Vaccinating the whole world quickly turns out to be hard

 As Covid vaccines became available, rich countries that had made early, advanced purchases at high prices had contracts that delivered available doses early, while countries and organizations that had made later purchases at lower prices had "best effort" contracts that allowed delivery dates to slip as supply chain problems developed.  The consequences were greatest for the poorest countries, despite efforts to speed vaccination worldwide.

The WSJ has the story:

Why a Grand Plan to Vaccinate the World Against Covid Unraveled. The multibillion-dollar Covax program was supposed to be a model for vaccinating humanity, but has hit problem after problem By Gabriele Steinhauser, Drew Hinshaw and Betsy McKay

"The Covax program, conceived in early 2020 as a kind of Operation Warp Speed for the globe, was supposed to be a model for how to vaccinate humanity, starting with those who needed it the most. The plan was scheduled to have the developing world’s entire healthcare workforce immunized by now.

"Instead, the idealistic undertaking to inoculate nearly a billion people collided with reality, foiled by a basic instinct for nations to put their own populations first, and a shortage of manufacturing capacity around the world.

"Dr. Berkley and a small crew of global health experts spent months trying to recruit much of the world into buying their vaccines from one common pool, rich and poor countries alike. While they were hammering out the details and raising money, nations that could afford it rushed to secure their own shots first.

...

"Most of the world’s poorest nations were left highly dependent on a single vaccine, produced by a single manufacturer in a single country. In a cruel twist, that supplier—the Serum Institute of India—ended up engulfed by the world’s worst Covid-19 outbreak.

...

"Dr. Berkley, the chief executive of Gavi, the Vaccine Alliance, a public-private partnership that secures childhood immunizations for the world’s poorest countries and is the central organization behind Covax, said the facility did its best to navigate a hypercompetitive vaccine market. “We hear a lot of criticism, and the truth is, we’ve tried to do something that we think is the right thing,” he said. “Hindsight’s 2020. Should we have not invested in India? Well, that was the fastest way to get there.”

...

"Covax started shipping Covid-19 vaccines within three months of the world’s richest countries administering their first shots—lightning speed, compared with the five to 10 years it often takes for new immunizations to reach the developing world.

"Yet now it is running out of vaccines just when Covid-19 cases are escalating across countries it was meant to protect: the low- and middle-income states of Latin America and South Asia. The program has shipped 72 million shots, far short of the 238 million it had targeted by the end of May. That’s 4% of the total 1.7 billion vaccines shipped world-wide.

"Some 20 million of Covax’s shots have come from India, which was due to ship 140 million by the end of the month but stopped exporting them as it works to inoculate the country’s 1.3 billion citizens

...

"Wealthy countries, including ones that had promised to fund Covax, were buying their own doses first. In late May, the U.K. had sealed its own agreement with AstraZeneca, for 100 million doses. The U.S., without a commitment to Covax, had signed up for 300 million from AstraZeneca, pledging up to $1.2 billion.

"In June, the European Union, worried that its own countries would start competing for limited supply, stepped in to buy shots for its 450 million citizens. As part of its deal with member states, the EU blocked governments from joining any parallel vaccine purchasing programs. That meant France and Germany were now effectively barred from buying doses from the pool they had championed.

...

"By late December, after months of haggling over prices, Covax had 2 billion doses lined up, enough to vaccinate some 20% of the population in over 100 countries. Yet most were soft agreements with no clear delivery dates or involved drugmakers whose shots hadn’t yet panned out. As Europe and the U.S. began to vaccinate, Covax’s only completed purchases were with AstraZeneca and the Serum Institute.

...

"On Feb. 15, the WHO approved the AstraZeneca shot for emergency use, six weeks after it was cleared in the U.K. That allowed Covax to make its first shipment to a developing country, Ghana, weeks after Serum began exporting shots to other countries.

"Three days later, the U.S., now under President Biden, announced a $2 billion contribution to Covax, with another $2 billion planned through 2022. The EU upped its commitment to 1 billion euro.

"By then, there were scant vaccines available to buy. This month, Covax reached a deal with Moderna for 500 million doses, of which 466 million won’t be delivered until 2022."

The common app and the growth of applications to selective colleges, by Brian Knight and Nathan Schiff

A pair of papers study the Common App, how it is used disproportionally by selective universities and liberal arts colleges, to which applications have increased over time.  The papers focus on how this has increased student choice. 

There's a parallel set of arguments made elsewhere, particularly in connection with application to medical residencies, that too many applications increase congestion in the admissions process. 

