By Kate Masters

VM – Last month, Virginia received 285,725 doses of COVID-19 vaccine, shipping them to hospitals and local health departments over the past two weeks. But less than a quarter of those vaccines — 54,295 — had actually been administered as of the new year’s eve, according to data from the state Department of Health.

Though some of that has been attributed to a lag in reporting the vaccinations, logistical challenges and confusion about where some health care providers — who are prioritized under the state’s plan —  can receive the doses have contributed to the delay.

What it means, however, is that Virginia’s hospitals and local health departments anticipate that some medical workers and long-term care residents — the first priority groups in the state’s multi-phase COVID-19 vaccine campaign — may not start the immunization process until the end of January or later.

The news comes as Virginia, like the rest of the country, experiences a slower-than-anticipated vaccine rollout presaged by lower allotments than anticipated from the federal government. In early December, the Virginia Department of Health announced the state would receive nearly half a million doses by the end of the year — enough to vaccinate nearly all of its health care workers and long-term care residents.

But just two weeks later, VDH revised the estimate, saying the state would receive more than 100,000 fewer doses than originally anticipated. Christy Gray, director of the agency’s division of immunization, said in a Wednesday news briefing that the initial — and incorrect — federal projections were based off inaccurate calculations of how many total doses were being produced, not accounting for quality control and shipping procedures.

Earlier this month, McClatchy’s Washington, D.C. bureau reported that the problem lay with the Pentagon system developed to track vaccine distribution. As a result, the federal government told many states they would receive more doses of vaccine in the coming weeks than were actually available.

The revised estimates came as a disappointment to both health care workers and a populace eagerly anticipating the vaccine as a light at the end of a nearly 10-month-long pandemic. But data from VDH also shows there’s been a lag in administering the doses of vaccine that the state has already received.

Gray said Wednesday that part of the gap in the number of doses the state has received and how many have been administered could be attributed to delayed reporting. But some health care providers said the disparity was too large to blame fully on a lag in submitting data to the state’s dashboard.

“Maybe it’s underreporting to some degree who’s been vaccinated,” said Dr. Costi Sifri, a professor of medicine and director of hospital epidemiology and infection prevention and control for UVA Health. “But I don’t think it’s enough to account for this large gap. I think it’s a reflection that the vaccine has been distributed but just has not made it into people’s arms yet.”

‘Quite a significant frustration’

It’s still unclear if a delayed first phase will impact projections for the rest of the state. In late November, Gov. Ralph Northam predicted that everyone in Virginia could be vaccinated by early to mid-summer. While vaccine delivery hasn’t matched federal goals, Gray said Wednesday that there were too many conflicting variables to make a prediction — including new immunizations that could enter the marketplace (the United Kingdom just approved a new vaccine from Oxford University/AstraZeneca, which is less expensive and easier to distribute than current competitors from Pfizer and Moderna).

But Sifri said the slow rollout has been a “significant challenge, and quite a significant frustration” to many providers in the roughly two and a half weeks since Virginia received its first shipment of vaccines. Some of the unadministered doses are part of an allotment that the state has reserved for a national pharmacy partnership with CVS and Walgreens. The chains are tasked with administering vaccines to residents and staff members at nursing homes and assisted care facilities over the next several weeks.

VDH couldn’t confirm how many of the state’s current 285,725 doses have gone to long-term care facilities. But Gray said Wednesday that the state was tasked with pulling vaccines from its overall allocation to cover the sites — a process that took roughly two weeks. Nursing homes began to administer vaccinations on Monday, and she said the process would likely take another three to four weeks before the partnership moved on to assisted living facilities. By that time, the partnership would also begin to administer second doses of the vaccine at facilities it already visited.

But part of the delay can also be chalked up to resources. The change in federal estimates means that hospital systems are receiving fewer doses than initially anticipated. Sifri said UVA identified 12,000 employees within its health system who work face-to-face with patients. Administrators later pared down the list to roughly 4,500 providers at the highest risk of exposure to COVID-19, including emergency room workers and physicians such as anesthesiologists, who come into close contact with aerosols while performing procedures.

“We were then told that it was too generous an estimate,” Sifri said. UVA reduced the list again to 3,000 employees and received an initial allocation of 2,925 Pfizer vaccines on Dec. 15. The system received another 2,500 Moderna vaccines on Dec. 22, and Sifri said more are expected later this week.

