The most vulnerable individuals to COVID-19 during the first phase of the pandemic in Los Angeles County were healthcare providers and those residing in skilled nursing facilities (SNFs). Immunizing these vulnerable populations as soon as vaccines became available was a critical strategy to reduce morbidity and mortality and protect local healthcare capacity. 

The roll-out of COVID-19 vaccine began during the most challenging time of the pandemic, during the largest surge in cases and deaths in the winter of 2020-2021.  With a limited supply of COVID-19 vaccine, vaccine eligibility was determined by prioritization developed at federal and state levels. Local planning was essential to further refine the prioritization categories and assist in implementation based on local trends of transmission. After the determination was made that the first tier of vaccine would focus on healthcare workers (HCWs) and skilled nursing facilities (SNFs), planning and collaboration with key stakeholders intensified to better refine prioritization across the population of HCWs.  

In order to address the various challenges that existed, the LA County Department of Public Health (LAC DPH) developed a novel multipronged strategy consisting of early strategic planning with healthcare partners and community stakeholders; distribution of vaccine directly to SNFs for local use; vaccine distribution through a hub and spoke model in hospitals; daily open calls with LAC DPH experts to answer healthcare facility questions; call lines for the public; liaison groups to interface with occupational settings; and strike teams in SNFs to quickly vaccinate HCWs and residents.  This comprehensive approach was able to deliver vaccine to HCWs and SNF residents quickly and was able to curb soaring trends in morbidity and mortality. New cases among HCWs dropped from a weekly high of 1,987 at year end to below 50 cases/week by early April with deaths dropping from 24 to 5 cases per week by mid-February. In SNFs, cases dropped from 1,109 to under 20 cases/week from the end of 2020 to early March and deaths dropped from 181 to less than 2/week by late March. 

The roll-out of vaccines in Los Angeles County occurred during a period of many challenges. Since limited supply of vaccines was initially available in the county, strategic and innovative planning was required to ensure that equitable access to the vaccine remained central.  

The California Department of Public Health offered guidance on creating prioritization within the eligible populations ensuring that the most vulnerable groups had access quickly.  This initial phase of the roll-out, referred to as Phase 1A, consisted of both HCWs and residents and staff at long-term care facilities.  In Los Angeles County, to further assist facilities in deciding who within their institutions would receive the limited doses, facility level sub-prioritization guidance was developed and made available.  The determinations were made based on both an individual’s risk of exposure to SARS-CoV-2 and clinical risk factors for developing severe COVID-19. Additional considerations, such as delaying vaccination for those with recent infection and staggering vaccination for staff within a single shift, were also provided. 

Innovative planning and implementation were also critical to many other aspects of vaccine distribution in LA County.  It was decided that in the initial week of the roll-out, vaccine would be delivered to 9 pre-positioned sites that were geographically dispersed across the county and well suited to managing the complex needs of redistributing vaccine through a hub-and-spoke model to other acute care hospitals. This approach allowed for a more controlled release of the vaccine during the initial distribution. Daily meetings and office hours were held by the DPH vaccine team with the hospitals and facilities to plan this initial distribution of vaccine. Ongoing support was then provided as delivery of vaccine in subsequent shipments went directly to the 84 receiving acute care hospitals and other settings. This support included assistance with onboarding to the state electronic vaccine administration system, quality assurance through site visits and assistance with data reporting. Facilities receiving vaccine were also required to provide a weekly accounting to DPH of vaccine utilization to ensure that vaccine doses were being quickly administered and not stored nor wasted. DPH staff continuously maintained a vaccine website to track vaccine roll-out measures in the county. This multi-pronged support strategy enabled facilities to navigate through the various challenges that they faced in those initial weeks. 

In addition to supporting healthcare facilities, there was a need to quickly stand-up ways to keep communities abreast of vaccination plans. In order to deal with the flood of questions from the general public regarding their priority status a liaison team was set up to manage public inquires in a timely manner.  A provider call center was also established to assist with navigating the state’s registration process. A public-facing webpage, VaccinateLACounty.com, was developed to provide information regarding vaccine distribution and the phases of the roll-out process. The website offered information in multiple languages to accommodate our diverse population. A vaccine workgroup with community stakeholders was also established to help ensure that community input shaped the development of vaccine plans and that equity for under-resourced communities were considered. 