The Common Application and Student Choice, By Brian Knight and Nathan Schiff, AEA Papers and Proceedings 2021, 111: 460–464, https://doi.org/10.1257/pandp.20211042

And here's a longer companion paper:

Reducing Frictions in College Admissions: Evidence from the Common Application by Brian Knight and Nathan Schiff, April 17, 2020

Abstract: College admissions in the U.S. is decentralized, creating frictions that limit student choice. We study the Common Application (CA) platform, under which students submit a single application to member schools, potentially reducing frictions and increasing student choice. The CA increases the number of applications received by schools, reflecting a reduction in frictions, and reduces the yield on accepted students, reflecting increased choice. The CA increases out-of-state enrollment, especially from other CA states, consistent with network effects. CA entry changes the composition of students, with evidence of more racial diversity, more high-income students, and imprecise evidence of increases in SAT scores.

********

For a look at applications through the other end of the telescope, see

Tuesday, April 20, 2021

The surge in exam-optional applications for college admissions

Vaccine shortages are more about congested supply chains than about patent protection: Alex Tabarrok at MR

 Alex Tabarrok has a nice post at Marginal Revolution about the actual problems in worldwide vaccine supply, involving congested supply chains much more than protected intellectual property.

Patents are Not the Problem! by  Alex Tabarrok May 6, 2021 

Signals and interviews in the transition from medical school to residency

Late last year I was interviewed by Dr. Seth Leopold, who is a Professor in the Department of Orthopaedics and Sports Medicine at the University of Washington School of Medicine, and Editor-in-Chief of the journal Clinical Orthopaedics and Related Research.   That interview has just appeared ahead of print on the journal's website: 

A Conversation with … Alvin E. Roth PhD, Economist, Game Theorist, and Nobel Laureate Who Improved the Modern Residency Match  by Leopold, Seth S. MD, Clinical Orthopaedics and Related Research: April 7, 2021 - Publish Ahead of Print - doi: 10.1097/CORR.0000000000001758

Here's one part of our Q&A:

Dr. Leopold:You once commented in a Not the Last Word column in CORR® that the Match might be improved if a bit more room could be made for candidates to send “signals” to programs that indicate particular interest[5]; if you could make one change to the Match right now to make it fairer all around, what would that change be?

Dr. Roth: I don’t yet know enough about the whole pre-Match process of applications and interviews to answer that confidently. I’m hoping to gain access to data that will illuminate more clearly how applications lead to interviews, and how interviews interact with other kinds of information to influence what rank-order lists are submitted by applicants and programs. Some of that process is surely in flux, between the pandemic causing interviews to be conducted remotely and the United States Medical Licensing Examination Step 1 going pass/fail. Signaling is a way to address miscoordination in interviewing (such as whether too many interviews are concentrating on too few candidates), but there are other ways the interview process might be broken that might better be addressed by other tweaks in how interviews are organized.

Dr. Leopold:I believe the study you’re proposing here would find a very attentive audience, both in medical schools and residency programs across the country, especially competitive ones like orthopaedic surgery. Based on other kinds of markets you’ve evaluated—I recognize I’m asking you to speculate—what do you think you might find here?

Dr. Roth: Presently, in at least some specialties, many interviews are conducted for each residency and fellowship position. It could be that interviews play a critical role in allowing programs and applicants to assess each other, regardless of the other information they may have. But it could also be that at least some interviews are being conducted “defensively,” because all the interviews that others are participating in make it hard for each program or applicant to predict how likely any interview will lead to a position being offered and accepted in the Match. So, it is possible that there is “too much” interviewing, in the sense that in perhaps predictable ways, some programs are interviewing some candidates they can virtually never hire, and some candidates they would never want to hire. Conversely, applicants are interviewing for some jobs they have hardly any chance of being offered, and some they sensibly think they won’t need to take. Of course, some things can be predictable even if they can’t be predicted by individual applicants and programs with the information they now have available. It might therefore be possible to suggest institutional reforms that would help reduce the uncertainty in deciding which interviews to offer. That might also reduce the number (and costs) of interviews. (In just such a way, the Match helped solve the problem of uncertainty involved in offers and acceptances, back when offers were exploding.) And there’s a possibility that fewer interviews could make everyone better off in terms of expectations, particularly if participants on both sides of the market will feel a reduced need to do so many interviews if everyone else reduces the number they do. But as you say, until we can look into this carefully, I’m just speculating.

