Three weeks into the most ambitious vaccination campaign in modern U.S. history, far fewer people are being protected against Covid-19 as the process moves slower than officials had projected and has been beset by confusion and disorganization in many states.
As a result, the federal government came nowhere close to vaccinating 20 million people by the end of 2020, as it had promised.
Of the more than 12 million doses of vaccines from Moderna Inc. and Pfizer Inc. with BioNTech SE that have been shipped, only 2.8 million have been administered, according to federal figures.
The shortfall is due in part to a lag in reporting data using new tools, government officials and health experts said. But as the federal government has left it to states to determine what to do with the vaccines it ships to them, and with some states pushing decision-making to local health departments and hospitals, the process has gone far from smoothly.
People in Florida are waiting in hourslong lines to get shots on a first-come, first-served basis. Some West Virginians got a Covid-19 treatment instead of vaccines. A medical practice in Texas had only two workers sign up to take the shots. While some states received fewer doses than they expected and some hospitals got their first ones this week, other health care providers have more doses than they know what to do with and are scrambling to find enough syringes to use them.
"Hospitals aren't vaccinating everyone at the flip of a light switch," said Claire Hannan, executive director of the Association of Immunization Managers, which represents state immunization officials. "There may have been an expectation from Operation Warp Speed or others that we'd give everyone the vaccine overnight....It was a logistics equation for them. If you've been in vaccines for a long time, you know that's the easy part. Getting it into actual arms is the hard part."
So far, vaccines have mostly gone to health care workers and residents of long-term care facilities, in line with guidelines from the Centers for Disease Control and Prevention. Essential workers like bus drivers or grocery clerks, plus older adults, are expected to be vaccinated next in 2021 as supplies increase and as more vaccination sites come online. The slow rate of vaccinations so far has raised questions about whether those groups will start getting shots this winter and the rest of Americans in the spring, as initially projected.
Moncef Slaoui, chief adviser for Operation Warp Speed, the U.S. government's coronavirus response program, and other federal officials said they hope the pace will increase. "We agree that that number is lower than what we hoped for," he said at a news briefing Wednesday. "We know that it should be better, and we're working hard to make it better."
Public health officials and states say uptake is lagging for several reasons, beginning with holiday seasons that have kept staff of hospitals and nursing homes away from work. They also note they are facing high percentages of people, including some health care workers, who are skeptical of taking the shots.
Hospitals and other sites are staggering appointments to avoid pulling too many workers from caring for patients amid a nationwide surge in Covid-19 cases, officials say. Administration of the vaccines also takes more time than a typical flu shot, particularly since they are being done socially distant, and may be preceded by a Covid-19 test.
In addition, people who receive vaccines are being monitored for at least 15 minutes in case of allergic reactions. At least 11 allergic reactions to Covid vaccines have been reported, according to the CDC. No serious safety concerns have been found, in line with findings from the clinical trials.
The federal government is sending vaccines to states based on their populations, and it has provided guidelines, but no rules, about how they should be distributed. State and local jurisdictions have been asking the federal government for more funding to support vaccine distribution than the $340 million disbursed so far. The economic stimulus package recently signed into law by President Trump contains an additional $8 billion.
Different state policies have led to confusion and shipment delays for hospitals, said Michael Wascovich, vice president of field pharmacy services for Premier Inc., a group purchasing organization whose members include 4,100 hospitals, 80% of which received doses.
"Every state is doing what they want to do," he said. "You could be in Philadelphia and it's completely different across the river if you're in Trenton or Camden."
Community Health Systems Inc., which operates 86 hospitals, is seeking state permission to redistribute doses across its Florida hospitals, while three hospitals in Indiana got no vaccine and workers must get shots elsewhere, complicating efforts to track company immunization rates. "It's not within our control," said Lynn Simon, the hospital system's chief medical officer. "It is a little anxiety producing."
