POLICY IMPACT

Although reserve systems have not been part of pandemic resource allocation guidelines prior to the Covid-19 pandemic, following the circulation of Pathak, Sönmez, Ünver, and Yenmez (2020) and our subsequent collaboration with various interdisciplinary groups and healthcare officials, they have recently been recommended or adopted in a number of settings.  This page summarizes some of these recent developments. 

 
 
 

 

Therapeutics Allocation

 

Pennsylvania and UPMC Weighted Lottery for Allocation of Scarce Covid-19 Therapeutics

May 2020: The University of Pittsburgh Medical Center (UPMC) developed a weighted lottery system via reserves to implement a transparent and fair approach to allocate scarce medications to treat patients with Covid-19. 

  • This policy was developed by an interdisciplinary team led by Doug White and our group provided software to facilitate rationing.  Details on the policy can be found here.

  • This lottery system was later endorsed by the Commonwealth of Pennsylvania for the allocation of scarce Covid-19 therapeutics.

 

Massachusetts Guidelines for Covid-19 Monoclonal Antibody Therapeutics 

November 2020: For allocation of monoclonal antibody therapeutics, Massachusetts became the first state that has recommended the use of a reserve system. For within-hospital allocation, the Massachusetts Department of Public Health Guidance for Allocation of Covid-19 Monoclonal Antibody Therapeutics recommends a 20% reserve for vulnerable populations.  

  • The Department of Public Health assembled a Working Group, comprised of infectious disease specialists, emergency physicians, community health center representatives, and ethicists to advise on equitable public health strategies to allocate the doses of Covid-19 therapeutics delivered to Massachusetts in the event that there is not sufficient capacity to respond to demand for this scarce resource. 

  • A member of the Working Group, Dr. Emily Rubin from Mass General Brigham, inquired whether our proposed reserve system can be used for the equitable allocation of Covid-19 Monoclonal Antibody Therapeutics, and if so, how it can be operationalized in practice. 

  • Our group supported the Working Group in their design of the Monoclonal Antibody Therapeutics allocation guidelines and provided them with an Excel spreadsheet implementation of our proposed reserve system tailored to the specifications for Massachusetts policies.

  • In Rubin et al (2021), we report the institutional experience at Mass General Brigham, with particular emphasis on how a reserve system can be used to promote equitable access to healthcare.

  • See also the following editorial by Makhoul and Drolet (2021),

 

 

NASEM Framework for Equitable Vaccine Allocation

 

July 2020: CDC and NIH commissioned the National Academies of Sciences, Engineering, and Medicine (NASEM) to formulate their recommendations on the equitable allocation of a Covid-19 vaccine. NASEM appoints a committee of distinguished experts.

 

September 2020: A discussion draft of the preliminary Framework for Equitable Allocation of Covid-19 Vaccine is made public and comments from the public are solicited.

  • In his written and oral comments, University of Pennsylvania bioethicist Harald Schmidt inquired about the mechanism to prioritize members of hard-hit communities, bringing our proposed reserve system to the committee’s attention as a possibility.

  •  In response to the NASEM discussion draft, JAMA published the viewpoint “Fairly Prioritizing Groups for Access to COVID-19 Vaccines,” endorsing our proposed reserve system (Persad, Peek & Emanuel 2020):

 

“Dividing the initial vaccine allotment into priority access categories and using medical criteria to prioritize within each category is a promising approach. For instance, half of the initial allotment might be prioritized for frontline health workers, a quarter for people working or living in high-risk settings, and the remainder for others. Within each category, preference could be given to people with high-risk medical conditions. Such a categorized approach would be preferable to the tiered ordering previously used for influenza vaccines, because it ensures that multiple priority groups will have initial access to vaccines.”

 

October 2020: NASEM published their final Framework for Equitable Allocation of COVID-19 Vaccine (2020), and formally recommended a 10 percent reserve for people from hard-hit areas:

 

“The committee does not propose an approach in which, within each phase, all vaccine is first given to people in high SVI areas. Rather the committee proposes that the SVI be used in two ways. First as previously noted, a reserved 10 percent portion of the total federal allocation of Covid-19 vaccine may be reserved to target areas with a high SVI (defined as the top 25 percent of the SVI distribution within the state).”

 
 
 

 

California Covid-19 Vaccine Allocation Plan  

In December 2020, we introduced and advocated for a reserve system to California’s Surgeon General Dr. Nadine Burke Harris and her team. We have been communicating with them on-and-off for their potential adoption of the reserve system for California's vaccine rollout to mitigate the disparities for hard-hit populations who have suffered disproportionate Covid-19 burden. These efforts have recently borne their fruits.  

March 2021: California announced its plan to use a reserve system to mitigate the disproportionate Covid-19 burden faced by its hardest-hit communities.  See this fact sheet for additional details.

