If vaccine administration is lagging, why are hospitals, cities and states running out of shots?

The U.S. began administering COVID-19 vaccines Dec. 14, and roughly 47.2 million shots have been distributed to states as of Jan. 27, according to the CDC. About 24.7 million doses have been administered, or 52 percent of the total distributed. 

Yet states across the U.S. have been reporting that they're giving vaccines quicker than they're receiving them from the federal government, according to Politico, slowing down the overall effort to vaccinate the majority of Americans. 

New York City temporarily closed 15 vaccination sites from Jan. 21-24 because it wasn't getting enough vaccine doses to keep up with demand. But the state of New York has only administered about 60 percent of its vaccine supply, according to CDC data. 

Esmaeil Porsa, MD, CEO of Harris Health System in Houston, told The New York Times Jan. 23 that the health system's entire vaccine supply could be depleted because it isn't receiving enough vaccine doses. Yet the state of Texas has only administered about 57 percent of its vaccines as of Jan. 27. 

Some states, including Colorado and Oregon, have had to reduce the number of people eligible for the vaccines because demand is outpacing supply, Politico reported. But the CDC has reported that Colorado has administered only about 63 percent of its vaccine supply, and Oregon has administered about 52 percent as of Jan. 27. 

Why are states reporting that they're running out of vaccines, and urging the federal government to give them more, when the CDC is reporting that states have only administered about half to two-thirds of their vaccines? 

The answer lies in a number of factors involved in a complex distribution system, including lack of communication between the federal government and states, data lags and differing eligibility requirements among states. 

Lack of communication between federal government, states and providers

The federal government hasn't been informing states how many vaccine doses they will receive for the week, making it difficult to plan ahead. The confusion over supply has further complicated the vaccine distribution process, with some states not ordering up to their limits, Michael Pratt, a former spokesperson for HHS, told The Washington Post.

Communication from both state and federal governments has been inadequate in identifying who is eligible for vaccination and encouraging those individuals to actually get vaccinated, Macdonald DuBose, MD, chairman of the South Carolina Medical Association, told the Post.

Dr. George Rutherford, MD, an epidemiologist at the University of California San Francisco, said hospitals and the public health department in San Francisco experienced a shortage of vaccine doses, The New York Times reported

"It's a little hard for the city to understand exactly what's left over, what they need to do, where the holes are to fill," Dr. Rutherford told the Times.  

"I think what this really is, is a continuation of the fallout of the lack of a coordinated federal response," Grant Colfax, MD, director of health for the city and county of San Francisco, told the Times. "Basically cities and counties were left on our own to deal with this pandemic."

Data lags

Several states have reported that data lags and other technology-related issues have caused a discrepancy between the actual number of vaccines administered and the numbers shown on the CDC's vaccine tracker. 

California reported Jan. 20 that coding problems and data lags have hindered the state's efforts to accurately count and publicly report how many doses are administered daily. The state said it sometimes took up to 96 hours for a vaccine administered to appear in the state's immunization database. The database has forced some jurisdictions to reenter data multiple times because the system kicks them out, health officials told Gov. Gavin Newsom. 

North Carolina county health department officials said Jan. 15 they were having issues reporting the number of COVID-19 vaccines they administered because of difficulties with the state's new data system. Halifax County, N.C., reported issues accessing the system, called CVMS, and entering data, which made it appear the county administered fewer doses than it had. The county's health director, Bruce Robistow, said the county had actually exceeded its allocation and administered every dose it received, and it had to ask a neighboring hospital for more doses. The issue caused some counties in the state to receive fewer doses, as it appeared they still had plenty to administer. 

Texas is using the ImmTrac2 system as its main method of tracking the number of vaccines administered in the state, as well as to transfer vaccine data to the federal government. Some system users have claimed ImmTrac2 is time-consuming and sometimes requires providers to change their own software to transfer data. Rannon Ching, a pharmacist in Tarrytown, Texas, said that at one point around the holidays, the system failed to record 500 administered doses that had been entered into the registry.

HHS on Jan. 19 granted about $20 million in funding to help states improve tracking and sharing of vaccination data among healthcare providers. 

Lack of visibility

At present, the federal government does not have sufficient information on jurisdictions' vaccine needs and allotments, in part due to a lack of data and little collaboration between the new and old administrations, The New York Times reported.