In Grand Rapids, Mich., Spectrum Health had lowered supply estimates as the state repeatedly revised projections. Hospital officials were stunned to learn two days before Christmas they would get 60% more than expected of Pfizer's shot and more than double Moderna's, said Chad Tuttle, senior vice president of operations across Spectrum's 14 hospitals.
Many states are following CDC guidelines to start with front-line medical workers and people in long-term care facilities, but not all. Florida Gov. Ron DeSantis on Dec. 23 extended eligibility to people aged 65 and older.
Because each county and hospital in the state implemented its own approach, many people didn't know whether to call, log on or show up in person to secure a spot.
Officials in Lee County, home to Fort Myers, learned last Saturday that the county would be one of eight in the state receiving doses the following day to inoculate people 65 and older, said Kevin Ruane, chairman of the county commission. With the local health department thinly staffed, they rushed to enlist paramedics and others. They weren't able to set up a reservation system, leading to hundreds of people lining up before dawn.
"It's a logistical nightmare," said Fort Myers Mayor Kevin Anderson.
Frustrated by the slow pace of inoculations, Arizona Gov. Doug Ducey issued an executive order Wednesday directing the state health department to create a vaccine-allocation system and allowing the agency to take possession of doses for reassignment.
Forty-two people in West Virginia were mistakenly given Regeneron Pharmaceuticals Inc.'s antibody treatment designed to fight Covid-19 in those already infected instead of Moderna's vaccine. None are at risk of being harmed, according to the West Virginia National Guard.
In Hidalgo County, Texas, one medical practice received 1,000 doses for health-care workers, but only two people responded, said Ivan Melendez, the public health authority for the county near the Mexican border.
"I think there was an overestimation of the numbers," Dr. Melendez said. "All of a sudden, there's a glut of vaccines."
More than 167,000 doses have been administered at long-term medical care centers. Facilities are getting shots at varying rates via drugstore chains CVS Health Corp. and Walgreens Boots Alliance Inc. because states met the requirements to begin the distribution program at different times.
CVS has begun administering doses at nursing homes and facilities in 48 states and Washington, D.C., with most eligible residents agreeing to be vaccinated, said Chris Cox, a CVS executive who is overseeing the vaccination rollout for the pharmacy chain.
In some cases, residents haven't been vaccinated because of active outbreaks at facilities, while other facilities have taken longer than others to schedule their vaccination clinics, a challenge exacerbated by the holiday season, Mr. Cox said.
West Virginia is the only state to report having delivered the first of two vaccine doses to all of its approximately 200 long-term care facilities. More than 80% of eligible residents have been vaccinated because the state relied on some 50 local pharmacies, said Martin Wright of the West Virginia Health Care Association, a nursing home trade group.
Many hospitals saw an opportunity to inoculate more people after discovering Pfizer's vials yielded six or seven doses instead of five due to so-called overfill, which typically happens with vaccines. The development sent hospitals scouring for more syringes and needles to utilize the extra doses, said Mr. Wascovich of Premier.
"They all value it like it's worth its weight in gold," he said.
Now, some public health officials are concerned the country may not be ready for the next phase of vaccination, expected to include essential workers such as grocery store clerks or first-responders.
The U.S. health system and its stretched local health departments weren't prepared for the volume to vaccinate an entire country in a few months, according to Ms. Hannan, the director of the immunization association.
"The real challenge is around what happens when we get a larger supply and what happens when we have to vaccinate people that don't work in a hospital," she said, noting that fewer physicians' offices and health clinics have signed up as vaccination sites than she expected.
Vaccination for the next priority groups, 49 million elderly people and front-line essential workers, such as teachers and grocery store workers, is expected to begin in the coming weeks, according to health experts. Delays so far could push back the start dates of those programs, however.
In addition, states will likely make different determinations about who counts as essential and which groups go first, potentially frustrating the public, health experts warn. Prison guards in one state might get inoculated months before those in a neighboring one.
"Those could be points of confusion in the week ahead as people try to figure out, 'Where am I in line?' " said Dr. Kelly Moore, associate director of immunization education at the Immunization Action Coalition.
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