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.”
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.
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.
Verifying if someone qualifies 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 who 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 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.
“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.
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.”
Wilde and others acknowledged that some perceived inequalities may exist among those who qualify under the underlying-conditions category due to poor lifestyle choices.
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.
“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.
Department of Health spokesman Daniel Bucheli said some parts of the plan moving forward will be fluid and open to adjustments.
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.
Experts urge people with questions to visit the state health department website, call their doctor and watch for media alerts that can help guide them on whether they qualify for a shot and when.
“We are absolutely dedicated to getting vaccines to everyone that wants it,” Wilde said.