The surge in exam-optional applications for college admissions

 Covid forced lots of colleges to make standardized tests optional in admissions, and that seems to have jolted the growth in college applications to new highs.  The Chronicle of Higher Education has the story:

The Endless Sensation of Application Inflation  By Eric Hoover

"consider a big-deal development: the suspension of standardized-testing requirements. After most of the nation’s big-name colleges adopted test-optional policies for the 2020-21 cycle, they all but guaranteed a surge in applications from students who otherwise wouldn’t have applied. When that surge came, some admissions deans publicly expressed surprise that their testing requirements apparently had been suppressing applications from underrepresented students all along, just as critics of ACT and SAT requirements have been saying for decades.

...

"there are some drawbacks to having an overwhelming number of choices, Brennan says: “In admissions, you don’t get a 20-percent increase in staff to account for a 20-percent increase in applications.”

Limiting job applications in an online labor market: by John Horton and Shoshana Vasserman

 Here's an experiment that involved limiting the number of applications to particular jobs in an online labor market, in which many applicants are likely close substitutes.

Job-Seekers Send Too Many Applications: Experimental Evidence and a Partial Solution by John J. Horton and Shoshana Vasserman

Abstract: As job-seekers internalize neither the full benefits or costs of their application decisions, job openings do not necessarily obtain the socially efficient number of applications. Using a field experiment conducted in an online labor market, we find that some job openings receive far too many applications, but that a simple intervention can improve the situation. A treated group of job openings faced a soft cap on applicant counts. However, employers could easily opt out by literally clicking a single button. This tiny imposed cost on the demand side had large effects on the supply side, reducing the number of applicants to treated jobs by 11%—with even larger reductions in jobs where additional applicants were likely to be inframarginal. This reduction in applicant counts had no discernible effect on the probability a hire was made, or in the quality of the subsequent match. This kind of intervention is easy to implement by any online marketplace or job board and has attractive properties, saving job-seekers effort while still allowing employers with high marginal returns to more applicants to get them.

"In this paper, we describe an experiment conducted in an online labor market that influenced the size of applicant pools faced by employers.1 This was done by imposing a soft cap on the number of applicants that a job opening could receive, as well as limiting the duration of the window of time during which applications could be received: when a job opening received 50 applicants—or when 120 hours (5 days) had passed—no more applicants could apply unless the employer explicitly asked for more applicants. The intent of the intervention was to prevent job-seekers from applying to jobs where their application was likely to either be ignored or simply displace some other applicant, without preventing employers with high marginal returns to more applicants from obtaining them.

...

There is no evidence that better or worse matches were made in the treatment group, as measured by the feedback given by the employer at the end of the contract or in hours-worked. If anything, employer satisfaction rose slightly in the treatment.

The lack of effects on hiring or match quality is seemingly surprising, but likely reflects the fact that price competition among workers “prices in” vertical differences among workers, leaving firms close to indifferent over applicants, as in Romer (1992). Because of this indifference, substitution among applicants is not very costly to employers.

...

"only about 7% of employers requested more applicants by pushing the button.

"The treatment intervention likely saved job-seekers substantial time—more so than the percentage changes in job post applicant counts would seemingly imply. To see why the treatment has out-sized effects on job seekers, note that although relatively few job openings were affected by the 50 applicant cap (about 10%), these job openings are disproportionately important to job-seekers, as they attracted 43% of applications. This difference simply reflects the fact that a randomly selected application is more likely to be sent to a job with a high applicant count.

Congestion in vaccine delivery: uncancelled extra appointments

 In school choice, the reason universal enrollment systems that give each child one assignment are so desirable is that if children are accepted by multiple schools, it often takes time (e.g. the first week of the school term) to sort out which children are going where, and to free up the unclaimed spaces.

The same thing is happening with decentralized appointments for Covid vaccines. The WSJ has the story:

Got Your Covid-19 Vaccine? Now Cancel Your Extra Appointments.  Pharmacies and community clinics say uncanceled appointments lead to no-shows, adding to their already heavy workload   By Jaewon Kang and Sharon Terlep

"Pharmacies and health officials are making a plea to Americans who received their Covid-19 vaccines: Cancel the other shots you booked.

"As vaccine eligibility expands and more places offer shots, many people are signing up for multiple appointments and not backing out of the ones they don’t need. The resulting influx of no-shows is forcing vaccine providers, from pharmacies to community clinics, to find last-minute replacements so doses aren’t wasted.

...

