they get the message from trusted — and it's not just going to be me as health officer, but our partners will also be pushing this information out to the community and to their patients.
Macchione: Yeah, mine's a two-parter. One, we are because of our community, we come together in San Diego like like no other in the state really do. And so my worry is that we don't get enough vaccine, that it trickles through, Tarryn, and we know that it's life-saving. And to me so urgency of getting a vaccine, as much as possible, we will get it out to our community.
Reaching right populations
Macchione: Tied then to Dr. Wooten's point, my biggest fear is the communities and the people who need it most, who have perhaps the greatest fear and our communities of color. When you look at what COVID has done for Latinos/Hispanic community where 34% of our population is Hispanic/Latino, but 62 to 63% of our COVID cases is Hispanic/Latino. We need to make sure that we get our Hispanic/Latino community, our African-American community, our API community, our refugee community, our communities of color, that in some cases — and you've read you know, this is not unique to San Diego, it's across the country — are feeling disenfranchised, not connected, worrisome. It's not COVID where we are now kind of doubling down on the connection — LiveWell San Diego, we've been doing this for decades, and our model and the county of working with community partners, not consulting, but collaborating with them in meaningful ways, and we can illustrate that. I think that has opened up a fair amount more trust in Dr. Wooten in our our local health officer and our local media believing our media, most of our media at least, you guys included, and I think we're in a in a way, a community that now needs to make sure we really work with those community ambassadors who are maybe not health care, but have standing in the community: resident leaders, faith leaders, non-elected community leaders, who are working with us and have done remarkable already in our response for COVID response, you know, COVID emergency. And what we're hoping that they will do and they're committed to doing is promoting the vaccine. But that's my worry, is that that we don't get to the level that I hope we do for our communities of color. So a lot more work that we're doing there, a lot of strategies. It's about relationships. It comes down to about relationships.
Wooten: Listen, I have said this many times before. The FDA next week will be reviewing Pfizer's application. They will be reviewing all of the applications for the other pharmaceutical companies to for the way the emergency use authorization. If FDA goes through that application process, they say it's safe, then we will recommend it to the community. And by recommending it to the community, I have to lead by example and get it myself. So with the flu vaccinations, you will see pictures of me getting the flu shot at those pods. So we will be doing the same thing.
Macchione: Yes, my father taught me that you take care of your family first and then you eat. So I'm going to make sure that there is — I took my seasonal flu shot. I look forward to getting my COVID vaccine shot, but I'm going to make sure first our community who needs it most, gets it, and then you'll see me there in line getting that COVID vaccine.
Wooten: Well, I can tell you in the words of our 16th Surgeon General: stay the course. I mean, that's you just have to stay the course. You know what needs to be done and you just keep your feet to the ground and just keep your nose down and be focused. And that's the way I get through. It's just you know what needs to be done and you get it done.
Macchione: It's a great question. I appreciate that. Dr. Wooten probably gets the most criticism from those that don't believe in, and so we got a fair amount of that. But when we get those notes, what motivates us is our own work family here and our community that keeps us together. Long hours working through tomorrow, Thanksgiving, as you know, it doesn't stop. It's our — we chose this profession as the noblest profession because it's about protecting our family. Our family is our county. And so we get those notes, those personal notes from individuals that tell us the difference it's made in their lives and that really motivates us, continues to motivate us and we keep on. So I appreciate that question and appreciate you helping get the word out. This is your part of our team, honestly, in getting this word out. So thank you.