That is how America will get its vaccines


Biden's newly published pandemic strategy is based on one central goal: to monitor the administration of 100 million vaccines in 100 days. To do it, he has to fix the mess.

Some critics have called his plan too ambitious; others have said it is not ambitious enough. It is guaranteed to be an uphill battle. Before we get to the solutions, however, we need to understand how the system is working right now – and which aspects of it should be discarded, replaced, or kept.

From manufacturer to patient

At the federal level, there are two core systems between the vaccine factories and the clinics where the shots are administered: Tiberius, the planning system for the allocation of vaccines of the Ministry of Health and Human Services and VTrckS, the ordering portal of the Centers for Disease Control and Prevention.

Tiberius takes data from dozens of mismatched sources and turns it into actionable information to help state and federal agencies plan distribution. States actually order and distribute recordings in VTrckS.

The two are technologically eons apart. While Palantir built Tiberius with the latest technology available last summer, VTrckS is a legacy system that has gone through several vendors in its 10 year existence. The two are largely linked with people downloading files from one and uploading them to the other.

Dozens of other private, local, state, and federal systems are involved in the allocation, distribution, tracking, and delivery of vaccines. Here is a step-by-step explanation of the process.

Step one: the manufacturers make the vaccine

HHS receives regular production updates from Pfizer and Moderna. Manufacturers share the estimated quantities in advance to aid HHS in planning before confirming actual production numbers, which will be relayed to Tiberius.

Both vaccines are made with messenger RNA, a biotechnology that has never been produced on a large scale before, and they must be kept extremely cold until they get into a needle: modernas must be kept at -25 to -15 ° C, while Pfizers requires even lower temperatures of -80 to -60 ° C. By the fall, it became clear that manufacturers had overestimated how quickly they could dispense cans, according to Deacon Maddox, chief of planning, operations and analysis at Operation Warp Speed and former MIT employee.

"How it will be manufactured, especially a nascent biological product, is very difficult to predict," he says. "You can try, and of course everyone wants you to try because everyone wants to know exactly how much they're going to get. But it's impossible."


This led to some of the first stumbling blocks in the rollout. While training states to use Tiberius, Operation Warp Speed ​​put these inflated estimates into a "sandbox" version of the software to allow states to model different distribution strategies for planning purposes. When these numbers didn't show up in reality there was confusion and anger.

“At the end of December, people said, 'We were told we were going to get this and they cut it down. "That was all because we put fictional numbers in the practice page, and people assumed this was what they wanted to get," says Maddox. “Allocation numbers are highly charged. People get very emotional. "

Step two: The federal government determines the vaccine allocations

Each week, HHS officials review production estimates and inventory counts and decide the "big number" – how many total doses of each vaccine will be given to states and territories. Lately they have stuck to about 4.3 million a week. They found that "we can break through manufacturing lows and save through highs," says Maddox.

That figure goes to Tiberius, who splits vaccines based on census data. Both HHS and media reports have sometimes described this step as using an algorithm in Tiberius. This should not be confused with machine learning. It's just simple math based on the assignment guideline, says Maddox.

Previously, the policy has been to distribute vaccines according to the adult population (18+) in each jurisdiction. Maddox says the logic in Tiberius could easily be updated should Biden choose to do so on a different basis, such as the elderly (65+).

Once the analysts at Operation Warp Speed ​​confirm the official allocation numbers, Tiberius will push the numbers into the jurisdiction of their software version. A HHS operator then downloads the same numbers to a file and sends them to the CDC, where a technician manually uploads them to set order limits in VTrckS. (You can think of VTrckS as an online store: when health departments order vaccines, they can only put that many in their shopping cart.)

That wasn't an exact science either. Just before the inauguration, outgoing HHS Secretary Alex Azar pledged to send the state 50,000 additional doses as a reward for efficiently administering vaccines in a phone call with Connecticut Governor Ned Lamont. The cans arrived the next week.

The deal was representative of "the fairly relaxed nature of the vaccine distribution process at the federal level," Lamont's spokesman Max Reiss said in an email.

Step three: States and territories distribute the vaccine locally

State and area officials learn how many vaccines they have been given through their own version of Tiberius, where they can model various distribution strategies.

With Tiberius, officials can put data overlay on a map of their jurisdiction to aid them in planning, including census data on where the elderly and healthcare workers are grouped. the CDC's so-called Social Vulnerability Index for various zip codes, which estimates disaster risk reduction based on factors such as poverty and access to transport; and hospital stay and other case data from Palantir's Covid monitoring system, HHS Protect. They can also enter and view their own data to see where vaccination clinics and ultra-cold freezers are, how many doses different locations have requested, and where the vaccines have already gone.

Once states decide how many doses of each vaccine to send to each location, they download a file of addresses and dose counts. You upload it to VTrckS, which sends it to the CDC, which sends it to the manufacturers.

A Pfizer show


Last week, Palantir introduced a new marketplace swap feature that effectively gives states the ability to swap vaccines. With the government splitting both Moderna and Pfizer vaccines regardless of how many ultra-cold freezer states have, rural states may have to trade their Pfizer allotment for Moderna shots from another state, Maddox says.

When you ponder the usefulness of the system, it's worth noting that many healthcare departments have a shallow bank of tech-savvy staff who can easily navigate data-intensive systems.

"It's a rare person who knows about technology and health," says Craig Newman, who studies health system interoperability at the Altarum Institute. "Now you're throwing in a large-scale epidemiology … it's really hard to see the whole thing A-Z."

Step four: the manufacturers ship the vaccines

It's somehow easy to ship millions of vaccines to 64 different jurisdictions at -70 ° C.

The CDC sends the states' orders to Pfizer and to Moderna's distributor, McKesson. Pfizer ships orders from FedEx and UPS direct to locations. Moderna vaccines first go to McKesson hubs, which then hand them over to FedEx and UPS for shipment.

Tracking information is sent to Tiberius for each shipment so that HHS can monitor the progress of shipments.

Step five: Local pharmacies and clinics will administer the vaccine

At this point things really start to break down.

With little federal leadership or money, the jurisdictions grapple with even the most basic requirements of mass vaccination, including vaccination planning and tracking.

Bringing people to the clinic may seem intuitively easy, but it was a nightmare almost everywhere. Many clinics in hospitals use their own systems. County and state clinics use any number of public and private options, including Salesforce and Eventbrite. Online systems have become a major stumbling block, especially for the elderly. Whenever jurisdictions set up hotlines for technologically insecure people, their call centers are immediately overwhelmed.

Even within states, different vaccination centers are putting together their own hodgepodge solutions. To help determine who is receiving vaccines, many states have upgraded existing systems for tracking child vaccinations. The agencies that manage these systems have already gone to great lengths to put messy data sources together.

FedEx and UPS trucks depart from Pfizer.


It may not even be clear who is responsible for allocating the doses. Maddox described incidents where state officials contacted HHS to say their caps in VTrckS were too low, only to find that someone else in her office had transferred doses to a federal program that distributes vaccines to nursing homes without other decision-makers to communicate.

"Operation Warp Speed ​​was an incredible effort to get the vaccine to market quickly," said Hana Schank, strategy director for technology of public concern at New America think tank. "All of that was done." nice. "However, the program paid little attention to how the vaccines would actually get to people.

Many doctors, disappointed with the introduction, agree with this feeling.


Steven Gregory