  • The state has developed a Healthy Places Index (HPI), which reflects 25 community characteristics using data related to the economy, education, healthcare access, housing, neighborhoods, clean environment, transportation, and social environment. California’s 1650+ ZIP codes have been divided into four quarters based on the HPI Index. Those with the highest HPI scores correlate to better health outcomes, while those with lower scores (first quartile) reflect worse health outcomes. 

  • 40% of the vaccines will be reserved for communities in the first quartiles of the HPI index, and 20% will be reserved for communities in each of the other quartiles. 

  • Within each socioeconomics quartile, 70% of the vaccines reserved for the quartile will be allocated based on age eligibility, and 30% of the vaccines reserved for the quartile will be based on sector eligibility. 

  • Based on media reports, a third of the vaccines allocated based on sector eligibility, i.e., 10% of the vaccines will be set aside for educators.

 

 

Tennessee  Covid-19 Vaccine Allocation Plan

October 2020: Tennessee became the first state that has announced its plan to use a reserve system for Covid-19 allocation. The interim plan by the Tennessee Department of Health included the following reserve categories:

  • 5% of the State’s allocation of Covid-19 vaccines will be distributed equitably among all 95 counties

  • 10% of the State’s allocation of Covid-19 vaccines will be reserved by the State for use in targeted areas with high vulnerability to morbidity and mortality from the virus  

  • 85% of the State’s allocation of Covid-19 vaccines will be distributed among all 95 counties based upon their populations

December 2020: Tennessee updated its plan to accommodate different vaccines.

 

 

Massachusetts Covid-19 Vaccine Allocation Plan

December 2020: Massachusetts became the second state that has announced its plan to use a reserve system for equitable Covid-19 vaccine allocation. 

  • 20% of the vaccines will be reserved (in an over-and-above form) for communities that have experienced disproportionate Covid-19 burden and high social vulnerability.

 

 

New Hampshire Covid-19 Vaccine Allocation Plan

January 2021: In New Hampshire's plan, 

  • 10% of the vaccines will be reserved (in an over-and-above form) for communities that have experienced disproportionate Covid-19 burden and high social vulnerability.

 

 

North Carolina Covid-19 Vaccine Allocation Plan

January 2021: In North Carolina's plan,

  • An over-and-above reserve will be used for counties to account for larger historically marginalized populations and larger populations over age 65. 

March 2021: In North Carolina's revised plan,

  • 3% of the vaccines will be reserved for long-term care settings, state facilities, and community vaccination events.

 

Pennsylvania Covid-19 Vaccine Allocation Plan

January 2021: In Pennsylvania's plan,

  • 10% of the vaccines received by each health-care provider will be reserved (in a minimum guarantee fashion) vaccination of Phase 1A non-hospital affiliated health care personnel.

 
 

 

Connecticut Covid-19 Vaccine Allocation Plan

February 2021: In Connecticut's plan,

  • 10% of the vaccines will be reserved (in an over-and-above form) for communities that have experienced disproportionate Covid-19 burden and high social vulnerability.

March 2021: Connecticut revised its plan so that

  • 25% of the vaccines will be reserved (in a minimum guarantee form) for communities that have high social vulnerability.

 

Minnesota Covid-19 Vaccine Allocation Plan

February 2021: In Minnesota's media-reported vaccine allocation plan,

  • 7,000 doses are reserved (in an over-and-above form) for 65 years and older individuals, and 10,000 doses are reserved (in an over-and-above form) for school and child-care workers.

May 2021: In Minnesota's new vaccine allocation plan,​ 

  • 40% of the vaccines will be reserved for communities in the first quartile of the CDC's SVI index, and 20% will be reserved for communities in each of the other quartiles to decrease the gap of vaccination rate for the adult population living in the first quartile and the rest of the quartiles and to prevent a gap in children from occuring.

 
 

 

Colorado Covid-19 Vaccine Allocation Plan

March 2021: In Colorado's  plan,

  • 15% of the vaccines are reserved (in an over-and-above form) for communities that have experienced disproportionate Covid-19 burden and high social vulnerability.

 

 

Illinois Covid-19 Vaccine Allocation Plan

March 2021: In Illinois' plan,

  • 300-500 weekly doses are reserved (in an over-and-above form) for each of nine sites serving hard-hit communities.

 

Maryland Covid-19 Vaccine Allocation Plan

March 2021: In Maryland's plan,

  • 2,100 weekly doses are reserved (in an over-and-above form) for the residents of Prince George’s County.

  • 2,100 weekly doses are reserved (in an over-and-above form)  for the residents of Baltimore. 

  • 2,100 weekly doses are reserved (in an over-and-above form) for the residents of Charles, Calvert, and St. Mary’s counties (divided among them by population).

  • 2,100 weekly doses are reserved (in an over-and-above form) for the residents of Wicomico, Worcester, Somerset, and Dorchester counties (divided among them by population).

  • 2,100 weekly doses are reserved (in an over-and-above form) for the residents of Washington, Allegany, and Garrett counties (divided among them by population).