The vaccine clinic management system that was initially deployed by the state was built out from an earlier legacy system which had been modified to manage COVID-19 vaccine administration. The many challenges posed by this system required the vaccine team to work closely with the state to find temporary fixes such as allowing facilities to provide direct data transfers to the state vaccine registry and bypass the management system.  In the meantime, the DPH team secured a vendor that would offer a vaccine management solution that was better suited to the COVID-19 vaccines. Ultimately the state, recognizing the benefits of the new DPH management system, decided to adopt it as a statewide solution.  

By early December 2020, SNF residents, representing 0.25% of Los Angeles County’s population, accounted for almost 40% of COVID-19 deaths in the county.  Rapid vaccine administration to this vulnerable population was critical, given that another devastating COVID-19 surge had begun just before the vaccine was approved.  The Federal Pharmacy Partnership (FPP) which was the state preferred solution to vaccinating those in long-term care facilities, offered 3 visits to each SNF over a 3-month period to administer vaccine to SNF residents and staff who were interested and available at the time of the visit.  While this program promised to lessen the administrative burden from SNFs and local health departments, the lack of flexibility was potentially detrimental in a number of ways: SNFs would be unable to stagger vaccine doses to protect against staff absenteeism due to frequent post-vaccination side effects; SNFs would not have vaccine doses on hand between visits to provide vaccines for absent and new staff and residents; the FPP could not easily offer the vaccine to those who initially refused the vaccine but might accept later after education; and the FPP required a signature on a paper consent form, which meant that residents without local family could be denied vaccine. 

Los Angeles County was only one of 2 public health jurisdictions to directly distribute vaccines to SNFs instead of relying on FPP.  Local control of the vaccination program in SNFs allowed LAC DPH to empower SNFs to tailor their own vaccination programs and to maximize vaccine acceptance, instead of the logistics of vaccine administration.  The program utilized frequent interactive virtual trainings and office hours, individualized technical support, and access to local LAC DPH expertise to overcome challenges. According to a CDC publication, by January 17, 2021, the median national first vaccination rate for SNF residents and staff was 77% and 37% respectively.  The SNF average vaccination rate in Los Angeles County on January 17, 2021 was 71% and 74%, respectively for residents and staff.  As of September 1, 2021, the vaccination rate was 87% and 88%, respectively, for residents and staff compared to 83% and 62% nationally. These results demonstrate that LAC DPH in partnership with local SNFs were able to vaccinate residents, and especially staff, more completely and more rapidly than the FPP, saving lives. 

Partnerships with both the community as well as hospitals and skilled nursing facilities were an integral component of the vaccine roll-out. The Department of Public Health worked closely with acute care hospitals and the skilled nursing facilities in the period leading up to vaccine availability to prepare these facilities for receipt of the vaccine.  This included guidance on storage and handling of the vaccine and developing plans for distribution to the other facilities. An initial 9 pre-positioned sites were identified for the first vaccine allocation. These 9 sites represented geographic variability, public/private entities, and facilities with adequate ultra-low temperature cold chain, and the willingness and ability to vaccinate both their staff and others should they be asked. Based on communication and survey information from the acute care hospitals in Los Angeles County, vaccine doses were divided pro rata by hospital licensed bed size. This helped to ensure vaccination of our highest risk healthcare workers across all areas of the county. 

Multiple meetings and “office hours” where facilities could ask questions and learn from each other were held both during the planning and implementation phases to ensure that all parties were kept abreast of changing guidance or issues. These office hours were so well received that they continue today and serve as an ongoing opportunity for vaccine providers in Los Angeles County to ask questions and continue collaborations.  

The Los Angeles County Department of Public Health leveraged their relationship with SNFs forged before and during the pandemic to empower these facilities to take on the administrative and logistical ownership of administering COVID-19 vaccines.  LAC DPH developed infrastructure to onboard and train all SNFs to manage their own COVID vaccine supply and to use the California COVID-19 vaccination administration management system.  The public health department also offered multiple daily 30-minute virtual interactive training sessions and office hours where facilities could ask questions real-time.  A phone helpline and on-site assistance were also offered to facilities.  LAC DPH set up a scheduled pick-up system at its vaccine warehouse for all facilities once they were completely onboarded.  Additionally, departmental strike teams were organized and deployed and established partnerships with third parties were leveraged to assist with the initial administration of vaccine. 

