Stephen Nuckolls, who runs a North Carolina health care medical group called Coastal Carolina Health Care, has deep freezers capable of storing the two authorized COVID-19 vaccines and hundreds of staff ready to give it. But after two weeks of emailing the North Carolina health department, he couldn’t get a supply.

“My medical practice and many others have mostly completed our annual flu shot clinics and have staff and freezers (yes -70c) standing by to administer the shots,” he wrote in a Dec. 23 email to the Medical Group Management Association, a Washington, D.C.-based trade group representing independent practices. “But despite our repeated emails to the [North Carolina Department of Health and Human Services] we have no vaccine and there appears to be no plan to send any in the near future.”  

Nuckolls’ practice even ranked its 30,000 patients on who had the greatest risk of developing severe COVID-19 symptoms in order to prioritize distribution according to Centers for Disease Control and Prevention recommendations. So far, just half of his own front-line health care workers have been able to get vaccinated.

While millions of vaccine doses sit on shelves at risk of spoilage at short-staffed, overwhelmed hospitals, smaller doctors’ offices and independent pharmacies have been sitting on the sidelines.

As of Tuesday, 9 million U.S. residents have been vaccinated, according to CDC data, a far cry from the 20 million people the administration promised to vaccinate by the end of 2020. Four weeks since celebratory first doses, federal officials have distributed 25 million doses to states.

The rollout contrasts sharply with flu vaccination, which saw 192 million doses sent to an estimated 150,000 hospitals, clinics, doctors’ offices, mobile clinics and schools within a few months. 

On Tuesday, the Trump administration sought to respond to the behind-schedule rollout by announcing that officials were expanding vaccine distribution to other locations like pharmacies and smaller health care clinics and would support mass vaccination sites if states wanted to build them. 

Last week, Health and Human Services Secretary Alex Azar said Operation Warp Speed, the federal COVID-19 vaccine and therapeutics initiative, was accelerating its partnership with pharmacies to speed uptake, which experts say could boost distribution.

When vaccinations started in December, federal officials said they would ship the first doses of the vaccine by Pfizer and BioNTech to 636 vaccination sites across the country and the vaccine by Moderna to 3,285 U.S. locations. That was a steep decline from the tens of thousands of providers at 65,000 to 75,000 places that Trump administration officials had estimated as recently as October. The administration announced Tuesday that the number of administration sites has increased to 16,000 since officials began releasing more vaccines to pharmacies last week.

Azra Behlim, who oversees vaccine distribution for Vizient, a supply chain company that works with hospitals, said the solutions to the botched launch are “not all that glamorous” and involve simply sending the vaccines to more places or increasing staff at the limited places to which they were being shipped.

“It’s simple math,” she said.

Vying to help

The doctors’ offices where most people get health care and independent pharmacies are eager for a role in distribution. Most state health departments designated well-resourced hospitals as vaccination hubs, in part because states were tasked with enrolling providers on a tight deadline without much federal funding. 

States received $340 million for COVID-19 vaccines in two tranches in September and mid-December, about $1 per U.S. resident. The latest coronavirus relief package cleared by Congress provided another $8 billion. The first $3 billion of that was distributed in the last week of December. 

While states awaited more funding, the Trump administration emphasized that providers should enroll to give the vaccine because they could eventually bill insurance companies and patients for an “administration fee.”

“The sense has been that if providers administer the vaccine, they can bill for it, and that’s the compensation mechanism. But it’s very difficult for providers to gear up and scale up without some kind of front-end funding,” said Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials.

Public health departments and hospital groups say it’s challenging to ramp up vaccinations at the same time that hospitalizations have surged. 

“The health care workforce is incredibly strained and stretched right now because they are caring for people in hospitals that are overrun,” said Steven Stack, commissioner of the Kentucky Department for Public Health. “There’s not a lot of idle health care workers to draw upon.”

Powerful hospital groups have expressed uncertainty about how much responsibility they have to vaccinate people beyond their own staff. 

“Hospitals are committed to be a central part of the vaccination effort, but hospitals alone cannot do it, especially as we care for burgeoning numbers of critically ill COVID-19 patients, and struggle to maintain sufficient staffing work to have enough personal protective equipment and other resources,” Richard Pollack, president of the American Hospital Association, wrote in a letter to Azar on Jan. 7. “We are aware that large chain pharmacies also have been enlisted, but it would be good to have a clear idea of precisely which organizations are engaged and for each to know what is expected of them to get to herd immunity.”

Federation of American Hospitals President Chip Kahn said it should be mostly up to pharmacies, not hospitals, to vaccinate non-hospital health care workers and the general public.

The administration’s recent approach also led to hospital administrators with little contact with patients getting doses before front-line health care workers not affiliated with major health care systems. With limited supplies, it made sense to only ship the vaccine to places like big hospitals, Stack said.

“In an ideal world, I would rather have adequate vaccines to say it’s going to every pharmacy and every doctor’s office and every hospital that wants it,” said Stack. “But there’s so little of it that if you sprinkle it like pixie dust all over the state, a site may only get five doses per week, [and] nobody knows who may or may not have vaccine. So you have a market failure.”

Uncertain shipments from Operation Warp Speed led some hospitals to hold back doses for fear of not getting out a second booster shot. Inconsistent shipments have continued weeks into the vaccination program, according to public health departments in Vermont and Tennessee. 

Unanswered questions

As vaccinators, public health staff and state governors grapple with these complexities, it’s not clear who is in charge of answering questions. 

Providers have unanswered questions about how soon hospitals can move through priority groups and how they will get enough ancillary supplies to keep giving six doses that can be squeezed from Pfizer vials instead of the previously predicted five. 

Providers say they couldn’t get clear answers from state health departments, and state health departments say they can’t get through to Operation Warp Speed. 

“Our communications with Operation Warp Speed have not been as strong as with CDC, but a lot of times CDC didn’t even know the details of what was going on on the Warp Speed side of things,” Plescia said. “CDC often didn’t have the full details on allocation numbers.”

Major hospitals weren’t always able to reach Operation Warp Speed either. In the AHA’s letter to Azar, the group indicated that HHS is not having regular calls with stakeholders as it did with the distribution of the therapeutic remdesivir. 

“It is unclear who is responsible for answering questions,” Pollack wrote.