Bart Pfankuch, South Dakota News Watch
South Dakota health officials and medical providers have been near the top of the nation in administering COVID-19 vaccines as they become available, but a significant new challenge awaits as the state moves into a much larger, more difficult-to-define population of people who may qualify for a shot.
That upcoming subset of people will include an estimated 80,000 residents with two or more underlying medical conditions as defined by the federal Centers for Disease Control and Prevention.
With that next group potentially in play as early as February, state officials and health providers as of Jan. 20 did not have a firm plan in place to definitively determine how they, and members of the public, will figure out who qualifies for a vaccine in that population group, how potential vaccine recipients will verify their conditions and whether proof of medical diagnoses will be required before shots are administered.
Health providers across the state have increasingly been fielding questions from residents with existing medical conditions who want to be vaccinated as soon as possible and who so far are unable to get clear answers about when they can get shots.
As of mid-January, the state and medical providers had not developed concrete plans on how to determine who qualifies in the Phase 1D subgroup of patients with two or more underlying conditions, said Scott Peterson, director of pharmacy at Monument Health in Rapid City.
“There’s been no decision that has been made on that yet,” said Peterson, who is leading that system’s vaccination efforts. “At this point in time, there is not a definitive plan on that … that is something that the health department along with the health systems, and with other input, are working on.”
The state recently entered the fourth phase of its long-range, seven-phase vaccination plan after completing initial phases that included front-line health-care workers, long-term care residents and staff, law enforcement, EMS and correctional workers and a few other small groups.
After having success in phases 1A through 1C, the state sped up entry into Phase 1D on Jan. 18 by making shots available to a newly created subset of 1D that includes the highest-risk patients within the group — those 80 and older, people with cancer, those on dialysis and very high-risk people in congregate settings.
But once that subset is complete, likely in early February, the state will move into the remainder of Phase 1D, a large, widespread population of people that includes as many as 250,000 residents and one subset in particular that will create diagnostic challenges and likely some controversy over who is next in line to receive the potentially life-saving shots.
In addition to all residents 65 or over, teachers and college staff and funeral service workers, Phase 1D also includes “persons with 2 or more underlying medical conditions,” a population estimated at roughly 80,000 people.
The state is basing vaccinations in that group on a list developed by the CDC of 23 medical conditions that are known or believed to put someone at higher risk of complications or death if the person becomes infected with the coronavirus. Like other states, South Dakota is prioritizing vaccinations partially on whether people have two or more of those underlying health conditions.
Verification and communication plans uncertain
Verifying if someone qualifies for a vaccine dose within the two underlying conditions category could be fairly simple for a doctor or practitioner who has extensive experience treating or diagnosing a patient, said Dr. Michael Wilde, vice president and chief medical officer at Sanford Health in Sioux Falls.
But determining whether a person has two of the CDC-listed conditions will be difficult if not impossible for front-line employees who will check in patients at hospitals, clinics or pharmacies where COVID-19 vaccines will be delivered, Wilde said.
Identifying and verifying who qualifies will also be tricky when it comes to patients with rare conditions or those that are not specifically listed on the CDC website but that likely put them at higher risk from COVID-19 complications, experts said.
The underlying-conditions subset will also include people who are at high risk but who do not have a general practitioner, are not affiliated with a hospital system, or who receive medical care only at emergency rooms or urgent-care facilities not affiliated with specific medical systems. That group of people whose numbers are unknown cannot be certain if they qualify and will not be alerted by vaccine providers.
Wilde said he has seen some federal guidelines that recommend that verification of underlying conditions be required at vaccination sites, and other potential guidelines that suggest verification of medical conditions may be unwieldy and could slow down the overall vaccination effort.
Wilde said he expects that someone who makes an appointment or shows up to get a shot in any category within Phase 1D will be vaccinated if doses are available. That includes those who may have questions about whether they technically qualify under the underlying conditions guidelines or not, he said.
“As a clinician it’s a pretty clear list,” Wilde said. “But I would be hard pressed to think that we’re going to sit there and try to verify, especially in gray areas where it’s tough to make a determination, that we’re going to turn someone away if we have vaccine available based on a lack of verification or a lack of those medical conditions.”
Dr. David Basel, vice president for clinical quality at Avera Health in Sioux Falls, said the five South Dakota health systems tasked with providing vaccines to the public — Sanford Health, Avera Health, Monument Health, Mobridge Hospital and the Northern Plains Health Network — have computer systems that can determine who has underlying conditions and generate a list of patients who qualify for a shot. State data show about 400,000 South Dakotans are estimated to have one underlying condition, and about 80,000 are estimated to have two conditions, Basel said.