"Appointments remain tough to score in many parts of the country even though the overall supply of vaccines and the pace of inoculation are improving. Some people are making multiple bookings in hopes of getting vaccinated sooner or sometimes because they don’t receive or see confirmation emails, according to pharmacies and community vaccination sites. Others receive shots at pop-up vaccination events before scheduled appointments and don’t notify providers.

"The U.S. lacks a concrete system of tracking wasted doses. Generally, local and state officials say that demand is high enough that no-shows aren’t leading to tossed vaccines, though vaccine providers say they sometimes fail to find takers for all the doses they have thawed in time to use them all safely."

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Previous post:

Monday, February 15, 2021

Multiple queues for Covid vaccines, as pharmacies join the supply chain

A call for capping residency interviews

 One clear symptom that the marketplace for medical residents is in crisis is the persistent drumbeat of suggestions for how to modify it.  The transition from medical school to residency has become congested, with many applications and interviews preceding the centralized clearinghouse known as the Match (which will yield its results on March 19).  

One way to treat a disease is to treat some of its most obvious symptoms. Here's the latest such proposal, to put a cap on the number of interviews. (Readers of this blog will wonder how those will be coordinated, and a number of proposals have been made including signaling, or a centralized interview match.)  

I'm hoping that data will become available to allow these proposals to be better evaluated, and perhaps to allow a market design that will deal with causes as well as symptoms.

Here's the latest, from Medscape.

Fixing the Match Crisis Starts With Capping Interviews  by Helen K. Morgan, MD

"Concern over the so-called "Match crisis" increases every cycle. This year, pandemic-related changes have shined a spotlight on the skewed distribution of interviews. Thanks to the shift from in-person to virtual interviews, applicants were no longer limited by travel and financial concerns. According to some experts, this has resulted in "top" candidates taking additional slots and subsequently reducing opportunities for others.

"Worry about residency interview distribution has surged, with letters of concern posted by the Association of American Medical Colleges and the American College of Surgeons. Before the start of this season, my colleagues and I modeled the potentially dire consequences of ob/gyn applicants "hoarding" too many interviews in an article published in the Journal of Surgical Education.

The residency application problems exposed by the pandemic aren't going anywhere without action. Establishing a cap on interviews is now clearly necessary...."

HT: Mike Rees

Allocating leftover vaccine before it spoils

 The NY Times has the story:

Hunting for a Leftover Vaccine? This Site Will Match You With a Clinic.  More than half a million people have signed up for Dr. B, a service that promises to match them with clinics struggling to equitably dole out extra doses before they expire.   By Katie Thomas

"a New York-based start-up is aiming to add some order to the rush for leftover doses. Dr. B, as the company is known, is matching vaccine providers who find themselves with extra vaccines to people who are willing to get one at a moment’s notice.

"Since the service began last month, more than 500,000 people have submitted a host of personal information to sign up for the service, which is free to join and is also free to providers. Two vaccine sites have begun testing the program, and the company said about 200 other providers had applied to participate.

...

"The company’s database sorts people by local rules about vaccine priority, giving providers better odds of administering their leftover shots to those in the greatest need.

"For many providers, that orderly procedure would be a welcome change from the haphazard systems they are using now. At some pharmacies and supermarket chains, workers have resorted to combing the shopping aisles to find people willing to get a last-minute vaccine. At other locations, vaccine hopefuls wait in line at the end of every shift, which could pose an infection risk, particularly to the most vulnerable."

Coordinating vaccine delivery is hard (California/Blue Cross version)

 The Mercury News has the story:

Santa Clara County will not participate in state’s Blue Shield-run vaccine program  by Maggie Angst

"Santa Clara County said late Monday it won’t take part in the state’s new centralized vaccine distribution system run by Blue Shield — a potentially huge blow to Gov. Gavin Newsom’s highly-touted plan.

"County Executive Jeff Smith said the county would not sign a contract with Blue Shield allowing the health insurance company to take over vaccine distribution in the county, claiming the new oversight wouldn’t do anything to improve vaccination speed or efficiency.

...

"According to officials from Blue Shield and the state, only one county of 58 in the entire state — Kern County — has signed a contract with Blue Shield.

“I think everyone sees it as a solution looking for a problem,” Smith said. “We’re talking about adding bureaucracies rather than vaccinating people.”

How do Zoom interviews change labor markets? Interview Hoarding by Manjunath and Morrill

 Suppose there were a pandemic that caused widespread lockdowns.  How might this influence the outcome of a labor market that was forced to switch from in-person, on-site interviews to remote interviews via Zoom or its equivalents?

