Why is the vaccination process so complicated/slow?

The Quarantine Zone
#1

I am assuming someone familiar with logistics or somesuch will be able to explain why the pace of vaccinations has been so slow. I’m hoping to avoid too much political criticism.

In this morning’s paper, they talked about a huge percentage (well over half) of IL longterm care facility residents not having been vaccinated yet. I would’ve thought that was the lowest of the low-hanging fruit. We know who they are, they are in one place, there are medical personnel around… If we can’t efficiently jab those folk, how the hell will we get everyone else?

I spoke w/ a friend who works in a hospital and had been vaccinated. She described a very complex multistep procedure to get vaccinated at work, involving several different people entering info into computers at various steps. I well understand the interest in tracing which batches go into which arms. But this hospital employee is in her place of employment, with her employment issued chipped and magstripped photo-ID.

I see things in the paper about old folks waiting in parking lots overnight. I understand that some set of folk might have challenges dealing w/ computer/app scheduling, but again, why can’t a system be set up having people apply - either by phone or computer, and then scheduling them to come in 1 hour bands reflecting the pace at which vaccinations can be given?

As a child of the 60s, I can remember being lined up in school to get our shots. I know the decision was made to not do kids first, but I’d think other group settings could be identified. I’m reading that it isn’t solely an availability issue. Instead, doses are available, but not administered.

And why is so much care needed to identify people - more than to vote? My friend said her ID was checked several times. What is the real harm of people presenting incorrect ID and doses going into the wrong arms?

I’m not trying to get into a political debate. And I’m not whining about ME not getting it sooner. I’ve kept safe til now, and I’ll get it when I get it. I’m just trying to understand why this is so complicated and slow.

#2

Part of the issue is that you need to take two shots within a certain amount of time. You do not want to lose track of who recieved the first shot and the date it happened. You don’t want people coming in too early or too late for the second shot. This adds to the complexity and there is an issue that older people are first in line and getting them to coordinate two separate appointments can be quite challenging as they may need travel arrangements or may not be able to physically stand or wait in long lines.

#3

But how does that apply to folk in longterm care, or hospital employees?

I’m wondering if this is a situation where they set up a VERY ROBUST procedure in order to accommodate the most difficult cases, but then are overly delaying/complicating matters by applying those robust procedures to EVERYONE.

#4

That part has been getting more and more common in hospital settings over the last decade or two. One of the doctors I go to gives you a hospital type wristband when you walk in. Everyone that comes into the room either verifies the name on your wristband or pulls up your chart and has you confirm your name or DOB to make sure they’re talking to the right person. No one just assumes the person in the room is the person that they expect to be in the room.
Hell, the last time I gave blood I had to verify my name, DOB and gender 4 times, including twice in about 30 seconds as the person, I assume, flipped from one screen to the next (or maybe she was starting over, I don’t actually know).

I don’t want to compare this to voting so we can keep the politics out of it. I think we’re just in a day and age where medical mistakes can not just be a huge health risk, but can quickly become regional or national headlines. Imagine them getting your name wrong and not being able to get your second shot or them trying to get you to come in for a third. Imagine finding out grandma got 3 or 4 shots and the fallout if you let the local news know about it.

The fact that the vaccines are scare enough that they have the have the ‘luxury’ to take their time might play into it as well. I have to imagine if a drug company suddenly handed the US 700m doses, getting shots into arms might take priority over making sure everything is documented to this degree.

#5

It’s also worth rembering that each patient needs to be distanced from all the others after all some of them might be symptomatic carriers, not just in line for the jab - but also for a period of time afterwards to ensure there is no allergic reaction - speaking of which, every site also needs to have immune staff available to deal with any possible allergic reaction and I would also expect that access to emergency treatment in an I.C.U would also need to be available.

Reports on the news suggests the post vaccination clearance time is around 30 minutes - so if you have a site doing 30 jabs a minute, you will need up to 900 socially distanced places on the facility outflow - chances are there will be congestion issues and a certain amount of backing up both on the ingoing queue and the outgoing queue.

#6

If we’re talking about the Pfizer vaccine, there are restrictions on how you can use it. I’m going to quote the UK rules and assume the US rules are the same (because they will be based on the same sponsor application data). We already know it has to be stored at -80C:

• Transit of the undiluted product at 2-8 degree Centigrade can occur either in two
journeys each up to 6 hours or, where there are real deployment needs, for a
maximum of 12 hours in one sitting. These times are to be taken within the 120
hour shelf life [at 2-8C, after thawing].
• The undiluted product can be held at room temperature below 25 degrees
Centigrade for up to two hours prior to dilution.
• The product can be diluted at room temperature less than 25 degrees Centigrade
using sterile unpreserved 0.9 percent sodium chloride and in line with the
healthcare professional information supplied by the company
• The diluted product can be used within 6 hours of dilution and then must be
discarded. Diluted product cannot be transported.