“We’re trying to take a more proactive approach to a lot of the chronic conditions; we are trying to reach out to those folks rather than have patients try to self-identify,” Basel said, adding that the process has been easier with targeted populations so far.
Residents of Native American reservations will receive vaccinations through the federal Indian Health Services, which is also busy prioritizing delivery of the vaccines and notifying those who qualify to sign up for a shot as soon as possible.
As of Jan. 21, South Dakota had administered about 58,500 doses of the two types of COVID-19 vaccines; roughly 11,000 people had completed the two-dose full regimen.
Wilde said people whose medical conditions can easily be verified or whose conditions obviously fit into the CDC list will be notified by health systems that they qualify — either by mail, email, text message or phone call — and invited to sign up to make an appointment to receive a shot.
Health providers are reluctant to create a system where people who haven’t made an appointment show up with medical records in hand to wait in line and then potentially be turned away because someone at the vaccination site determines that the patient doesn’t qualify for a shot or because there are not enough vaccine doses available, Wilde said.
“For people to just show up and stand in line could be really disappointing for people,” Wilde said. “We also don’t want to upset people by inviting them and then not having vaccine available.”
Basel said that at the current allocation of vaccines to South Dakota, about 11,000 doses per week, medical systems have not had difficulty in reaching out to people who qualify for a shot.
But if vaccination supply increases, as most providers anticipate, Basel said the number of qualifying patients may overwhelm the ability of medical systems to call them all.
“There may come a time where we open it up wider to a kind of honor system,” he said, “but it all depends on the supply.”
Not a perfect prioritization system
Wilde and others acknowledged that some perceived inequalities may exist among those who qualify under the underlying-conditions category due to poor lifestyle choices or in categories related to living in congregate settings that can include prison or jail inmates.
For example, using the CDC at-risk conditions list as a guide will mean that obese cigarette smokers will qualify for a shot before people with single serious health conditions such as Type 1 or 2 diabetes, sickle-cell disease, Down Syndrome, asthma, liver disease, weakened immune system, chronic pulmonary disease or pregnancy.
Wilde urged the public to be patient and have an understanding that no system of prioritization will be perfect.
“There will be nuances and some of them could be a little bit of a head scratcher, and that’s kind of that grace we’re seeking from the public,” Wilde said.
Vaccinating prisoners, smokers or obese people makes sense from an overall health perspective amid a pandemic, health experts said.
Basel noted that the use of the CDC guidelines is meant to prioritize vaccination of people who have underlying conditions of any type or cause, which can reduce preventable deaths or prevent further taxing of the capacity and capabilities of the state medical system.
Those people are just as likely to spread the virus as a healthy person or someone with any other high-risk illness, and vaccinating as many people as possible as quickly as possible remains the overriding goal of a widespread vaccination effort.
“I’m a physician and I work for a health system and I look at it more from the resources-allocation side, as in ‘Who are those more likely to be hospitalized and overwhelm the health-care system? Who has the highest rate of hospitalizations?’” Basel said. “I haven’t looked at it as much as the social aspect as I have for the health-care risk.”
When it comes to obesity, for example, which is defined by a body-mass index of 30 or higher, Basel said the evidence is overwhelming that COVID-19 patients who are obese are at much higher risk of complications or death from the virus. With that in mind, it makes sense to vaccinate those patients as early as possible, he said.
Department of Health spokesman Daniel Bucheli said the vaccination plan has worked well so far in South Dakota, and health officials expect to see continued success.
But Bucheli noted that some parts of the plan moving forward will be fluid and open to adjustments, as evidenced by how the state opened the small subgroup of Phase 1D group on Jan. 18.
Bucheli said these adjustments likely will be judgment calls that must be made as to who qualifies under the two or more underlying medical conditions subset. He said the state is still working to develop a process for deciding who fits into that group and how they will be notified, including those whose medical conditions might not appear specifically on the CDC list.
“Someone is going to have to make the call, and we’re leaving that to your medical professional,” Bucheli said. As far as alerting potential vaccine recipients with two underlying conditions, “that’s one of the logistical issues the health systems are working through right now.”
Aside from that, the greatest unknown at this point is how many shots South Dakota will receive from the federal government moving forward, which will play a critical role in determining how many people will qualify for vaccinations and how many can actually get a shot, Bucheli said.
“We have the partners, we have the infrastructure and we have the know-how on how to get shots in arms,” he said. “We’re waiting for final allocation numbers … and that is our biggest holdup.”