Fewer vaccines means fewer providers can be immunized. But Sifri pointed out that the hospital system is also scheduling the shots at a time when it’s managing more COVID-19 cases than at any other point in the pandemic. Roughly 50 to 65 patients are hospitalized with the disease on any given day. UVA’s nursing team is short-staffed, and the system is currently postponing elective procedures to free up resources.

“People are out on quarantine or isolation because they’ve been exposed,” he said. “We’re doing this essentially in the nexus of the storm. And the same people who are needed to provide vaccine are the same people who are needed to provide patient care.”

As of Dec. 27, UVA can schedule 5,300 vaccine appointments a week and plans to expand that capacity. Of the 5,425 doses the system received since Dec. 15, it’s delivered 3,130 of them, with more than 7,000 appointments scheduled over the next few weeks.

But in addition to roughly 5,000 more employees who don’t work in clinical settings, the hospital system is anticipating it will assist in vaccinating anywhere from 6,000 to 10,000 community providers who aren’t affiliated with UVA or nearby Sentara Healthcare.

“I didn’t hear a lot of cautionary voices, I’d say,” Sifri said, referring to the state’s initial projection of nearly half a million doses and hopes that all health care providers might be vaccinated by the end of the year. “If I’d been interviewed at that time, I would have said that our ability to vaccinate all health care workers at UVA by the end of the year was simply not going to be possible, even with a best-case scenario in our vaccine allocation.”

Confusion on where to turn

Community providers across Virginia have also described widespread confusion over where they should turn for a vaccine.

While UVA is planning to help with immunizing outside medical workers, the Richmond-Henrico Health District is planning to take on the responsibility for local employees who aren’t affiliated with a larger health system, Deputy Director Dr. Melissa Viray said Wednesday.

An early document from INOVA health system in Northern Virginia, dated Dec. 10, also seemed to indicate that independent providers would be offered vaccine appointments through INOVA in rounds two and three of the state’s “Phase 1a.” Round Two, the system wrote, would include “patient-facing positions in affiliate or joint venture facilities and community partners.”

But spokeswoman Tracy Connell later said in an email that “health care workers not affiliated with any hospital system in the region, including independent/community providers and their office staff, should contact their local health department to coordinate vaccine distribution.” Many local doctors said the message was finally conveyed not through INOVA or the Fairfax County Health Department, but through communications from their professional associations, including the Virginia chapter of the American Academy of Pediatrics.

“I think that’s part of why we were so frustrated and angry,” said Dr. Ann Tannous, a pediatrician with The Kidz Docs in Alexandria. Other community providers said they reached out directly to INOVA and were told not to expect a vaccine until the end of January.

Viray said the initial uncertainty has likely contributed to some delays in administering the vaccine. Her department received its initial shipment of Moderna vaccine last week and is still encouraging independent practitioners to reach out to the health district for appointments. Another hurdle has been registering employers through the Vaccine Administration Management System (or VAMS), an optional application from the U.S. Centers of Disease Control and Prevention. The system allows independent practices to upload employee information so local health departments can reach out to them directly to schedule an immunization.

“I think some of the challenges have been a combination of logistics and getting the ball rolling by bringing partners online,” Viray said. The department is also in the process of distributing vaccines to urgent care centers and safety net health clinics so they can vaccinate their own staff.

But the district has struggled to fill slots in some of its early vaccination clinics for community providers. Viray said it’s possible that vaccine hesitancy could be playing a role, but said it’s also likely that many doctors are still contacting their local hospitals or simply not reaching out at all. At times, it’s led to inconsistencies in who receives the vaccine and when.

Dr. Kristen Powell, a private pediatrician in Richmond, said she was able to receive a vaccine at Henrico Doctors’ Hospital earlier this month. Nurse practitioners at her practice, on the other hand, were turned away at Bon Secours St. Mary’s Hospital because they weren’t employees of the health system.

“I think it just means that some providers aren’t reaching out to us,” Viray said. “Because they don’t know to reach out to us. And it means we need to do a better job of getting it out there that we can connect them with vaccinations.”

Both VDH and local health departments are hopeful that immunization numbers will increase along with shipments of the vaccine. Viray said she’s impressed that the state has already delivered more than 54,000 doses within a roughly two-week period. But Sifri said that widespread vaccination — especially as the state expands access to medically vulnerable residents and essential workers — will require extensive resources, from staffing to space to education.

“It seems to me like Operation Warp Speed produced a lot of vaccines, but the final mile was not part of the administration’s plan,” he said. “There was this anticipation that local health departments, state health departments and hospitals would complete that job without funding and without direction. And that’s, in essence, anticipating some kind of magic wand.”