My bold, source.

The thawed vaccine must be diluted in its original vial with 1.8 mL sodium chloride 9 mg/mL (0.9%) solution for injection, using a 21 gauge or narrower needle and aseptic techniques.

NOT my bold.

After dilution, the vial contains 5 doses of 0.3 mL. Withdraw the required 0.3 mL dose of diluted vaccine using a sterile needle and syringe and administer. Vial volume was optimized to reliably obtain 5 doses regardless of syringe type used as most syringe and needle combinations require withdrawal of excess volume in order to ensure the full 0.3 mL dose of vaccine can be administered. When low deadvolume syringes and/or needles are used, the amount remaining in the vial after 5 doses have been extracted may be sufficient for an additional (sixth) dose. Care should be taken to ensure a full 0.3 mL will be administered to the subject and that all doses from a single prepared vial are administered within 6 hours of the time of dilution. Where a full 0.3 mL dose cannot be extracted the contents should be discarded.
Any unused vaccine should be discarded 6 hours after dilution. The vaccine should not be shipped (transported) by motor vehicle after dilution away from the site of dilution. Any shipping (transportation) by motor vehicle after dilution of the vial is at the risk of the Health Care Professional.

Events of anaphylaxis have been reported. Appropriate medical treatment and supervision should
always be readily available in case of an anaphylactic reaction following the administration of the
vaccine.
Close observation for at least 15 minutes is recommended following vaccination.

Source

So: shipping diluted vaccine is a no-no (actually, any shipping is a problem); dilution should be done aseptically - so ideally not in an old folks home; and for efficient use of vials you need your patients supplied in groups of 5 (or 6). It just isn’t an easy task to take the vaccine to care home patients.

j

#7

It’s behind a paywall for most, but this came out from the New York Times yesterday:

How West Virginia Became a U.S. Leader in Vaccine Rollout

WV also ranks well on not having appointments cancelled, as happened to my 94 year old mother on Saturday. In WV, they don’t give far-out appointments, instead waiting until they are sure they have the vaccine before giving one.

The article explains a big weakness of the West Virginia system – telephone numbers that are continually busy with people calling to see what has opened up. But this is better system then where only the computer literate have a chance.

As for hospital procedures, I don’t think we can judge without having a whole lot of information. While some delays are a sign of intelligent caring, others could be bad defensive medicine.

The article notes that the planning is done at an in-person location, despite COVID risk, because work at home leads to a lower quality of staff work. I know that this is controversial, but I personally think subtle process defects are missed when a team works remotely.

#8

UCHealth is planning to give 10,000 vaccinations over a weekend in the parking lot of Coors Field (the Colorado Rockies baseball stadium). The did a test run recently and gave 1,000 vaccinations in 2 hours. The lines to get into the parking lot are longer on a game day than what’s shown in the article photos.

It is a drive up treatment with multiple tents delivering the vaccine simultaneously. People then are instructed to pull over and wait for 15 minutes. If they develop any problems they should honk and flash their lights, and roving medical staff will come to over.

This is in a parking lot that can hold 4,300 cars, and they expect to be able to do 5-8,000 doses per day. The limiting factor is vaccine availability. Setting up something like this obviously takes coordination, people, and money.

The point being, UCHealth is a good hospital, but I don’t think they have any magical logistic dust that enables them to do something other places can’t. I suspect lots of the problems being encountered are the result of rushing things into place, and not knowing where the choke points will be. Hopefully over the next few weeks most places will sort out those problems.

#9

There is nothing about a long term care facility that would make it hard to do an aseptic dilution. Aseptic is not the same as a sterile operating field.

I could do an aseptic procedure in your kitchen, bathroom, bedroom or mine. I have done aseptic injections in cars in parking lots.

This is an example of why medically trained professionals are needed to do the vaccinating. It is more than being willing to jab something in someone’s arm.

#10

I’m glad WV seems to be doing well. I guess it helps that there are no huge cities, but OTOH, I suspect some folk are hard to reach.

That’s the kind of creative thinking that I would imagine.