Vikram Manjunath and Thayer Morrill take up the challenge, motivated by the case of the National Resident Matching Program, which matches new doctors to hospital residency programs. (Match Day is March 19 this year, so we may know some relevant things about how the pandemic influenced the Match not too long after.)

Interview Hoarding  by Vikram Manjunath and Thayer Morrill, February 22, 2021

Abstract: Many centralized matching markets are preceded by interviews between the participants. We study the impact on the final match of an increase to the number of interviews one side of the market can participate in. Our motivation is the match between residents and hospitals where, due to the COVID-19 pandemic, interviews for the 2020-21 season of the NRMP match have switched to a virtual format. This has drastically reduced the cost to applicants of accepting interview offers. However, the reduction in cost is not symmetric since applicants, not programs, bore most of the costs of in-person interviews. We show that if doctors are willing to accept more interviews but the hospitals do not increase the number of interviews they offer, no doctor will be better off and potentially many doctors will be harmed. This adverse consequence results from a mechanism we describe as interview hoarding. We prove this analytically and characterize optimal mitigation strategies for special cases. We use simulations to extend the insights from our analytical results to more general settings.

***********

Update: Manjunath, Vikram, and Thayer Morrill. "Interview hoarding." Theoretical Economics 18, no. 2 (2023): 503-527.

Vaccine supply and delivery in Germany: I'm interviewed in Zeit

 Here's an interview in the German newspaper Zeit, in which I was asked in early February about the vaccine rollout here and there. (Google translate is pretty readable, although some of the Q&A is a bit garbled by the translation from English to German and re-translation back into English...)

"Die Welt kann es sich leisten, einiges zu bezahlen" Alvin Roth weiß, wie man begehrte Güter effizient verteilt. Er hat den Nobelpreis dafür bekommen. Ein Gespräch über knappen Impfstoff und wie er vermehrt werden kann.  Interview: Lisa Nienhaus

Google Translate: "The world can afford to pay a lot" Alvin Roth knows how to efficiently distribute desirable goods. He got the Nobel Prize for it. A conversation about scarce vaccine and how it can be propagated. Interview: Lisa Nienhaus February 15, 2021,

The interview starts off talking about congestion, and line jumping, and the tradeoffs between speed and fairness (and how it's really costly to allow some vaccine to expire unused in the name of fairness).  It then turns to shortages of vaccine in the near term:

ZEIT ONLINE: Attempts are being made to build new production facilities. But in Germany we are - to be honest - pretty late.

Roth: But now is not the time to give up. Everything we build now may help us in August. Even if Germany is running late, there is still time to expand production facilities. Especially since these systems would certainly not have to be destroyed after Covid. Being able to produce mRNA vaccines oneself is also a good thing in the future. Vaccine production is not that complicated. You can build production facilities anywhere. And you should too.

ZEIT ONLINE: It's not happening on a large scale yet. What to do?

Roth: Laws are really useful for that. Pfizer / BioNTech and Moderna could be forced to license the production technology to other German pharmaceutical companies.

ZEIT ONLINE: That sounds radical.

Roth: I only think it's logical. If you had a pharmaceutical company, you'd think, "I'm paid by the dose. I've got enough capacity to ship to the whole world in the next year and a half. Why should I hurry?" There is no need to set up production facilities just to supply the world in six months instead of 18. It doesn't make any difference from a business perspective. But for the German or American government, these two options are by no means equivalent. It is important that we vaccinate quickly. We need a lot more production capacity than the pharmaceutical companies think it makes sense.

ZEIT ONLINE: Economists rarely suggest such a strong market intervention. And that also applies to companies that we must first be grateful to because they show us a way out of lockdown.

Roth: It's a global pandemic. It is economically necessary to think about how to avert the damage to the economy. But of course you have to pay the manufacturers. Many forget that.

ZEIT ONLINE: How fair the companies think that probably depends on how much you pay them.

Roth: Yes. But the world can afford to pay a lot. Because the world economy is currently largely at a standstill. We have a multi-trillion dollar economy. Paying a billion to save a trillion is good business.

ZEIT ONLINE: Why is that not happening so far?

Roth: The pharmaceutical companies themselves don't think that way at the moment. But we need the vaccine now. And it's very expensive for the world to shut down its economy like that. If you lose a few percentage points of GDP growth in Germany, that's a huge number. And there is almost no amount to pay to license the vaccine that is not worth it.