 
 

 

New Mexico Covid-19 Vaccine Allocation Plan

March 2021: In New Mexico's plan,

  • 25% of the vaccines are reallocated to high social vulnerability and hard-hit areas.

  • Media also reports that 1,000 weekly doses are reserved (in an over-and-above form) for disabled individuals and the elderly.

 

 

City and County Vaccine Rollout Plans

 

New York City Covid-19 Vaccine Allocation Plan

January 2021: In New York City's plan, 

  • Some hours and appointments for residents of 33 high-risk areas are set aside (in an over-and-above manner).

 

 

Chicago, IL Covid-19 Vaccine Allocation Plan

March 2021: In Chicago's plan, 

  • Appointments are set aside for residents who live in high CCVI (Covid Community Vulnerability Index) zip codes or zip codes with low vaccination rates.

 
 

 

Richmond & Henrico, VA  Covid-19 Vaccine Allocation Plan

March 2021: In Richmond and Henrico Health Districts in Virginia's plan, 

  • In Phase 1b allocation, 50% of the vaccines are reserved for people 65 and older, 23% are reserved for frontline essential personnel, 23% are reserved for people in age-group 16-64 with comorbidities, and the remaining 4% of the vaccines are reserved for people living in congregate-care setting and Phase-1a-eligible but yet unvaccinated people.

  • Within each category, preregistered individuals are prioritized using category-sepcific criteria and are offered according to this priority order.

Richmond-Henrico-Vaccine-Reserve_edited.
 

 

Washington, DC  Covid-19 Vaccine Allocation Plan

March 2021: In Washington, DC's plan, 

  • 20% of the vaccines are reserved for people 65 and older who living in prioritized zip codes and 20% of the vaccines are reserved for people 65 and older in any zip code.

  • 20% of the vaccines are reserved for people in the age-group 18-64 with a qualifying medical condition living in prioritized zip codes and 20% of the vaccines are reserved for people in the age-group 18-64 with a qualifying medical condition living in any zip code.

  • 10% of the vaccines are reserved for eligible workers in the age-group 18-64  living in prioritized zip codes and the remaining 10% of the vaccines are reserved for eligible workers who are in the age-group 18-64 living in any zip code.

 

 

Rhode Island Covid-19 Vaccine Allocation Plan

January 2021: In Rhode Island's media-reported vaccine allocation plan,

  • The state has reserved (in an over-and-above form) additional doses for five hard-hit communities: Central Falls, parts of Pawtucket, Providence, North Providence, and Cranston.

 
 

 

Florida Covid-19 Vaccine Allocation Plan

February 2021: In Florida's media-reported vaccine allocation plan,

  • 1,500 doses are reserved (in an over-and-above form) for homebound seniors, 750 of which are reserved for Holocaust survivors.

 

Boston, MA Covid-19 Vaccine Allocation Plan

February 2021: In Boston's media-reported vaccine allocation plan,

  • In Reggie Lewis Center mass vaccination site, 40% of the appointments are reserved for private community groups (in an over-and-above manner).

 

 

Columbus, OH Covid-19 Vaccine Allocation Plan

February 2021: In Columbus' media-reported vaccine allocation plan,

  • 20% of the vaccines are reserved for vulnerable populations.

 

 

Toledo-Lucas County, OH Covid-19 Vaccine Allocation Plan

February 2021: According to the Toledo-Lucas County, OH media-reported vaccine allocation plan,

  • 20% of the vaccines are reserved for people of color.

 

 

Cone Health Care, NC Covid-19 Vaccine Allocation Plan

February 2021: In Cone Health Care Company's media-reported vaccine allocation plan for North Carolina,

  • 35% of its vaccine allotment are reserved for minorities.

 

 

Georgia Covid -19 Vaccine Allocation Plan

March 2021: In Georgia's media-reported vaccine allocation plan,

  • 15,000 vaccines are reserved (in an over-and-above form) for court staff.

  • In Chatham County, 3,000 vaccines are reserved (in an over-and-above form) for K-12 educators.

 
 

 

Mississippi Covid-19 Vaccine Allocation Plan

March 2021: In Mississippi's media-reported vaccine allocation plan,

  • 300 doses are reserved (in an over-and-above form) for the Vietnamese community.

 

 

Nebraska Covid-19 Vaccine Allocation Plan

March 2021: In Nebraska's media-reported vaccine allocation plan,

  • In the next phase, 90% of the vaccines will be reserved for residents in the 50-to-64 age group or people who qualified under previous phases, while 10% of the vaccines will be reserved for people with health conditions that are chosen by local doctors and public health officials in each region.

 

Montgomery County, PA Covid-19 Vaccine Allocation Plan

March 2021: In Montgomery County, PA's media-reported vaccine allocation plan,

  • 25 percent of vaccine doses are reserved for those in Phase 1A, which includes health care workers, nursing home residents and staff members, first responders, and other specific essential workers and the remaining 75 percent are reserved for 75 years and older.