Jurisdiction-level costs of the initial phase of the COVID-19 Vaccination Program in the United States, December 20, 2020–May 31, 2021

Abstract

This study aimed to quantify U.S. jurisdiction-level costs related to the COVID-19 Vaccination Program by estimating the per-dose-administered cost during December 20, 2020–May 31, 2021, from a combined federal and local government perspective. Costs were limited to vaccine purchase, administration (including operations and wastage), and local redistribution by jurisdictions. Data were collected through publicly available sources, published literature, and a survey of 62 jurisdictions (38 responded). A total of 284.6 million doses of COVID-19 vaccine were distributed to jurisdictions during the study period, of which 284.2 million doses were administered, and 0.4 million doses were wasted. The estimated cost per-dose-administered among the 38 jurisdictions that responded to study survey was $57.45 and imputed cost across all jurisdictions was $63.11. The findings on jurisdiction-level cost per-dose-administered and vaccination cost during the initial period of U.S. COVID-19 Vaccination Program, when demand exceeded supply, may be considered in future pandemic preparedness planning

1. Introduction

In response to the COVID-19 pandemic, the U.S. federal government made unprecedented investments in developing, procuring, and distributing COVID-19 vaccines. COVID-19 vaccines were effective against severe illness from SARS-CoV-2 [1]. The first COVID-19 vaccine by Pfizer-BioNTech received emergency use authorization (EUA) by the U.S. Food and Drug Administration (FDA) on December 11, 2020 for individuals aged ≥16 years, followed by the Moderna vaccine for individuals aged ≥16 years [2]. In February 2021, the Janssen COVID-19 vaccine received an EUA for individuals aged ≥18 years and by May 2021, the Pfizer-BioNTech and Moderna vaccines were approved for emergency use among individuals aged ≥12 years [3].

When COVID-19 vaccines first became available, demand exceeded supply coupled with a steep learning curve for how best to broadly reach target populations efficiently. The vaccine distribution strategy included prioritizing high-risk groups (i.e., adults aged ≥65 years, adults living in long-term care facilities, and adults who are immunocompromised), building on existing jurisdiction immunization programs (U.S. states, localities, and territories), implementing mass vaccination sites operated by state and local public health departments and the Federal Emergency Management Agency (FEMA), as well as expanding vaccine administration sites to retail and independent pharmacies [4].

While studies modeled hypothetical COVID-19 vaccine cost-effectiveness to inform the vaccination program roll-out, costs of distributing the COVID-19 vaccines at the jurisdiction-level were not specified or considered in these studies [5,6]. Additionally, previous pandemic planning models were based on refrigerated influenza vaccine, but COVID-19 vaccine doses were stored in multidose vials and required ultra-low temperature storage with order quantities best fit for mass vaccination site needs [7,8]. Jurisdiction-level costs associated with redistributing the COVID-19 vaccine from a central location or ‘hub’ (e.g., central warehouse, large hospital system) to distal sites or ‘spokes’ such as clinician offices in rural areas have not been described. This analysis aims to quantify costs related to jurisdiction-level COVID-19 vaccination by estimating the per-dose-administered cost during December 20, 2020–May 31, 2021, from a combined federal and local government perspective.

1.1. Vaccine distribution process

Fig. 1 illustrates the COVID-19 vaccine distribution process, with detailed description available in the literature [9]. Costs were incurred at every level, beginning with the federal government’s purchase of doses, upon which allocations to 62 jurisdictions, federal entities, and pharmacies were determined by considering supply and jurisdictions’ population sizes. During the study period, COVID-19 vaccines were available by Janssen, Moderna, and Pfizer-BioNtech. Janssen and Moderna vaccines with corresponding ancillary kits were shipped to ordering sites/providers through a central distributor. Pfizer-BioNtech distributed doses directly to providers because of ultra-cold storage requirements. During this period, redistribution may have occurred to break-down the Pfizer-BioNTech 975 dose/1170 dose orders into smaller units for distal distribution or to support delivery and storage of Pfizer-BioNTech doses. Large minimum ordering size and associated large storage needs limited smaller providers from directly ordering doses from the federal government. Jurisdictions had varying vaccine distribution strategies; some received federal supplies at local warehouses or large providers and redistributed smaller tray sizes of vaccine doses to smaller community-based sites in a ‘hub and spoke’ model, or vaccine was directly delivered from the central distribution site to providers. The total number of providers who received redistributed vaccine is unknown and accounted for about 40 % of administered doses during this period [10].