Vaccine delivery improving, with congestion

 A statewide vaccine appointment list is a good idea, but it can crash:

Massachusetts Vaccination Website Crash: What Went Wrong?  The state thinks the high volume of traffic may have been the cause, but they still aren't 100% certain

"Massachusetts’ COVID-19 vaccine appointment portal temporarily crashed Thursday morning as more than 1 million additional state residents became eligible to schedule a shot.

"Gov. Charlie Baker said the administration had run through different scenarios to try to avoid problems with the vaccine portal. He said people in the administration are in the process are trying to determine what happened.

"The state on Thursday for the first time began allowing those age 65 and older, people with two or more certain medical conditions, and residents and staff of low income and affordable senior housing so sign up for a vaccine shot. But it came with a warning that it could take up to a month to book an appointment.

...

"As of Friday morning, the issues appeared to have been resolved and the website seemed to be working properly. But vaccination appointments remained hard to find.

"People who went to vaxfinder.mass.gov on Friday to book an appointment were told none were available. A statement from state health officials said “a small number of appointments for other locations,” including pharmacies and regional collaboratives, would be posted over the next few days."

Economics envy: signalling proposals for the radiation oncology match (to reduce congestion and coordination failure)

 Here's a call to introduce signaling into the resident match for radiation oncologists, explicitly modeled after the signaling used in the job market for economists.

I Need a Sign: The Growing Need for a Signaling Mechanism to Improve the Residency Match

Wesley J. Talcott, MD, MBA , Suzanne B. Evans, MD, MPH, 

Int J Radiation Oncol Biol Phys, Vol. 109, No. 2, pp. 329-331, FEBRUARY 01, 2021, DOI:https://doi.org/10.1016/j.ijrobp.2020.09.008

"Increased attention has been directed toward the radiation oncology interview application process, as the COVID19 crisis threatens to exacerbate its many longstanding inefficiencies.1,  2,  3 A signaling mechanism, by which applicants can send a signal indicating strong interest to a strictly limited number of programs, has been discussed in other specialties to remedy similar inefficiencies4,  5,  6 and will be implemented this application cycle by otolaryngology residency programs. We strongly believe our field should similarly take a leading role on this initiative this application cycle.

Such a system is not novel. A signaling mechanism was introduced in the Economics postdoctoral job market match, which has resembled the Radiation Oncology market in terms of applications submitted per applicant and interview invitations per application. Candidates submitting applications have the option to signal to employers with up to 2 “signals of interest.” These signals are sent through a secure portal associated with the American Economic Association,7 rather than through an extrinsic third party. The instructions for the portal encourage applicants not to send signals to their top 2 programs, but instead to programs who would be likely to factor the signal into their interview invitation decision. 

...

"To improve the interview application process, we recommend granting applicants a strictly limited supply of free virtual “signals of interest” that can be submitted via a monitored online portal. An applicant would be allowed to submit up to 2 signals from this portal to programs of interest. Signals must be limited, as value of these virtual signals comes from their scarcity; strict enforcement of a 2-signal limit means received signals convey credible interest, whereas the absence of an accompanying signal (the case with the vast majority of submitted applications) conveys essentially no information. This system should be free for applicants, to not introduce more financial inequities in this process. The cost to set up the online portal would be minimal given its simplicity, with little overhead once established, and could be shouldered by programs or radiation oncology organizations."

Multiple queues for Covid vaccines, as pharmacies join the supply chain

 It is good news that pharmacies are now being included among the places that can dispense Covid vaccinations, because not everyone is connected to another kind of health care provider.  But it will not end the congestion in getting appointments and delivering vaccines.

Having multiple waiting lists for appointments--i.e. for appointments at different pharmacy chains, health care providers, county vaccination centers--will add to congestion. People will have incentives to make appointments with more than one provider, because supplies at each provider are uncertain, so that some appointments may be cancelled due to shortages of vaccine on the appointed date.  After getting vaccinated, at least some people will neglect to cancel their other appointments, and so some doses of vaccine will not be delivered when scheduled. (Hopefully they won't be wasted).  So vaccinations will still be slower than we might hope.

Here's a CBS report:

Pharmacies now offering COVID-19 vaccines: Here's what you need to know BY KATE GIBSON

"The federal government this week started sending supplies of COVID-19 vaccines to 21 national drugstore chains and to independent pharmacies in a move to accelerate distribution. The program will be implemented in stages, based on available vaccine supplies, according to the U.S. Centers for Disease Control and Prevention.

...

