Need for Speed in Vaccines Heaps Pressure on Health Teams

Michele Cohen Marill

January 11, 2021

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When a broken freezer at a northern California hospital threatened the viability of 830 doses of the Moderna vaccine, it seemed like one more example of a stuttering COVID-19 vaccination rollout. Yet in 2 hours, Adventist Health Mendocino County managed to deliver the shots before they expired, an impromptu demonstration that swift, efficient delivery of vaccinations is possible.

As of January 11, about 25.5 million doses had been distributed to states, but only about 35% had been administered in vaccinations, according to the Centers for Disease Control and Prevention (CDC). Although the numbers shift by the day, vaccination success varies widely across the country, from a low of about 19% of available doses administered in Georgia to almost 73% in North Dakota. There is a built-in lag time in the CDC data because health providers report their vaccinations up to 72 hours after they deliver them.

The logistics of delivering the vaccine are daunting. States determine which health professionals can give vaccines — typically, physicians, nurses, physician assistants, dentists, and pharmacists — and many of those workers are already consumed with the surge in COVID patients.

Patients also have to be monitored for 15 minutes after injection (or 30 if they have a history of severe allergic reactions), with medical care available in case anyone experiences anaphylaxis.

Staffing is a major issue nationally, and there's a need for vaccine providers at "large public health clinics and in smaller outreach teams for rural areas and high-risk communities where transportation is a challenge," Kelly L. Moore, MD, MPH, deputy director of the Immunization Action Coalition, told Medscape Medical News.

The slow pace of vaccination has been a sore point across the country. New York Gov. Andrew Cuomo became so frustrated that he threatened to fine hospitals up to $100,000 if they didn't use their allotment in the week in which they receive it. He had a list of hospital systems that had administered most of their shipments and those that had administered the fewest.

Vaccinate or Else

Northwell Health, a 23-hospital system based in Long Island, New York, was on the "good" list, having vaccinated about two-thirds of its 72,000 employees. But ramping up has been a learning process, says Mark P. Jarrett, MD, MBA, MS, senior vice president and chief quality officer. New challenges await as Northwell helps set up mass vaccination sites in Nassau and Suffolk counties.

Initially, each vaccinator was scheduled to give a shot every 15 minutes, allowing time to ask people about their history of allergies and respond to any concerns. They soon increased that to six per hour, and as clinicians become more accustomed to conducting the safety checks, that could rise to eight per hour, says Jarrett, who is also deputy chief medical officer.

To staff the points of distribution for community vaccination, Northwell is reaching out to retired physicians and nurses and to medical and nursing students. "We're looking everywhere to line up people and they are coming forward," Jarrett says.

They will need training related to both vaccines, and systems are being set up to handle appointments and create standby lists so no doses go unused at the end of the day. "We are preparing everything we can so we're ready to move," he says.

Two Hours to Deliver

Back at the California hospital with hundreds of thawed vaccines, the staff faced a use-it-or-lose-it scenario. The team at Adventist Health Ukiah Valley Medical Center in Mendocino County discovered the freezer problem at 11:35 AM on Monday. The Moderna vaccine can stay at room temperature for no more than 12 hours, and a sensor showed the vaccine had reached room temperature at 2 AM. A freezer alarm had failed as well.

No one wanted to waste doses, and that meant overcoming the obstacles — quickly. Adding to the predicament, a jack-knifed tractor-trailer had cut off a main highway leading to a sister facility 30 minutes away.

Adventist Health Mendocino County president Judson Howe immediately reached out to the local public health department and gave 200 doses to the county, which used them to vaccinate jail employees and public workers. Hospital leaders contacted nearby skilled nursing facilities and the largest ambulatory care provider in the community. Then they strategized.

Bessant Parker, MD, MBA, chief medical officer of Adventist Health Mendocino County, personally drove 70 doses to nursing homes and administered them to healthcare workers there. The hospital quickly set up four mass vaccination clinics: one on the hospital campus with nine vaccination stations and three other sites in the community.

Mendocino County is forested and mountainous, and the community is battle-tested from responding to wildfires. The hospital sent an alert to all employees. More than 70% of them had already received the first dose of the vaccine, but anyone who hadn't and wanted one could come immediately.

The alert asked for volunteers to help vaccinate and provide clerical support. The hospital also wanted to spread the word throughout the community for people to come and get the vaccine.

By 1:45 PM, all the doses had been administered. The decentralized approach allowed for more doses to be given at once, while still each person was still monitored for adverse reactions, says Parker. "It's changed the way we are looking at how we do our vaccinations going forward," he says.

The hospital will seek to give its future vaccinations in a shorter timeframe, although "probably not as short as this," Parker says.

Nationally, hospitals have had their own struggles with vaccinations, including concerns about how at-risk workers were prioritized. But they were well-equipped to manage the vaccines and communicate with employees.

When some states expanded vaccination to the community (typically older adults and adults with chronic medical conditions), the resulting chaos resembled a mad rush for the most coveted concert tickets.

As Hard to Get as Concert Tickets

In Lee County, Florida, public health officials at first decided to give out tickets on a first-come, first-served basis for people 65 years and older; they had 300 doses per site. Although county officials urged people not to line up before the first site opened at 8 AM, dozens camped out on lawn chairs overnight. Lee County is now taking appointments by phone.

Palm Beach County, Florida, opened a call line, but it crashed from the intense demand. In Tallahassee, people began emailing and texting a local newspaper reporter when they couldn't get through to the health department. Within a few days, she had fielded 167 calls and 75 text messages.

Houston created an online portal and call line, but January appointments quickly filled up. The Texas Department of State Health Services provides an online interactive map of clinics, hospitals, long-term care facilities, health departments, medical practices, pharmacies, and other facilities that will provide the vaccine, but most list the availability as "pending."

Everyone should have expected a gradual ramp-up at the onset of mass vaccination, says Rebecca Wurtz, MD, MPH, an infectious disease physician and population health informaticist at the University of Minnesota School of Public Health in Minneapolis.

She previously served as deputy director of the Illinois Department of Public Health and led the state's smallpox vaccination campaign in 2003 amid concerns about bioterrorism. She was part of a vaccine distribution advisory committee in Chicago during the H1N1 pandemic in 2009. She notes that the current COVID vaccines present unique challenges — for example, the Pfizer vaccine requires ultracold storage — and the first doses were distributed during a holiday period. Nonetheless, by January 11, about 9 million Americans had received a vaccine.

"Certain states are a little more chaotic than other states, but it's a little frustrating to hear that we failed," says Wurtz, who is not involved in the current vaccination programs. "I actually think that's a great victory and it's only going to be up from here."

Many of the initial doses were designated for long-term care centers, says Moore of the Immunization Action Coalition. "Once those doses were reallocated to the pharmacies running that program within the state, the pharmacies had at least 2 weeks to prepare and schedule vaccination visits," she says. "Those vaccinations are getting underway in earnest as of January, and you will see doses-administered numbers rise rapidly as a result."

Michele Cohen Marill is a freelance journalist based in Atlanta. She has written for Wired, STAT, Health Affairs, and other publications. She can be reached at michele.marill@gmail.com.

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