Fig. 1.

COVID-19 vaccine distribution process in the United States, December 20, 2020–May 31, 2021.

BARDA: Biomedical Advanced Research and Development Authority; HHS: Health and Human Services; IIS: Immunization Information System; VTrckS: Vaccine Tracking System. Costs associated with the orange arrows were included in this study. Costs associated with the blue arrows were not included in this study. Non-cost related data on vaccine dose shipment, administration, and wastage units along the blue and orange arrows are captured in this study.

* VTrckS is CDC’s vaccine management and ordering system for publicly funded vaccines.

^ⴕ Awardees include 62 jurisdictions, 21 federal retail pharmacy partners, 2 renal dialysis partners, and federal entities (Indian Health Services, Health Resources and Services Administration, Department of Defense, Veterans Health Administration, Department of State, Bureau of Prisons).

^§ The IIS’s are computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area.

This figure was adapted from https://www.cdc.gov/flu/pdf/pandemic-resources/pandemic-influenza-vaccine-distribution-9p-508.pdf (Accessed on March 26, 2024).

2. Methods

For this study, costs related to vaccine purchase, redistribution (within jurisdiction storage, staffing, and shipping/delivery), and administration (including site operations and wastage) from December 20, 2020–May 31, 2021 were included (Supplement Table 1). The focus of this study is the within-jurisdiction costs, specifically for vaccine doses, administration, and redistribution of vaccine doses and ancillary supplies from these hubs to smaller sites to increase vaccine access. Costs of reporting and staffing for vaccine operations at the federal-level, and distribution from the federal government to jurisdictions’ hubs were unavailable and therefore not included.

2.1. Study period

Data were limited to December 20, 2020–May 31, 2021 to capture costs related to the initial vaccine program roll-out when there were high case counts, limited prevention measures (e.g., therapeutic drugs and vaccines), high demand for vaccines, but low vaccine supply. During this period, jurisdictions experienced challenges around rapidly implementing distribution and administration plans. By June 2021, the vaccine program entered a second phase where most of the population aged ≥65 years who were disproportionately affected by COVID-19 had been vaccinated, supply exceeded demand, and wasted doses increased [11].

2.2. Vaccine doses and redistribution costs in jurisdictions

The costs of government-purchased doses were collected from publicly available press releases by the Biomedical Advanced Research and Development Authority (BARDA), excluding investments in vaccine research and clinical trials [12].

Data on jurisdiction-level redistribution was collected via an Excel survey (Supplement Table 2) from jurisdictions in February 2023 and included data collection on two main redistribution scenarios for ‘hub and spoke’ models and contracting redistribution efforts to a third party. For hub and spoke models, data were collected on start-up costs, supplies and materials for storage and handling, staffing, and shipping of repackaged vaccine. For third party contracts, total contract values were collected, and responsibilities covered under the contracts. Vaccine redistribution costs included any logistics activities related to hub and spoke redistribution within a jurisdiction, and use of depots/ couriers/third party logistics companies for storage, handling, and shipment of doses to providers after receipt from the federal government or Pfizer-BioNTech. Redistribution costs included supplies and materials needed to store, handle, and ship/deliver vaccine doses and the requisite labor. CDC Vaccine Data Support Officers (VDSO) were trained on data collection and distributed an Excel survey to all jurisdiction contacts via email, providing weekly follow-up support to collect the data. We received data from 38 of 62 (61 %) jurisdictions (50 U.S. states, District of Columbia, 3 cities [Chicago, Illinois; New York, New York; and Philadelphia, Pennsylvania], 5 U.S. territories [American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and U.S. Virgin Islands], and 3 freely associated states [Micronesia, Marshall Islands, and Palau]). Five jurisdictions reported decentralized redistribution strategies and provided data from 30 local health departments and 2 large health systems. Two jurisdictions reported no redistribution costs during the study period. Data on the mean wage of each state in 2021 was collected from the Bureau of Labor Statistics to estimate staffing costs needed for redistribution [13]. We obtained costs for standardized supplies from medical supply catalogues [14].

