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Management in Practice

Leading through COVID: How Connecticut Accelerated Its Vaccinations

As most of the country expanded eligibility for the COVID-19 vaccine to frontline workers and those with medical conditions, Connecticut switched to an age-based approach. Josh Geballe ’02, chief operating officer for the state, says the decision was controversial but has helped make Connecticut a national leader in vaccinations and likely saved lives.

Q: How did Connecticut prepare for the vaccine rollouts?

As the Pfizer and Moderna vaccines were working their way through clinical trials, we were planning with providers. By the time they received emergency use authorization, providers had been enrolled, trained, and were able to get out of the gates fast.

In the first wave of vaccinations, the national approach was relatively consistent; it focused on healthcare providers, medical first responders, and long-term care facilities. The federal government’s Operation Warp Speed contracted with CVS and Walgreens to administer vaccines in nursing homes. While many states took a relatively passive approach to that program, we set up regular meetings with CVS and Walgreens to help remove barriers and improve their ability to move quickly. Through that intervention, on January 8, Connecticut became the first state in the nation to complete first dose vaccinations at all of our nursing homes.

Q: In February the governor decided the next phase of vaccine eligibility would use an age-based approach. Why not include populations with higher risk due to medical conditions?

As we progressed through January and February, prioritization became more complicated. The recommendations from the CDC and the Advisory Committee on Immunization Practices (ACIP) for the next stages included long lists of frontline and essential workers as well as two different lists of medical conditions that should be considered for prioritization—one list of conditions that have been shown to increase risk of severe illness and another list of conditions that might increase risk.

“Two thirds or more of the entire population of Connecticut would potentially qualify under the CDC’s recommended categories. You’re then in a position where you really haven’t done much prioritization at all.”

We realized there would be unintended consequences of following those recommendations. Two thirds or more of the entire population of Connecticut would potentially qualify under those categories. You’re then in a position where you really haven’t done much prioritization at all.

Administering vaccines at large scale also involve significant operational challenges, so we were talking with providers, the people on the ground doing the work, getting the shots in arms. It was becoming increasingly clear that while the recommendations seemed logical theoretically, translating theory to the practice was going to be very problematic because of the logistical complexities.

For example, issues we were evaluating included: Are you going to require proof of eligibility based on medical conditions? What counts as proof? Who checks it? Would that create more barriers to access for people who are underserved? If we went with an honor system, how many people would end up, either consciously or inadvertently, jumping the line because the criteria were confusing? Providers foresaw people flooding them with questions or asking for doctor’s notes to prove their eligibility, reducing their ability to execute on the true goal of getting shots in arms. We envisioned the process breaking down pretty rapidly. That was influential on the governor’s decision-making.

So, Who has actually been dying from COVID? A year’s worth of data made it very clear that death rates from COVID across all races and ethnicities are highly correlated to age. The older you are, the more at risk you are of severe illness and death.

The governor focused on the data and factored in how things work on the ground, in the real world then made an incredibly courageous decision to continue our focus on age-based criteria for subsequent phases. [Connecticut also made teachers and school workers eligible for the vaccine on March 1, alongside residents over 55.]

Q: What have the results been?

I think we’re deep enough into this now where the data are really starting to speak for themselves: we took the right approach in Connecticut.

Because of the approach as well as the outstanding execution of our providers, Connecticut has been in the top five states in the nation from day one in terms of the percentage of the population that’s received their first vaccine dose. As of today, we’re number two in the nation. What’s perhaps even more important than that is, because of how we prioritized based on age, we’re also number two in the nation in the percentage of everyone 65 and above who has already been vaccinated.

That has become critically important over the last weeks as we’ve seen an uptick in the Northeast in infection rates and cases. Right now, of the 10 states in the nation with the highest case rates per capita, 9 are in the Northeast. Connecticut is one of those states. But when you look at the death rates per capita, while many of those same Northeastern states are in the top 10, Connecticut is number 35.

I think it’s increasingly evident that that has a lot to do with prioritizing vaccine for older people first.

Q: Has there been pushback about the choice to focus on age for vaccine eligibility?

Yes, there has been, and it’s understandable. The challenge being the governor of Connecticut is that he has to make decisions every day for 3.6 million people and what’s best for the state overall.

