Like many older Americans, my father wanted to receive his COVID-19 vaccine, but he found the application process for an appointment frustratingly complicated. In his home state, Oklahoma, there were several websites. It was not clear, however, whether each site offered the same or different commitments. And updating the page at the right time to get a coveted spot seemed impossible. “I have my annual checkup tomorrow,” he told me. “Can’t I just get the vaccine from my doctor?”
Unfortunately, the answer was no. Americans are used to thinking of doctors’ offices as the place to go for vaccines, but the process of distributing the COVID-19 vaccine has been largely ignored by primary care physicians. This is something that doctors themselves have been frustrated recently. In a survey of primary care physicians, 32 percent said they were not included in any state or regional planning and had no idea when or whether they would receive vaccines for their patients. Years of research suggest, however, that primary care physicians are the most reliable source of information on vaccines and vaccine safety. A 2015 survey of Oklahoma residents, for example, found that 81% trusted their healthcare providers for health information – compared to 24% who said the Internet was a reliable source. (Presumably, your daughters writing on the Internet has a higher rating.)
The exclusion of primary care physicians is just one of many ways in which the launch of a pandemic vaccine differs from the normal, daily process of vaccinating people. We have a process that we know works – experts I spoke to described the United States’ normal vaccination system as one of the best in the world. So, why not use it in a pandemic?
Because everything – from vaccine logistics to patients themselves – is different.
There are a number of reasons why people like my dad can’t just go to the primary care doctor for a COVID-19 vaccine, said Julie Swann, professor and head of the department of industrial and systems engineering at North Carolina State University. The storage and distribution needs of the different vaccines, especially the requirements for ultra-cold storage, are a big part of this. Initially, the Food and Drug Administration said that the Pfizer vaccine had to be stored between -112 degrees Fahrenheit and -76 degrees Fahrenheit – something most doctors’ offices could not do. Nor do they have the ability to vaccinate as many people a day as public health experts say is necessary to fight the virus effectively.
“What is the maximum number of doses that the doctor’s office will distribute in a single day?” said Swann. “Even if you have more of these individual doctors, if you have 10 mass vaccination sites and each giving 5,000 injections per day, how many doctors would you need if they gave only 100 [vaccinations] per day?”
Likewise, there are time limits on how quickly each vial of vaccine should be used once opened, said Julie Murphy, senior administrator at the nonprofit Immunization Action Coalition. “We are used to single-dose vials or pre-filled syringes in the refrigerator,” she said. Even when other vaccines come in multi-dose vials, they are stabilized with preservatives that make them work well in a primary care setting, where you are likely to take five doses in a few days, but not necessarily in the six time window according to demand for COVID vaccines without preservatives.
The absence of primary care physicians is not the only way in which the distribution of the COVID vaccine differs from normal. For example, vaccines are generally not free to the public or assigned to states by the federal government. There are also no reporting requirements that require anyone who distributes vaccines to regularly send information about the supplies left in their inventory. The distribution process has changed in several ways – even from one state to another or from one municipality to another. And while there are many ways to get the vaccine wrong, experts say there is also no single way to do it the right way.
In fact, it is important to remember that the distribution of the vaccine is unlike anything we’ve done before, said Dr. Yvonne Maldonado, professor of pediatric infectious diseases at Stanford University. No one has ever tried to eliminate a pandemic in real time like this. The closest analogy, she said, is probably the elimination of smallpox, and it did not have such a short time limit. It is no wonder, then, that what we are doing now does not always look like what we have done in the past.
But that does not mean that experts are ignoring the lessons of previous vaccination campaigns. In fact, during the H1N1 pandemic, Swann was part of a team that modeled pandemic supply chains for the Centers for Disease Control and Prevention. One of the things she did was to analyze which types of vaccine distribution sites were most effective. “The states that sent the most vaccine to places that were easier for people to access had higher rates of vaccine administration for high-risk adults.” When she talks about places that are easier to access, she is referring to pharmacies.
Open after hours and on weekends and without the need for a prior relationship with the patient, pharmacies have proven to be very efficient in getting vaccines to more people, more quickly. Before the H1N1 pandemic, however, only a few states allowed pharmacists to administer vaccines. The lessons learned from that pandemic ended up changing laws across the country, and pharmacies are now not only a normal place to get a flu vaccine, but also a large part of the response to the COVID-19 vaccine.
However, mass vaccination sites can leave a gap in the confidence of those who are vaccinated. They are good at effectively vaccinating many people quickly – not necessarily good at vaccinating Worldwide. When the Kaiser Family Foundation conducted a survey of Americans on COVID-19 vaccines in December, they found that 39% were taking a “wait and see” approach – they did not want to be among the first and fastest to receive the vaccine . This same group, however, showed a lot of confidence in their doctors to tell them which vaccine was safe and when it was safe to get it – 87% of waiters trusted their own health care providers. Primary care physicians are likely to become an important part of the COVID vaccination later, said Murphy, when vaccinating more people means “vaccinating hesitant people”.
In the meantime, though, primary care offices can help with another pandemic vaccination problem – updating Americans about the daily vaccines they may have missed in the past year. “We have been monitoring a drop in immunization rates across all age groups for all other diseases,” said Murphy. “It is a serious concern.”
It is a pandemic, but your health is important in addition to contracting COVID. For older adults, having an annual physical exam – even if there is no winning vaccine dose waiting – is very important. So this is what my father did. And then, without being intimidated by his annoyance with the system, he made a separate appointment to receive his vaccine COVID-19.