I suspect the real problem was a lack of guidance by the feds, leaving it up to the states - many of which shat the bed. Heard on the radio about problems in The Villages in Florida. Now if there were EVER an easy population to reach…

Since they are fucking up so much getting this stuff into bodies, I think they should just focus on jabbing as many easy folk as possible, whatever their age/risk…

#11

Here’s what appears to be a NHS template SOP for vaccine prep. WARNING - when I clicked on this it downloaded the word document: https://www.sps.nhs.uk/wp-content/uploads/2020/12/VH8-Preparation-of-Pfizer-BioNTech-COVID-19-Vaccine-Syringes-for-Administration-Issue-1.2-03.12.20.docx

I guess you could do that in a care home (and judging from TV news, it is being done). But the question wasn’t Why is the process impossible? It was: Why is it complicated/slow?.This prep is much better suited to being performed in a single location in a dedicated space in a GP surgery*, rather than in whatever space is available in a care home - and then move on to the next care home with a different set-up and adapt the process to a space there.

Absolutely. Many vaccinators are inexperienced, having been rushed into the role through sheer need. It doesn’t help.

j

(*) - in the UK roll-out is currently primarily through GP surgeries. Dedicated vaccination centres are being set up - but I presume it is not the role of vaccination centres to remotely service care homes.

#12

An additional bottleneck is trying to keep the vaccination process fair to everyone, but with classes of people who should receive priority. So a system has to be set up to verify what class a particular person is in, which has to be doubly verified at the time of vaccination. And since there aren’t enough vaccine doses, ANOTHER system has to be set up (usually a lottery) to rank people within a class.

By the way, try a web search on “covid vaccine line jumping”. If this gets out of hand, people will lose trust in the fairness of the system and things could get even worse.

#13

There are two separate issues here, with two separate causes: It’s slow and it’s complicated. It’s slow mostly because we just don’t have the doses. It takes time to manufacture the vaccine, and efficient planning won’t change that. And it’s complicated because it’s something we’ve never really done before, and so everyone who’s doing it is figuring out how.

#14

My father got his first dose yesterday. It was a little convoluted getting him signed up but after that - he chose a walk-in rather than drive through vaccination - he said it was a little tedious but efficient.

#15

i hear you. But I’m wondering if the efforts to try to reduce ALL inequities, is unreasonably detracting from efficiency. Like I said, go to places where there are likely to be large concentrations of old/frail people and “essential” workers, ad jab as many folk as you have doses for, w/o overly worrying whether someone “jumps the line.”

And if someone is really old/frail/needy - provide some framework to enable them to participate.

But my impressio is that seeking perfect equity is undesirably impacting efficiency.

Yeah, there is some element of that. But my understanding is that only a fraction of the existing doses have been administered. So it isn’t solely a supply issue.

And we (and other nations) HAVE administered large scale health initiatives, and logistics and record keeping have been HUGE industries for some time.

#16

True but generally not in the middle of a pandemic. I bet planning and staffing are a bit more of a nightmare at the moment in some places.

#17

This has become a real issue for my mother - no working computer, zero internet access, no e-mail*. The only way to sign-up in her county (where I do not live) is online. Period. I’ve tried calling for additional info - can’t get through. I’ve tried e-mailing detailing the problems and asking for advice - get a form response to sign up online. She has no regular physician as she only has Medicare Part A and is not eligible for MediCal (long story - she’s 78 and hasn’t seen a doctor in years, drives me crazy).

Basically the only way to get her in the system, any system even an inadequate county one, is to sign her up under my e-mail and act as a gatekeeper. Which is fine, but I’ve seen mindless bureaucratic blowback from that sort of thing before. Thankfully I’ll probably get vaccinated through my job first, or failing that my HMO second and so shouldn’t have to worry about conflicts between different county government efforts. But it’s frustrating.

  • By her choice - she’s had computers and sparsely used e-mail accounts in the past but can’t risk typing much anymore due to degenerative disc disease complications and won’t let me buy her a new one. Nor will she let me purchase a smartphone or any other access. She even refuses to get any cable TV despite my offer to foot the bill - it’s 3-4 broadcast stations on rabbit ears or nothing :roll_eyes:. Her stubborn luddite tendencies are a pain in my ass.
#18

Must be frustrating for you. And the govt SHOULD allow a phone option. But it would be a weird example of refusal to adopt technology potentially killing you.

Takes an interesting person to stand so strongly to one’s position in the face of such obstacles.

#19

My 92 year old mother, who lives at home and not in a longterm care home, cannot get an appointment, nor can she even get anybody to tell her if or when she might get an appointment.

#20

Oof. You apparently can sign up by phone here but the news has warned everyone that the phone lives are being overwhelmed.