The data are very clear that an exceptionally, blessedly, small number of people under the age of 40 die from COVID. But there are young people with certain severe illnesses who to protect themselves have had to take extreme measures over the last year. Staying home, isolated from their families and living in constant fear of what could happen to them if they got COVID. Certainly, we have immense empathy for those people. The tough decision to prioritize by age understandably frustrated people who thought that they were going to be up next or who continue to live in fear of COVID, but it was clearly the strategy that was best to save the most lives.

“Our death rate has declined much more quickly than all of our neighboring states. Their death rates are declining too; we’ve just declined much faster. We believe that our vaccine strategy and execution have saved many lives.” 

We’ve done an analysis that shows that, sitting here on April 2, our death rate has declined much more quickly than all of our neighboring states. Their death rates are declining too; we’ve just declined much faster. We believe that our vaccine strategy and execution have saved many lives.

In addition, by keeping the process simple for our providers we’ve been able to move very quickly through our phases of eligibility, opening up to everyone 16 and older as of April 1—only a one-month delay for younger people with higher-risk conditions.

Q: How do you get that across to the public?

It’s a great question. I think one of the governor’s great strengths is the way he communicates with people and talks them through his decision-making process, the pros and the cons of different decisions. He doesn’t claim to have all the answers. I think that’s been really helpful.

We hear a lot from people who appreciate the regular COVID briefings, where he’s very transparent, direct, and speaks to people in a language that they understand about where we are and why we’re doing what we’re doing.

Although the state obviously is not a business—it doesn’t operate against the bottom line—we do have goals. Our overarching goal is to, as quickly as possible, reduce deaths from COVID-19. With respect to vaccines, the two primary goals we’ve had throughout are speed and equity. Speed is shots in arms. A vaccine sitting in a refrigerator does no one any good, but a vaccine in an arm is going to help prevent death, help prevent community transmission, help get schools reopened, help get our economy back to normal.

Equity is ensuring that everybody in the state has access to vaccine, regardless of where they live, the color of their skin, whether they have good access to technology, whether they have time to figure out complicated eligibility criteria.

Q: What has the dynamic been between the state and federal levels?

Under the prior administration, I think it’s been well chronicled that largely, states were on their own in terms of solving the big challenges of COVID, whether that was establishing testing infrastructure, acquiring PPE, making policy determinations around masks and business restrictions, or other actions to try to keep people safe. This year, with the new administration, the federal government is taking a much more active role in trying to help states solve these challenges.

The one thing I would give credit to the prior administration for—and the governor has said this too—is the scale up of the vaccine program: initially putting tremendous federal resources at risk with guaranteed purchase commitments so the vaccine developers could get products through clinical trials as quickly as possible. Then getting those vaccines out to the states as quickly as possible.

Sitting here, basically a year after COVID came to the United States, we have three vaccines that are all incredibly effective in preventing infection, illness, and death. The fact that they’ve been developed, manufactured, distributed, and administered to 80% of all the senior citizens in Connecticut a year later is probably as close to a medical miracle as we’ll ever see in our lives.

Q: At some point all of those who are eager for a vaccine will be vaccinated. Are you thinking about those who are reluctant or hesitant for various reasons?

There’s a tremendous amount of work underway right now to get the vaccination rates up higher in communities where they are lagging. The game is about to change from one of scarcity to one of excess supply. Soon, people will be able to walk into almost any pharmacy or supermarket and get a vaccine on the spot without an appointment.

We will be increasing the number of mobile vaccination vans holding pop-up clinics at churches, festivals, and at housing developments. We will even be adopting what we’re calling the ice cream truck model, where you will be able to flag down one of these very clearly identified vans and get a vaccine right there.

Q: What has it been like to be a public servant during the pandemic?

I think it’s safe to say that this has been the challenge and the honor of a lifetime. Up until two years ago, when the governor recruited me into public service, I’d spent 20 years in the technology industry at two Fortune 500 companies and at a software startup and I enjoyed every minute of that as well.

Over the last year, under the governor’s leadership, we’ve had the opportunity to chart the path through this once-in-a-century pandemic. We’ve tried try to minimize the impact on people’s lives, in terms of their physical and mental health, their children, and their jobs. The degree to which the people of Connecticut and the organizations that we’ve worked with have risen to the challenge has been really, really remarkable.