On Sunday morning, the first vials of Covid-19 vaccine left Pfizer’s factory in central Michigan on trucks and planes tailed by cameras and police escorts. Packed in specialized cartons stuffed with dry ice, they traveled at -70 degrees Celsius to a few hundred hospitals and health departments in all 50 states, executing a complex logistical dance at the peak of the holiday shipping rush. These first shots were limited in number. Most will wind up in the arms of medical workers on the front lines of Covid-19 care, like Sandra Lindsay, a New York nurse who received one of the first vaccinations on Monday.
Bill Litton, the director of emergency management in Osceola County, Florida, was as happy as anyone to see “the light at the end of the tunnel.” But even as the first shots were administered in the Orlando area on Tuesday, he was still mostly thinking about the tunnel. For the next few weeks, the local hospital system, which has received 20,000 doses so far, is largely taking care of its own; big pharmacy chains will take care of nursing home residents scheduled to receive shots later this month. But Litton and local health officials have spent months on drills and meetings for the bigger task ahead: how to inoculate a much larger and more diverse pool of people in harder-to-reach places.
In Florida, state officials hope to begin vaccinating the general public—beyond health care workers and the elderly—in late February or early March. The date could easily slip. It depends not just on a smooth rollout for the first two vaccines—from Pfizer, which received approval from the US Food and Drug Administration last week, and Moderna, which could receive the same within days—but also on a steady supply of doses from other vaccines that are now in late-stage clinical trials.
The scale and complexity of the task dwarfs other mass vaccination campaigns in recent memory. Officials in some areas plan to administer shots at sites like mobile clinics and mass vaccination sites, as well as at smaller doctors’ offices with less experience with vaccine storage and data systems. States have asked Congress for billions of dollars to help cover the logistics. But Congress has been slow to consider an aid package, leaving local and state officials strapped as they work to bring health care providers on board. “We’re far behind. There’s no question about it,” says Claire Hannan, executive director of the Association of Immunization Managers, which works with state and local health officials on vaccination strategy.
In Osceola County, home to more than 375,000 people just south of Orlando, the scale of the challenge is on Litton’s mind. Officials have identified six sites in the area that could host drive-up or walk-up vaccinations, some of which are currently used for Covid-19 testing. That includes Osceola Heritage Park, where the fairgrounds used for the annual Silver Spurs Rodeo could soon host teams of nurses and EMTs administering doses to people in serpentine lines of cars. Large open spaces like that one will be useful, Litton says, because of social distancing needs and the need to observe people for 15 minutes after their injection for adverse reactions. While politicians in Congress debate aid, he’s been advised to keep track of expenses and overtime to seek potential reimbursement.
Some of the uncertainties are expected to be resolved as vaccinations begin at larger medical centers and pharmacies. “I think it’s going to be very eye opening what’s happening this week,” says Hannan, of the immunization managers group. That includes the logistics of handling the delicate Pfizer vaccine, such as warming the vials from their deep freeze and diluting the doses. They’ll also learn how to ask patients about their medical history to help prevent adverse events, like allergic reactions. Even small things like the average time to ready a kit, confer with patients, and perform the injection will have a big impact when vaccinations are being scheduled at scale.
The next few weeks will also be a trial run for the computer systems states plan to use to track and schedule vaccinations. Ideally, people showing up for vaccinations will be notified of their eligibility and sign up ahead of time through systems tied to state vaccination registries. Doing that would mean fewer paper forms onsite, and less manual labor for local staff who have been asked to report updated vaccination tallies daily. That will allow states and the Centers for Disease Control and Prevention to monitor the progress of allocating doses. In addition to electronic notifications, people receiving vaccinations will also receive a physical card with the date of their immunization and a reminder to come back for a second dose in three or four weeks, depending on which vaccine they have received.
Those notification and tracking features are a major improvement over those in place during past immunization campaigns like for H1N1 in 2009, says Rebecca Coyle, executive director of the American Immunization Registry Association, which advocates for improving vaccine IT systems. But new systems are bound to have kinks, especially at scale. The next few weeks will be a test for those systems, starting with hospital systems that have extensive experience with vaccine record-keeping. “The easy data capture will happen first,” Coyle says, “My assumption is that there will be opportunities for improvement.”
One disadvantage of not sending people to their usual doctors for shots may be keeping track of those people in the long term, well beyond the second dose, says Hemi Tewarson, a senior scholar at the Duke-Margolis Center for Health Policy who has been reviewing state vaccination plans. That long term surveillance is necessary to build trust in a vaccine. “There’s so much focus on getting the shot into people’s arms that states haven’t had time to think about this piece,” Tewarson says.
In Teton County, Wyoming, home to 23,000 people spread sparsely across 4,200 square miles, the regional hospital received an initial tray with 975 doses of the Pfizer vaccine, according to the state health department. Earlier this year, hospital staff ignored guidance from the CDC to purchase a freezer capable of storing the vaccine. “Luckily they did it, and we’re very happy they did,” says Jodie Pond, the county health director. As a result, the hospital is now a storage point for Pfizer vaccines for much of the western half of the state.