"We don't have the visibility that we would hope to have into supply and allocations," Jeff Zients, the new White House COVID-19 response coordinator, said during a Jan. 20 media briefing.

Rochelle Walensky, MD, the new director of the CDC, told CNBC Jan. 24: "One of the biggest problems right now is, I can’t tell you how much vaccine we have, and if I can’t tell it to you, then I can’t tell it to the governors, and I can’t tell it to the state health officials."

This lack of visibility makes it difficult to tell how many doses are available for states week to week and how much of a  supply states  need to vaccinate people in eligible priority groups, according to The Washington Post. As a result, some areas face worsening vaccine supply shortages, while other areas struggle to use all their doses.

Second dose distinctions

Some states are stockpiling vaccines for second doses, leaving more limited supplies of "first dose" vaccines.

Florida Surgeon General and Health Secretary Scott Rivkees, MD, on Jan. 26 said the state cannot give hospitals "second dose" vaccine supplies to administer initial doses, CBS affiliate WKMG-TV reported.The state's top health official said Florida is withholding the doses for its 65 and older population and urged hospital executives to tap county health departments if they need to vaccinate new staff members and patients.  

The federal government is maintaining a small emergency stockpile of vaccines, but overall most vaccines are being shipped out weekly as they are manufactured, according to The New York Times

Differing state guidelines for vaccine prioritization 

In December, the CDC Advisory Committee on Immunization Practices recommended prioritizing healthcare workers and nursing home residents in phase 1a of state vaccine plans, and including those over age 75 and essential front-line workers in phase 1b. On Jan. 12, HHS recommended states open vaccine availability to all people 65 and older, and to those with high-risk medical conditions.  

Many states expanded vaccine eligibility in response and incorrectly assumed they would receive additional vaccine supplies after former HHS Secretary Alex Azar, MD, said the U.S. would no longer stockpile vaccines for second doses, reported Politico. There was no stockpile of second vaccine doses waiting to be distributed, as the U.S. had already begun shipping out all doses of the vaccine at the end of December, state and federal officials told The Washington Post

As of Jan. 19, 28 states include people 65 and older in their priority groups, up from 16 states Jan. 11, according to an analysis by the Kaiser Family Foundation. Of the 28 states, only 15 are currently registering individuals 65 and older for the vaccine. As of Jan. 19, a total of 19 states include younger adults with high-risk medical conditions in phase 1a or 1b, including 6 states that have revised their plans since Jan. 11. 

As states expand or revise priority groups eligible for vaccination, they must also effectively communicate these changes to the public. 

What the future holds for vaccine distribution 

President Joe Biden has issued a series of changes to the country's COVID-19 vaccine strategy, which transfers oversight from states to the federal government. These changes could eliminate some of the communication gaps and disparities associated with vaccine distribution and allotment.

President Biden has said that his goal is to ensure 100 million Americans receive a vaccine within his first 100 days in office. This week, the president said the U.S. may be able to increase that goal to 150 million. 

The president's plans include allocating $20 billion for a program that involves community vaccination centers and mobile vaccine units to reach remote areas. He also plans to hire 100,000 public health workers to conduct vaccine outreach and contact tracing, as well as to reimburse states for the use of National Guard troops administering vaccines. 

The Federal Emergency Management Agency could operate up to 100 vaccination sites within the next month. FEMA would provide "federal support to existing or new community vaccination centers and mobile clinics across the country," according to a draft form of the plan. Shots given at the sites would come from an area's allocated vaccine supply rather than a new federal allocation stream. 

The president has also said he will establish a "COVID-19 Health Equity Task Force" to ensure vaccines, as well as treatments and other supplies, reach communities of color that have been disproportionately affected by the virus. 

He has said he would invoke the Defense Production Act to boost the nation's vaccine supply if necessary, but has not taken that step as of Jan. 27. 

On Jan. 26, the president said he predicts that anyone who wants to get a vaccine should be able to get one by spring, and that the U.S. should soon be vaccinating 1.5 million people every day. 

He also said the government will increase the supply of vaccines sent to states by about 16 percent for the next three weeks and give states three weeks' notice of their estimated vaccine allotments to allow them to better plan for vaccine appointments. The government plans to buy enough doses of the vaccine to inoculate the whole U.S. population by the end of the summer, as it is working to buy an additional 100 million doses each from Pfizer and Moderna, increasing the U.S. total to 600 million.

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COVID-19 vaccine should be available to all who want it by spring, Biden says
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