Bucheli and Basel said the state has received mixed signals from the federal government about whether allocations of vaccine doses will increase in the coming weeks and months. Officials are hoping that allocations may rise after new vaccines from AstraZeneca and Johnson & Johnson receive approval for use. President Joe Biden has also vowed to speed up the vaccination process across the country.
New and ongoing challenges lie ahead
Determining who qualified for a vaccine in Phases 1A, 1B, 1C and the new subset of 1D was fairly easy, said Kim Rieger, vice president of marketing and communications at Huron Regional Medical Center, the vaccine provider to Beadle and Sanborn counties in northeastern South Dakota.
In the case of nursing-home residents and staff, for example, it was simple to call the homes and ask for a list of people who wanted to get a shot, and then make appointments. The same is true in regard to checking the age of someone to see if the person is 80 or over, she said.
But Rieger said it will likely require a judgment call to determine who fits into the 1D category of having two underlying conditions. “As someone with a non-medical brain, I would put high blood pressure into that heart-condition category,” she said. “But I’m not sure whether that is right or not.”
She said there could be some confusion among people who do not have a health-care plan or lack stability in where they received medical treatment or by whom. That could include people who tend to receive medical treatment only in crisis situations at an emergency room or an urgent-care clinic, she said.
“The question I can’t answer is if someone doesn’t have a primary-care provider and no one has a list of their conditions,” she said. “I would encourage them to just call their local clinic and see if they qualify.”
The vaccination process has placed a significant staffing and paperwork burden on the Huron hospital, Rieger said, though the hospital is making arrangements to have some vaccinations occur at its five regional clinics to spread out some of the stress on staffing.
The Moderna vaccine can be held in refrigeration for 30 days, but the Pfizer vaccine must be administered within five days of receiving it and within six hours once it is compounded for injection, Rieger said, putting pressure on health providers to make sure they have more than enough people lined up to get a shot once the vaccines are received.
Rieger said state and local health officials have tried to develop solid plans, but providers must remain nimble and flexible because no one is sure how many vaccine doses will be received each Friday.
The most doses the Huron hospital has received in a single week was 325, but the hospital has also seen weeks where only 80 or 100 doses were received, Rieger said.
“The state has put a plan together in theory [of] how this would work, but until we hear that, ‘Oh, yes, this many doses are coming next week,’ it may be that we said we’re going to do one thing and then, ‘Oops, nope, that isn’t going to work, we’ll have to do this instead,’” Rieger said. “We absolutely do not want to waste any drop of vaccine.”
Maintaining the efficacy of the vaccines while transporting doses to rural areas has been a challenge in South Dakota and other wide-open states, providers said. Doses have been transported by ambulance and by airplanes flown by the South Dakota Civil Air Patrol.
Rieger said doses shipped to northeastern South Dakota start at Avera Medical Center in Sioux Falls and then are shipped to Watertown, where they are divided up and shipped again according to population to Brookings, Huron and Madison.
In Rapid City, Monument Health has been administering vaccines from a small set of offices on the lower level of the system’s Heart and Vascular Institute, away from the main hospital campus. Peterson said Monument is anticipating an increase in allocation of vaccine doses to South Dakota and in preparation is examining other buildings in the system that could be used to accommodate a significantly expanded vaccination operation.
Peterson said he also expects that Monument may have to hire temporary workers to aid in vaccine delivery without affecting personnel who are already busy with other medical procedures and duties.
Peterson said Monument and other health providers have explored partnerships with other health providers to deliver and administer vaccine doses in rural areas of the state – including, for example, teaming with rural provider Horizon Health care in Mission, Martin and White River, S.D. Health systems may also consider creating temporary “points of dispensing” sites, known as PODs, that have been set up during previous mass-vaccination events.
“We could also partner with EMS services inside of these areas where there are very few people but a lot of square miles to cover,” Peterson said.
Rieger said she had received phone calls about twice a week in recent months from a woman in her early 60s in the Huron area who has underlying conditions and is eager to know when she will qualify for a shot so she can get vaccinated as soon as possible.
While health officials were reluctant to acknowledge that being persistent or proactive may increase one’s chances of getting vaccinated, they do recommend that people who want a shot should stay tuned to local media, check the website of their local health providers regularly and stay engaged in how the vaccination plan in South Dakota is evolving.
“It’s going to be very dynamic; none us really have experience with something like this,” Wilde said. “This is a very significant project that we’re doing, and it’s incredibly important and we feel that right now we’re well-positioned and we’d also ask for the grace to adjust as needed.”
He added, “We are absolutely dedicated to getting vaccines to everyone that wants it.”