"National drugstore chains CVS Health and Walgreens are among those getting supplies of COVID-19 vaccines from the federal government. But getting a shot isn't as easy as walking through the pharmacy door. Consumers are instead being discouraged from flocking to the stores, but rather get in line by making an appointment online or the phone. "

***************

Here's the CDC site:

Pharmacies Participating in the Federal Retail Pharmacy Program

Equity v. efficiency in vaccination

Here's a sad story from the NY Times, as we struggle with getting people vaccinated, while making sure that everything is fair and square:

The Vaccine Had to Be Used. He Used It. He Was Fired.  By Dan Barry

"The Texas doctor had six hours. Now that a vial of Covid-19 vaccine had been opened on this late December night, he had to find 10 eligible people for its remaining doses before the precious medicine expired. In six hours.

...

"The doctor figured that if he returned the open vial to his department’s almost certainly empty office at this late hour, it would go to waste. So as he started the drive to his home in a neighboring county, he said, he called people in his cellphone’s contact list to ask whether they had older relatives or neighbors needing to be immunized.

...

"The next morning, he said, he submitted the paperwork for the 10 people he had vaccinated the previous night, including his wife. He said he also informed his supervisor and colleagues of what he had done, and why.

"Several days later, the doctor said, that supervisor and the human resources director summoned him to ask whether he had administered 10 doses outside of the scheduled event on Dec. 29. He said he had, in keeping with guidelines not to waste the vaccine — and was promptly fired.

"The officials maintained that he had violated protocol and should have returned the remaining doses to the office or thrown them away, the doctor recalled."

Vaccine delivery in the U.S. continues to be congested

As of today, congestion is still competing with short supply to limit vaccination in the US.

Some doses are being wasted or delayed in the name of fairness,  to better honor the priority orderings being used in each state, some doses are being sequestered for second vaccinations rather than being used now for first vaccinations, and some regions and/or providers have too little vaccine on hand, or too little predictability of supply to plan efficient distribution.

 USA today has the story:

Amid sputtering COVID-19 vaccine rollout, 16 states have used less than half of distributed doses  by Ken Alltucker

"The Biden administration has vowed drug companies will make enough vaccine to immunize 300 million Americans by the end of the summer.

But getting the vaccine from the factory to the arms of people has been anything but smooth. Of 47.2 million doses shipped to states and nursing homes, 24.6 million doses have been administered, the Centers for Disease Control and Prevention reported Thursday. 

The nation's slow rollout has boiled over from California, which tapped Blue Shield of California to allocate vaccines, to Maryland where Gov. Larry Hogan implored the federal government to send more doses of the potentially life-saving vaccine.

An Arlington, Virginia, hospital canceled 10,000 vaccine appointments, citing the state's decision to send doses to county health departments rather than directly to hospitals and other health providers.  In Minnesota, a vaccine lottery offered just 8,000 appointments to more than 226,000 people who signed up over a 24-hour period this week."

Vaccine congestion: short planning horizons

 ProPublica has the story:

How Operation Warp Speed Created Vaccination Chaos--States are struggling to plan their vaccination programs with just one week’s notice for how many doses they’ll receive from the federal government. The incoming Biden administration is deciding what to do with this dysfunctional system.       by Caroline Chen, Isaac Arnsdorf and Ryan Gabrielson

"Hospitals and clinics across the country are canceling vaccine appointments because the Trump administration tells states how many doses they’ll receive only one week at a time, making it all but impossible to plan a comprehensive vaccination campaign.

"The decision to go week by week was made by Operation Warp Speed’s chief operating officer, Gen. Gustave Perna, because he didn’t want to count on supplies before they were ready. Overly optimistic production forecasts turned out to be a major disappointment in the rollout of the H1N1 vaccine more than a decade ago, also leading to canceled appointments and widespread frustrations with the government’s messaging.

"This time, however, the most pressing problem isn’t the overpromising of supply. For each of the past three weeks, the federal government got about 4.3 million shots. But the amount that each state is sent has fluctuated as Operation Warp Speed changes the quantities available week by week.

State health officials say the unpredictable shipments have led to chaos on the ground, including the inability to quickly use up all of the doses sent to them. The week-by-week system also makes it hard to plan for the second doses that everyone needs because they come three or four weeks after the initial dose.

...

"The makers of the two authorized vaccines, Pfizer and Moderna, are each contracted to supply 100 million doses by the end of March. But with just 31.2 million delivered as of Jan. 15, according to data from the Centers for Disease Control and Prevention, the companies will need to ramp up their pace to hit their targets."

