Vaccine Delivery

Massachusetts had received 875,825 doses of COVID-19 vaccine, but had administered only 442,703 (51%) as of 6AM on January 26.

How could it be that the life sciences hub of the world appears to be lagging in administration of vaccines? I am hearing from many who want the vaccine but have been unable to get the vaccine, so the thought of vaccines sitting in refrigerators unused is deeply troubling.

Massachusetts is not unique and there is a plausible explanation for the apparent lag. According to the Center for Disease Control, nationwide 44.4 million doses of vaccine had been distributed to states, but only 23.7 million (53%) had been administered. All over the country, roughly half of the doses delivered have been administered.

The apparent explanation for this national state of affairs is that many providers seek to assure that they will be able to comply with available vaccine protocols as approved by the FDA. Those protocols require two doses spaced by 3 weeks for the Pfizer vaccine and 4 weeks for the Moderna vaccine. Many providers administer one dose and hold the second to assure that they will be able to comply with the protocols. (While some have urged deviation from the protocols, the FDA has been taken the view that deviation is not supported by the available evidence.)

Since vaccine administration started only a few weeks ago (the first reports date from December 14), of the 19.9 million who have received at least one dose of vaccine, only 3.5 million have received a second dose. So, one would expect that hospitals and other providers across the country might be holding as many as 16.4 million doses (19.9 minus 3.5) for the purpose of providing a second dose. Counting this holdback together with the vaccines administered, 90% of the vaccines distributed nationwide are accounted for.

There is another dynamic which helps account for the remaining 10%. The distribution data should be up to date, as the vaccine distribution is centrally controlled by the federal government. But the count of doses administered depends on all the various administration channels reporting back their activity. So, overall, the data are likely to somewhat understate the total amounts administered and exaggerate the gap in administration.

In summary, the vaccine distribution and administration data compiled nationally by the CDC give no reason to believe that there is a pattern of vaccine administration delays at the state level. We lack the visibility into state distribution systems to fully verify the interpretation offered here that second dose hold-backs and reporting delays account for most of the apparent administration lag in the national data. However, statistics gathered informally from several Boston area hospitals do solidly confirm the interpretation offered here.

There may be some delay within Massachusetts that cannot be explained by second dose holdbacks and reporting lags. According to the CDC tracker data, Massachusetts second dose holdback would be 310,552 (total dosed of 376,313 less second dosed of 65,761). This holdback, added to the 442,703 administered accounts, for 753,255 out of 875,825 received or 86% — a little below the 90% accounted for nationwide. This difference is too small to interpret with confidence, but we should acknowledge it. Some hospitals surveyed do admit having small overages attributable to vaccine refusal on the part of some of their employees.

States range widely in their percentage of vaccines administered. A few are near the 80% level — North Dakota, South Dakota, New Mexico, West Virginia. These states have risen to the top of rankings by assuming that second doses will be available in the supply line.

For example, West Virginia is the state with the highest ratio of doses administered to population. West Virginia has received 278,400 doses and has administered 210,492 or 75.6% of them. 167,660 West Virginians have received one dose, but only 42,821 have received two doses, meaning that 124,839 need a second dose, while their available stockpile is only 67,908.

Running somewhat ahead of the supply line may be a reasonable strategy. West Virginia is holding a roughly 50% buffer for supply delays. That may be adequate to assure a high probability that everyone will get a timely second dose. On the other hand, since the federal government is sticking with its plan of allocating vaccines by population, although West Virginia’s approach meant more people got vaccine in the first month, West Virginia’s approach may not actually result in more people getting a first dose in the first two months. States that have been holding second doses will be able to use new supply for new patients, but West Virginia will have to use new supply to catch up on second doses.

Understanding these supply pipeline effects is important to understanding the situation in Massachusetts. Massachusetts has been one of the last states to open vaccination to seniors. Before yesterday’s announcement by the administration, Massachusetts was one of only 5 states that had not opened up to senior citizens generally.

This has created understandable consternation. But because its hospitals have been stocking second doses, Massachusetts will be able to use more of incoming supply for new doses and within weeks will likely be abreast of other states in the actual number of seniors vaccinated.

Like most states, Massachusetts chose to target the first vaccination wave of vaccination narrowly, consistent with guidance from the Centers for Disease Control: The first wave of people to receive vaccines would include health care workers, first responders and those living in group residential settings, like nursing homes.

Those involved in responding to COVID-19 are at especially high risk of being exposed to COVID-19. When they are exposed, they need to quarantine like anyone else and the result can be crippling absenteeism. So, given a scarcity of vaccines and huge pressure on the health care system, targeting health care workers and first responders makes sense from an operational standpoint as well as a fairness standpoint.