The department also created a Los Angeles County Public Health COVID-19 Vaccine Workgroup to assist with planning and coordination of COVID-19 vaccine. Membership in this workgroup included a wide array of stakeholders including unions, hospitals, clinics, and various other sectors. The Workgroup met to discuss updates on Los Angeles County Department of Public Health COVID-19 vaccine activities and to provide the department with stakeholder perspectives on the planning and coordination of distribution efforts, including recommendations on methods to increase vaccination rates for the groups that they represented. Workgroup-related activities included: 1) Offering a series of situational updates for workgroup members related to federal and state frameworks, local health department assignments, proposed actions, and timelines; 2) Establishing three committees with membership open to non-workgroup members aimed at a) ensuring equity in vaccine distribution; b) effectively communicating with sectors and residents; and c) aligning resources to support massive vaccination administration. Each committee provided reports back with recommendations to the work group in 45-60 days; 3) A series of listening sessions with key sectors to discuss vaccine messaging, known and potential barriers to vaccination administration and acceptance, and strategies for successful collaborations with each sector and community residents; 4) Reviewing key findings from the listening sessions and recommendations from committees which was then used to adjust existing draft vaccination plans and further refining action steps; and 5) Meeting regularly to assess and provide feedback on implementation of vaccination plan activities. 

Many adaptations and improvements were instituted as the vaccine distribution process evolved. As noted early on, the department fielded many questions from the general public when it became clear that vaccine was not going to be available for everyone. Since priorities were established for healthcare personnel, various healthcare and healthcare-associated sectors began reaching out to understand where they fell within the priority groups and non-healthcare groups contacted the department as well to understand when their turn would come. In order to deal with these many questions which were quickly overwhelming the vaccine team, the liaison team that had previously been set up to communicate with various sectors in regarding COVID-19 was leveraged to also help manage these vaccine-priority-related questions.  A provider call center was also quickly established to assist facilities with navigating the state’s registration process as well as with other storage and handling questions. A public-facing webpage VaccinateLACounty.com was developed to provide information regarding vaccine distribution and the phases and tiers of the roll-out process for the general public, offering a “one-stop shop” for vaccine-related information. The website offered information in multiple languages to accommodate and recognize the diverse population of our county.  

Improvements also quickly became necessary with the vaccine management system. The initial vaccine clinic management system that was deployed by the state was built out from an earlier Influenza vaccine management system that had been modified to manage COVID-19 vaccine administration. The many challenges posed by this system required the vaccine team to work closely with the state to find temporary fixes such as allowing facilities to provide direct data transfers to the state vaccine registry and bypass the management system.  In the meantime, the DPH team identified and secured a vendor that would offer a more robust vaccine management solution. Ultimately the state, recognizing the benefits of the new DPH system decided to adopt it and build it out as a statewide solution.  

In an effort to ensure rapid access to vaccines for residents and staff at skilled nursing facilities the decision was made to disenroll from the federal pharmacy program and begin direct allocations to skilled nursing facilities that had been approved to store and handle vaccine. For those sites that had not been approved to receive vaccine a DPH team was set up to help shepherd those submitting applications to ensure timely review and approval.  Vaccines were provided in the interim by either DPH strike teams or through another vaccine partner. This allowed for vaccinations to begin more quickly at skilled nursing facilities compared to what was possible through the pharmacy partnership.  Local control of the vaccination program in SNFs allowed LAC DPH to empower SNFs to tailor their own vaccination programs and to maximize vaccine acceptance, instead of focusing only on the logistics of vaccine administration.  The program utilized frequent interactive virtual trainings and office hours, individualized technical support, and access to local LAC DPH expertise to overcome challenges. 

Vaccinations of healthcare workers resulted in a steep and significant decline in cases in this population. Vaccines rolled out to healthcare workers the week of December 17th, 2020, and we saw that cases peaked the week of December 27th with 1,987 cases per week followed by a decrease to less than 400 cases per week by the end of January 2021 and about 50 cases per week by early April 2021. Similarly, mortality peaked in the first week of January with 24 deaths followed by a steep decline down to 5 cases during the second week of February.  Deaths have remained low to none since then.  A similar picture is seen in SNFs after vaccine roll-out with cases among residents peaking at 1,109 cases per week at the end of December 2020 and dropping to less than 20 cases per week by early March 2021. Deaths among residents peaked at 181 in the first week of January and dropped to less than 2 deaths per week by mid-February 2021. Therefore, these innovative and nimble solutions to an ever-evolving initial roll-out of vaccine allowed Los Angeles County to curb the tide of morbidity and mortality in our most vulnerable groups