On the ground, the pledge to vaccinate 20 million against Covid-19 in December seems unrealistic

Hospitals across the United States are preparing for a Covid-19 vaccine distribution timeline that’s well behind official government targets as they face ongoing confusion about the process for inoculating frontline employees.

Leaders of Operation Warp Speed have repeatedly said they are on track to vaccinate 20 million people in December, enough for nearly all the health care workers and long-term care residents who are first in line to get a vaccine. But those involved in vaccine planning at four health care systems, in California, Illinois, Wisconsin, and Kansas, told STAT they expect to still be giving staff their first shots in mid-January. These workers would then receive their second vaccine dose three to four weeks later, depending on the vaccine, and would receive the full immunization effects a week after that, in mid-February.

With hospitals across the U.S. filling up, as numerous states set daily records for Covid cases, federal officials have pledged a massive distribution push within days of the expected FDA approval this month of the first two vaccines. Moncef Slaoui, head of Operation Warp Speed, said in a briefing last week he was confident “we will be able to distribute … enough vaccine to immunize 20 million people in the U.S. in December.” But on the ground, the reality is murkier.

“We’re not going to get 300 doses [immediately] for a hospital that has 300 employees,” said Pat Schou, director of the Illinois Critical Access Hospital Network, which works with 57 critical access rural hospitals. “I think it’s going to take a couple months. By mid-February, I would hope that we would have almost all our health care workers and EMS and be moving into long-term care. I think that’s the best we can hope for.”

Wisconsin’s health department recently released prioritization plans for those within the first tier of vaccination. “If we were able to [vaccinate] all almost immediately, I’m not sure they would have gone to that trouble,” said Tim Size, executive director of Rural Wisconsin Health Cooperative.

These delayed expectations reflect the basic questions and concerns that many of the first Covid-19 vaccination sites still have about a process due to start in a matter of weeks. “We don’t know a lot yet,” said Dave Dobosenski, chief executive of St. Croix Regional Medical Center in Wisconsin, a state with one of the highest case rates in the country. “We’re craving to get some information here to understand what we’re doing.”

The biggest questions among health care systems include when they will receive their vaccines, and how many. But there are also logistical hurdles, including not wasting unused doses, not leaving patients unattended while staff are vaccinated, and not having workers take sick days all at once when they experience expected side effects of the vaccines, including fatigue and fever.

Even when health care providers have information, it can frequently change. Houston Methodist Hospital was originally told it was a “pre-position” vaccine site, due to receive the vaccine five to seven days ahead of other providers in the state, said chief executive Roberta Schwartz. But the vaccine will no longer be going to pre-positioned sites first, said Texas health department spokesperson Chris Van Deusen. Schwartz said she was most recently told to expect a delivery on Dec. 12 or 13. “If you asked me that tomorrow, I’ll give you another day,” she added.

Sanford Health, with hospitals in North Dakota, South Dakota, Minnesota, and Iowa, has received an estimate of how many vaccines it will first receive from only one of those states, said Jesse Breidenbach, senior executive director of pharmacy support services. That delivery would be sufficient to cover the majority of staff who have volunteered to take the vaccine in that state.

The logistics involved in planning vaccination will be challenging. Wisconsin health workers were told they might be expected to drive up to one hour each way to get their vaccine. “You can’t just pull someone off their shift to go get vaccinated, you’re gonna have to rotate your staff to do that,” said Anita Lundquist, executive director of pharmacy services at St. Croix Regional Medical Center.

She’s also not certain who will be included within the first wave of vaccinations: A Centers for Disease Control and Prevention advisory committee has one definition of health care workers, the U.S. Department of Homeland Security has a broader list, including dentists and chiropractors, and the Wisconsin Medical Advisory Board has its own definition, said Lundquist. “We’re looking at three different documents that have a different scope of tier-one health care workers.”

While larger hospitals don’t know whether they’ll have enough vaccine for their staff, smaller facilities are unsure what to do if they receive too many. Moderna vaccines are shipped in boxes of at least 100 doses; Pfizer’s are shipped in minimum-975-dose boxes, and cold-chain manufacturer AeroSafe Global said it was providing 125-dose storage containers to Walgreens and CVS, which are distributing vaccines to nursing home residents.

“If you have 130 staff, what do you do with the extra 70 doses” in a shipment of 200, said Jason Belden, director of emergency preparedness at the California Association of Health Facilities, which represents long-term care facilities. “Do the facilities have to partner together, because they’re not going to break the shipment down to any less than 100?”

If vaccine clinics are set up at long-term care facilities, Belden said he doesn’t know if his staff will be required to get consent or set up part of the clinic before deliveries arrive, and whether he should start training staff about the organizational process. “There has not been any notification from the state to us that describes the process in which these vaccines will get to the facilities in the appropriate amount,” he added in an email.

Hesitancy among some workers about being vaccinated only complicates this process. At Sanford Health, 60% of staff are currently expected to sign up to take the vaccine, said Breidenbach. Hospitals are unsure if they need staffers’ commitment to take a vaccine ahead of time to try and reduce waste. “What do you do if you’re planning to give 100 doses in a location, and only 95 people showed up that week?” he said.

In rural areas, some worry that logistical issues will make it difficult for them to have equal access to vaccines. “If you’re a hospital in Tribune, Kansas, a small town, six hours from Topeka, are health care workers going to get the same access at the same time as the hospital in Topeka?” said Brock Slabach, senior vice president for member services at the National Rural Health Association.

Operation Warp Speed recently announced that Walgreens and CVS would help distribute vaccines to long-term care residents, but these pharmacies are not evenly distributed across the United States. “We don’t have either of those organizations anywhere near our service area,” said Lundquist. “I don’t logistically know if that private sector is going to be able to provide that [distribution].” Nursing homes also have the option to partner with local pharmacies, but these are unlikely to have the necessary staff or storage resources.

Access is an added challenge for Pfizer’s vaccine, which needs to be kept at ultra-cold temperatures. Both Belden, in California, and Lundquist, in Wisconsin, said some rural facilities were struggling to get hold of dry ice, which is used to keep the vaccines at proper temperatures. “We don’t know to what extent we’re going to need to source the dry ice, whether it would be us individually or whether it will be the state health department,” said Belden.

St. Croix Regional Medical Center previously used dry ice from a meat-packing plant, but the quality isn’t good enough for Pfizer’s vaccine, said Lundquist. The hospital is trying to secure another vendor, but the nearest is an hour to 90 minutes away. Moderna’s vaccine doesn’t require this ultra-cold storage, but none of the facilities STAT contacted knows yet which of the vaccines it will receive.

Even for larger, urban hospitals, planning for so many distribution eventualities is a huge resource drain. There are six teams working on various aspects of the plan, said Houston Methodist’s Schwartz, taking care of details including staff shifts, moving needles and alcohol preparation wipes to vaccination locations, education to help reduce hesitancy, and deployment itself.

There are endless eventualities to worry about. “Will every staff person who’s delivering the vaccine dilute it properly? What if it breaks, what if the shipment doesn’t come? What if it sits on the dock and doesn’t get to the freezers?” said Schwartz.

For vaccine distribution to run smoothly, manufacturing, federal distribution, state plans, and local health care providers have to work together. While some providers say their state is providing as much information as possible given the fast-paced developments, others are frustrated by the lack of basic details.

“When you’re working in collaboration, you need to know what your partner is doing to make sure what you’re doing and thinking fits together,” said Size. “The decisions each of them make about their piece of the puzzle need to be compatible.”

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