Those working and living in group residential settings, whether nursing homes or prisons, are at enormous risk by virtue of their constant close contact with many others. Last year before we had adequate testing and personal protective equipment available, we saw overwhelming infections and high death rates in several nursing facilities in Massachusetts.

For those high risk populations, Massachusetts may be doing quite well. Massachusetts is one of the first 8 states to have administered over 100,000 doses in long term care facilities and all the other 7 are much larger states (California, Texas, Florida, Illinois, Ohio, Pennsylvania, New York). (West Virginia, the state with the highest overall share of population vaccinated, has not supplied data as to how many are vaccinated in long term care.)

States running ahead of their supply line, or less focused on meeting their initially stated priorities, could open to non-institutionalized seniors sooner than Massachusetts. But having reserved much of its second dose supply, Massachusetts is well positioned to catch up in dosing seniors. Massachusetts is now transitioning to Phase II and opening up vaccination to its non-institutionalized older citizens and also standing up more vaccination sites, including more mass vaccination sites.

An additional measure that would give great comfort and could accelerate distribution of vaccines would be a pre-registration system available to all members of the public. West Virginia encourages all citizens to pre-register for real time updates and to facilitate appointment scheduling when supplies allow vaccination within eligibility category. West Virginia also offers a central vaccination hotline open 6 days a week.

We can hope that we will see more system improvements and that our administered-as-percent-of-delivered statistic will improve over the coming weeks. We will certainly be watching this number closely. All involved are passionately concerned that as many as possible receive the protection of vaccination as soon as possible.

As we open distribution channels wider to the roughly one million Massachusetts senior citizens, we need to work to assure that populations who are at higher risk of exposure are not crowded out of the process — for example, workers in grocery stores.

All statistics quoted above in this post were retrieved on January 26, 2021.

Update on January 29: The state has recently changed its distribution management system to put all vaccinators on a shorter leash, disallowing the reservation of second doses and requiring frequent accounting for supplies and amounts actually administered.  The state is now taking unused vaccines back and reallocating them to other vaccinators.  The state has also brought in supply chain management experts to make sure that the new process is working as effectively as possible. We should see the amount of idle vaccine sitting in the supply chain diminish substantially.

A note about an alternative theory of the numbers:

An early version of this post developed an argument that Massachusetts’ high share of unadministered vaccines was due to the the fragmentation of its delivery systems which makes it more difficult to reallocate unused supply. Comments from my colleague Senator Cindy Friedman pushed me to look at the national data with the second dose constraint in mind. That second look forced me to reframe the argument of the post. As argued above, the formal national data and the informal local data are both completely consistent with the second-dose-holdback explanation of the numbers.

Additionally, a quick survey of practices in other states is not consistent with my first theory that by partnering with many providers, as opposed to standing up a centralized state-run delivery system, Massachusetts had created a siloed process that made unused vaccine doses hard to reallocate. The chart below shows the result of an impressionistic review of the websites of other states. The states selected are those with the highest ratios of vaccines administered to vaccines delivered on the New York Times compilation as of January 27 at 8AM.

Almost all of those high rate states are using a siloed approach like that of Massachusetts, so the distribution model does not account for the difference in vaccine administration rates. The better explanation is policy choices these states have made to open broader eligibility earlier and not to hold back second doses to assure supply.

Incidentally, the quality of the websites for public information varies widely in these top 12 states. A a couple have friendly pre-registration systems and a couple are completely opaque. But most provide lists of providers (possibly, like Massachusetts, in a map format) and leave members of the public the challenge of scrounging for available appointments on a list where most providers do not have available appointments. Many members of the public may belong to a group that will receive direct notice in some other way — from their employer or health care system.

Impressionistic review of web information about vaccine distribution models in the 12 states with the highest rates of vaccine administration.

State	Information	Administration
North Dakota	Map with scheduling links	Multiple small outlets
New Mexico	Preregistration for notice of availability and scheduling; hotline.	Multiple small outlets
West Virginia	Preregistration for notice of availability/scheduling; hotline.	Multiple small outlets plus dedicated community clinics
South Dakota	Map with scheduling links	Multiple small outlets
Connecticut	Map with scheduling links; required central registration for scheduling	Multiple small outlets
Washington, D.C.	Sign up for alerts, but scheduling through providers	Multiple small outlets
Montana	Links to local county health departments.	Multiple small outlets
Colorado	Map with scheduling links	Multiple small outlets
Oklahoma	Pregistration for notice of availability/scheduling	Multiple small outlets
Utah	Preregistration with notice through district health departments	Dedicated county clinics
South Carolina	Map with scheduling links	Multiple small outlets
New York	Central eligibility screening and scheduling portal for state clinics.	Multiple small outlets and state operated facilities