2.3. Site-level vaccine administration costs

The local jurisdiction cost of site-level COVID-19 vaccine administration was estimated from prior literature that captured operational costs such as staffing and resource requirements ($38 per dose administered) [15]. Vaccine administration data reported to HHS and vaccine wastage data from the central vaccine operations database (called Tiberius) were used [10]. Providers were required to directly report wasted doses to HHS, however because of underreporting, the number of wasted doses was calculated as number of shipped doses minus the sum of numbers of administered doses, reported wasted doses, and wasted doses based on inventory expiry. Vaccine doses administered and estimated wastage was extracted from Tiberius for only jurisdictions during the study period. Costs related to wastage include purchase, storage, and shipment, excluding administration costs. No costs incurred by vaccine recipients (e.g., travel, time) were included.

2.4. Analysis of costs

Costs from the various sources were aggregated and the mean total cost of vaccination per dose was calculated among the 38 jurisdictions that responded to the survey. For the 24 jurisdictions that did not respond to the survey, the same approach was used, however redistribution costs were imputed by applying the average redistribution cost from the 38 survey jurisdictions. Total costs for vaccine purchase, redistribution, site operations, and wasted doses are presented separately for 38 jurisdictions and across all 62 jurisdictions. All doses acquired by the federal government are not included in this analysis because doses expired at the central level or donated internationally were excluded, and only first or second doses administered or wasted were included.

3. Results

During December 20, 2020–May 31, 2021, the federal government distributed about 284.6 million doses of COVID-19 vaccine to jurisdictions, of which 284.2 million doses were administered (156 million first doses and 122 million second doses) and 0.42 million doses (0.01 %) were estimated as wasted (See Table 1). By the end of May 2021, about 60 % of adults aged ≥18 years had their first COVID-19 vaccine dose by a jurisdiction provider. A total of 114.5 million doses were distributed to the 38 jurisdictions that responded to the survey, of which 114.4 million doses were administered and 0.12 million doses were wasted. In total, the cost of the COVID-19 Vaccination Program among 38 jurisdictions was $6.6 billion and $18 billion across all 62 jurisdictions. More than 60 % of the costs were attributed to the cost of site operations ($37.96/dose in 38 jurisdictions and $41.78/dose in 62 jurisdictions), followed by 33 % on vaccine purchase ($19.03/dose in 38 jurisdictions and $20.96/dose in 62 jurisdictions), less than 1 % on redistribution of doses ($0.44/dose in 38 jurisdictions and $0.35/dose in 62 jurisdictions), and 0 % on wasted doses ($0.02/dose in 38 jurisdictions and $0.02/dose in 62 jurisdictions). The estimated mean cost per dose administered among the 38 jurisdictions was $57.45 and $63.11 for 62 jurisdictions.

Table.

COVID-119 vaccine doses administered and wasted^* and associated costs in the United States, December 20, 2020–May 31, 2021

	Number of doses among 38 jurisdictions N		Number of doses among 62 jurisdictions N
	Administered	114,358,969		284,180,103
Wasted	122,941		418,249
Total	114,481,910		284,598,352
Cost Type	Cost among 38 jurisdictions¶		Cost among 62 jurisdictions with imputed redistributionⴕ
	Total	Per dose	Total	Per dose
Vaccine Purchase§	$2,178,174,849.81	$19.03	$5,966,580,391.36	$20.96
Redistribution	$50,667,388.00	$0.44	$99,386,030.31	$0.35
Site Operations	$4,345,640,822.00	$37.96	$11,891,077,534.00	$41.78
Wasted Doses	$1,974,937.06	$0.02	$6,718,795.62	$0.02
Total Cost	$6,576,457,996.88	$57.45	$17,963,762,751	$63.11

^*Wasted doses were calculated as shipped doses minus the sum of administered doses, reported wasted doses, and wasted doses based on inventory expiry.

