The COVID-19 booster dose rollout: Where 3 states stand

The CDC director recommended booster doses of Pfizer's COVID-19 shot for tens of millions of people in the early morning hours of Sept. 24, with vaccination clinics across the U.S. quickly moving to start administering the shots later that day. 

As of Oct. 5, 11 days into the CDC's approval, more than 6 million booster doses had been  given to people 65 and older, who have jobs that increase their risk of infection, or who are at high risk for severe COVID-19, according to the eligibility guidelines set by the FDA and CDC.

That number also includes the more than 2.8 million immunocompromised people who have gotten a booster dose since the FDA authorized the shots for this patient population in August. The agency's emergency use authorization update at that time allowed for people with immunocompromising conditions who received either Pfizer or Moderna's shot to receive a third dose. 

With Pfizer's booster shot now available to a wider range of people, Becker's Hospital Review spoke to three states about the status of the current rollout, as well as how it compares to the initial vaccination rollout that began in December 2020. 

Two of the states have less than half of their population vaccinated, and one state had nearly 70 percent of its population vaccinated.

West Virginia
Boosters administered as of Oct. 4: 24,000
Percentage of total population vaccinated as of Oct. 5: 40.53

While vaccine supply largely isn't an issue with this rollout, West Virginia remains strategic with its booster distribution approach.

"While we certainly want to distribute the boosters widely and make them available, we're also being very intentional," said Clay Marsh, MD, West Virginia's COVID-19 czar and vice president and executive dean for health sciences at West Virginia University in Morgantown.

Since older adults have made up most of the state's breakthrough COVID-19 hospitalizations and deaths, West Virginia has prioritized its nursing home population and is nearly done giving booster shots to nursing home residents, Dr. Marsh told Becker's.

"We're really trying to reach out to our older population both because we know that pre-vaccine time, that's the population that had the highest death rate per capita, but also because we're starting to see that's the group that is starting to have vaccine breakthroughs," he said.

As of Oct. 4, data from West Virginia's COVID-19 dashboard shows there have been 170 breakthrough deaths — about 6 percent of all COVID-19-related deaths since the start of the vaccination program. Of the breakthrough deaths, most occurred in residents who were at least 70 years old, Dr. Marsh said.

"So we know that for a lot of these people, the boosters are going to be really, truly lifesaving and hopefully reduce our hospital stress by reducing the capacity and the need for hospital beds for about 5 to 6 percent of our [vaccinated] population that we're seeing with vaccine breakthrough cases."

Relative to the initial vaccination rollout, the eligibility criteria for boosters is much broader, which has been difficult for some booster-seekers to decipher.

"People are asking for a simpler, more clear way to do that," Dr. Marsh said.

In the same vein, in a state with high rates of obesity and smoking where many people are at increased risk for severe illness, the loosely defined eligibility has made it simpler for most adult residents seeking a booster dose to get one, so long as they finished their initial Pfizer vaccination series at least six months ago.

"[Eligibility] is so inclusive that I believe basically almost everybody fits at some level," Dr. Marsh said. "If you have any medical problem, you can fit within that."

Residents self-identify that they meet criteria when scheduling an appointment for a booster dose, he said.

Overall, West Virginia's booster dose launch has been going smoothly, Dr. Marsh said. The greatest challenge is not having concrete answers for Moderna and Johnson & Johnson vaccine recipients who are eager to get booster shots.

"Our biggest challenge right now is a lot of people who had Moderna vaccines earlier in the pandemic, six months ago or more, or [who] received the Johnson & Johnson vaccine, are also now becoming very anxious about when do they get boosted, can they get boosted with the Pfizer vaccine."

Boosters administered as of Oct. 4: 32,226
Percentage of total population vaccinated as of Oct. 4: 68.71

Wendy Osgood, vice president for adult medicine at Maine Medical Center in Portland, told Becker's the hospital was able to rapidly implement its booster plan using the same model it developed for the initial vaccination rollout in December 2020.

"The hospital's vaccination leadership team has remained the same, as has most of the staff involved in the initial rollout. As a result, [Maine Medical Center] was able to begin giving out booster shots to its care team with far less time spent on planning," Ms. Osgood said. "The hospital also is leveraging its existing outpatient practices to begin administering booster shots to existing patients."

To verify eligibility of people requesting a booster dose, Maine Medical Center, part of Portland-based MaineHealth system, is pulling data from the state's vaccination system, called ImmPact. For those who got their initial vaccination out of state, the hospital is relying on people to show their vaccination cards to prove they received the Pfizer vaccine more than six months ago.

A spokesperson for the Maine Department of Health and Human Services told Becker's it doesn't have a verification process to determine eligibility for boosters.

Ms. Osgood said the hospital was ready to include Moderna shots in the rollout, but when it became clear that only those who received the Pfizer vaccine would be eligible for a booster, the hospital easily adjusted.

"[Maine Medical Center] vaccine clinics were created with the idea that eligibility would change over time, and so flexibility is built into the planning process," she said.

Boosters administered as of Oct. 4: 33,961
Percentage of total population vaccinated as of Oct. 4: 41.96

A spokesperson for the Idaho Department of Health and Welfare told Becker's it received a booster dose readiness checklist to assist with the department's planning for booster doses in the state.

The department said it's expecting the public to be confused about who is eligible for boosters because of the varying recommendations coming from the FDA and CDC and both of their advisory committees.

"We anticipate continued misinformation being distributed by anti-vaccination groups," the department spokesperson added.

But the confusing messaging coming from the FDA and CDC didn't hurt the state's ability to plan for its booster rollout, the department said.

"There were unknown variables throughout the rollout. We were planning for the highest number of people being eligible for booster doses. We had communication templates ready to distribute to Idaho's COVID-19 vaccine providers and the public. We were able to easily revise these documents when CDC made their final recommendation," the spokesperson said.

Laura McGeorge, MD, the medical director for primary care at St. Luke's in Boise, Idaho, told Becker's she thinks the differing eligibility requirements released by the FDA, the CDC's vaccine advisory committee and the CDC director may have slowed the health system's electronic health record vendor in getting its clinical decision support software set up for boosters.

The software tells providers if a patient qualifies for a booster shot based on factors such as which shot they received for their initial vaccination and how long ago they were vaccinated.

Dr. McGeorge said there was a longer than normal waiting time for the health system's EHR vendor to debut the software.

During the initial vaccination rollout in December, there were so many people requesting COVID-19 vaccinations at once that St. Luke's opened several COVID-19 vaccination clinics. But this time around, the health system is mainly relying on its primary care clinics to give booster shots, Dr. McGeorge said. The health system began administering Pfizer boosters Oct. 5.

Like West Virginia and Maine's health departments, Idaho's health department and St. Luke's are relying on people to self-attest their eligibility for booster shots. Dr. McGeorge said the CDC has been clear that it doesn't want to erect any more barriers for eligible patients to get boosters.

"Way back when we didn't have enough vaccine and everybody wanted it, people had to prove they worked at a certain job to qualify for the vaccine. I suspect those days are just generally globally gone now, and it's more the honor system," she said.

She added that the health system has no concerns about a low supply of COVID-19 vaccines.


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