*********

HT: Peter Cramton

Congestion in decentralized vaccination

 The news is full of stories of people obsessively refreshing web pages, hoping to get an appointment for a Covid vaccine.

The Washington Post has this story:

Tipsters, tech-savvy kids, pharmacy hopping: How Americans are landing coronavirus vaccines.  ‘It feels like I’m trying to get a Beyoncé ticket,’ said a woman trying to get her mother an appointment  By Fenit Nirappil, Karin Brulliard and Sarah Fowler

"Those searching for a shot face a decentralized system of vaccine distribution operated by cash-strapped public health departments and a disparate network of clinics and medical providers, all crushed by unprecedented demand for a shield against the virus decimating American life.

"While many Americans have had no problem getting shots, others like Cohen have spent hours trying to get vaccinated, to no avail. The challenges in vaccinating people mirror the botched rollout of coronavirus testing as a mix of government and private providers navigate unfamiliar terrain while communicating with the public in different ways.

"Some vaccine appointment websites crashed almost as soon as they launched. Older Americans are enlisting their kids and grandchildren to stay on the phone and keep refreshing websites until they land an appointment. Tiny intelligence networks are forming around the country to scour for morsels of information on how to get a leg up on the vaccine search.

"Claire Hannan, executive director of the Association of Immunization Managers, said these struggles are unavoidable as the federal government defers distribution to localities without the resources to create a centralized sign-up for vaccines or to hold mass inoculation drives.

...

"The Centers for Disease Control and Prevention plans to encourage people to use VaccineFinder as a national resource for finding shots, but a public search function has not launched while supplies are still limited."

Preference Signaling for the Otolaryngology Interview Market

 From the journal The Laryngoscope, a thoughtful description of the growing interest in signaling for medical residency interviewing (which I believe will be implemented for Otolaryngology residency positions in the coming year).

Preference Signaling for the Otolaryngology Interview Market

C.W. David Chang MD  Steven D. Pletcher MD  Marc C. Thorne MD, MPH  Sonya Malekzadeh MD

First published: 06 October 2020 https://doi.org/10.1002/lary.29151

"The impact of the coronavirus disease 2019 pandemic extends beyond patient care and into graduate medical education (GME). The pandemic has created disarray in the residency application process. Visiting rotations and residency interviews—two cornerstones of the application cycle—are gone.

"Just as the pandemic has exposed healthcare disparities in medical care, it also shines a light on inequalities with GME. Even before the pandemic, many residency specialties observed a meteoric rise in the number of applications submitted by each applicant. In 2019, otolaryngology applicants submitted an average of 72 applications, an 80% rise over 15 years.1 This increase drives a cycle of programs receiving more applications and students feeling the need to apply more broadly to maintain competitiveness. Students with monetary resources are better able to mitigate match risk through prolific residency application and by traveling for away rotations to cultivate faculty advocates. Financially disadvantaged applicants may find it more difficult to amass influential social capital.

"With the deluge of applications, applicants are unable to distinguish themselves from the crowd. Such dilution impairs the applicants' abilities to credibly convey interests to programs. Similarly, the program director has a hard time selecting candidates from a pool of excellent applicants for interview.

"The interview is a limited resource. Selection committees often react to this scarcity by declining to interview qualified candidates they think (but do not really know) are unlikely to choose their program and instead interview candidates who they think (but do not really know) are more likely to accept an offer. This approach is inefficient.

"Preference signaling is an intriguing solution. Since 2006, the American Economic Association has operated a signaling service to facilitate job interviews for graduate students. This applicant‐initiated concept aligns goals of interested applicants with programs. Students send signals to up to two employers to indicate their interest in receiving an interview. In reviewing their outcomes, signals were found to increase probability of interview, especially for niche scenarios (nongraduate applicants, applications to liberal arts colleges, and small city locations).2 Signaling has received interest among medical residency specialties as well.3, 4

...

"The Otolaryngology Program Directors Organization (OPDO) Council has worked diligently with stakeholders to incorporate their input throughout the development process. We thank members and leaders of the academic otolaryngology community, including the Association of Academic Departments in Otolaryngology (AADO), the Society of University Otolaryngologists (SUO), and the greater community of program directors for their support. We appreciate the guidance and valuable insight from the Association of American Medical Colleges (AAMC)—specifically the Group on Student Affairs (GSA), the Committee on Student Affairs (COSA), and the Electronic Residency Application Service (ERAS)—along with the National Resident Matching Program (NRMP). We are hopeful that signaling will improve the residency interview selection process by facilitating the successful pairing of applicants with programs."