^¶Estimated costs for COVID-19 vaccine doses administered and wasted in 38 jurisdictions that provided redistribution data and costs.

^ⴕData include COVID-19 vaccine doses administered and wasted in 62 total jurisdictions (50 US states, the District of Columbia, 3 cities [Chicago, Illinois; New York City, New York; and Philadelphia, Pennsylvania], 5 US territories [American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and US Virgin Islands], and 3 freely associated states [Micronesia, Marshall Islands, and Palau]).

^§Pfizer-BioNTech vaccine purchase price includes their distribution costs.

4. Discussion

The findings present the jurisdiction-level costs of COVID-19 vaccination and cost per administered dose during the initial U.S. COVID-19 Vaccination Program when demand exceeded supply. The COVID-19 vaccine purchase price was low compared with other licensed adult vaccines, ranging from an average of $76 for CDC to $119 for private sector [16]. The jurisdiction-level costs of rapidly expanding vaccine access and administration were substantial relative to the cost of vaccine purchase. These estimated costs indicate that when planning for rapid implementation and broad vaccine access, vaccine distribution strategies require sufficient funding for redistribution and administration, as well as vaccine purchase.

Insufficient reimbursement rates and costs of vaccine purchase are cited as barriers for participating in routine immunization programs [17]. The Vaccines for Children (VFC) program provides federally purchased Advisory Committee on Immunization Practice-recommended vaccines at no cost to provider offices enrolled in the program to administer vaccines to eligible children; vaccine administration fees are reimbursed by Medicaid and other payers [18]. The program has successfully increased childhood immunization rates equitably while also decreasing provider operational burden [18,19]. For COVID-19 vaccines, doses were purchased by the federal government and average reimbursement rates per dose of COVID-19 vaccine (regardless of manufacturer) were set by the Centers for Medicare and Medicaid Services [20], and adopted or adapted by other payers, with additional funding assistance to providers through the COVID-19 Coverage Assistance Fund [21]. Although administrative costs were not as frequently recovered using traditional routine vaccination procedures during the study period, our study illustrates that given the high cost of site vaccination, pandemic planning should consider adequate reimbursement models for initiating a population-wide vaccination program, particularly at vaccination sites that do not have established systems and staffing for ensuring efficient and sustained vaccine administration.

This analysis has several limitations. Several costs were not included because data were unavailable, including central vaccine distribution costs, likely resulting in underestimated costs. The per-dose administration cost from Yarnoff, et al. did not include costs incurred by state immunization information systems or other entities that supported vaccine distribution and reporting [15]. Costs for public health communications and messaging to raise vaccine awareness were also not included. Only redistribution and administration costs by jurisdictions were included, excluding costs by pharmacies, federal entities, and other entities that received separate vaccine allocations. Redistribution costs were limited to jurisdictions who reported costs and may not accurately reflect the remaining 24 jurisdictions that did not submit data. Vaccine administration and distribution costs for mass vaccination sites operated by FEMA were not included. Federal government emergency pandemic funding passed in March 2021 provided resources to jurisdictions for their vaccination programs. However, some jurisdictions reported not receiving funds or did not have the capacity to redistribute vaccines during the study period. This study captured the costs of the initial COVID-19 vaccine program noting that costs during subsequent phases would change because of the changing context of the pandemic. Future studies may consider exploring costs at later phases of the pandemic as jurisdictions relied more heavily on redistribution efforts for their vaccination program.

The federal government’s purchase of all COVID-19 vaccine doses and provision of emergency funds to jurisdictions may have helped reduce provider burden and ensured broad access to vaccines during the pandemic. This analysis contributes to future pandemic preparedness planning for understanding vaccination program costs. Additionally, results could inform future vaccine cost-benefit analysis.

Highlights.

• The estimated cost per-dose-administered among the 38 jurisdictions that responded to study survey was $57.45.

• The estimate cost per-dose-administered across all jurisdictions was $63.11.

• When planning for rapid vaccine access, sufficient funding is needed for redistribution and administration.