In California, where public health is largely a county-level operation, the same departments managing testing and contact tracing for an out-of-control epidemic are leading the effort.
This article was published on Thursday, January 14, 2021 in Kaiser Health News.
In these first lumbering weeks of the largest vaccination campaign in U.S. history, Dr. Julie Vaishampayan has had a battlefront view of a daunting logistical operation.
Vaishampayan is the health officer in Stanislaus County, an almond-growing mecca in California’s Central Valley that has recorded about 40,000 cases of covid-19 and lost 700 people to the illness. Her charge is to see that potentially lifesaving covid shots make it into the arms of 550,000 residents.
And like her dozens of counterparts across the state, she is improvising as she goes.
From week to week, Vaishampayan has no idea how many new doses of covid vaccines will be delivered until just days before they arrive, complicating advance planning for mass inoculation clinics. The inoculation clinics themselves can be a bureaucratic slog, as county staffers verify the identities and occupations of people coming in for shots to ensure strict compliance with the state’s multitiered hierarchy of eligibility. In these early days, the county also has provided vaccines to some area hospitals so they can inoculate health care workers, but the state system for tracking whether and how those doses are administered has proven clumsy.
With relatively little help from the federal government, each state has built its own vaccination rollout plan. In California, where public health is largely a county-level operation, the same departments managing testing and contact tracing for an out-of-control epidemic are leading the effort. That puts an already beleaguered workforce at the helm of yet another time-consuming undertaking. A lack of resources and limited planning by the federal and state governments have made it that much harder to get operations up and running.
“We are flying the plane as we are building it,” said Jason Hoppin, a spokesperson for Santa Cruz County. ”All of these logistical pieces are just a huge puzzle to work out.”
It’s a massive enterprise. Counties must figure out who falls where in the state’s multitiered system for eligibility, locate vaccination sites, hire vaccinators, notify workforce groups when they are eligible, schedule appointments, verify identities, then track distribution and immunizations administered.
Some of that burden has been eased by a federal program that is contracting with major pharmacies Walgreens and CVS to vaccinate people living in nursing homes and long-term care facilities, as well as a California mechanism that allows some large multicounty health care providers to order vaccines directly. As of this week, some smaller clinics and doctors’ offices also can get vaccine directly from the state.
But much of the job falls on health departments, the only entities required by law to protect the health of every Californian. And they are doing it amid pressures from the state to prevent people from skipping the line and a public eager to know why the rollout isn’t happening faster.
As of Monday, only a third of the nearly 2.5 million doses allocated to California counties and health systems had been administered, according to the most recent state data available. Gov. Gavin Newsom has acknowledged the rollout has “gone too slowly.” Health directors counter it’s the best that could be expected given the short planning timeline, limited vaccine available and other strictures.
“I would not call this rollout slow,” said Kat DeBurgh, executive director of the Health Officers Association of California. “This isn’t the same as a flu vaccine clinic where all you have to do is roll up your sleeve and someone gives you a shot.”
It has been one month since the first vaccines arrived in California, and just over five weeks since the state first outlined priority groups for vaccinations, then passed the ball to counties to devise ways to execute the plan.
Like most states, California opened its rollout with strict rules about the order of distribution. The first phase prioritized nursing home residents and hospital staffs before expanding to other broad categories of health care workers. In the weeks after the vaccines first arrived, state officials made clear that providers could be penalized if they gave vaccinations to people not in those initial priority groups.
Multiple counties said there had been little in the way of line-skipping, but stray reports in the media or complaints sent directly to community officials need to be chased down, wasting precious public health resources. The same goes for reports of vaccine doses being thrown away. One of the vaccines in circulation, once removed from ultra-cold storage, must be used within five days or discarded.
State officials have since loosened their rules, telling counties and providers to do their best to adhere to the tiers, but not to waste doses. On Jan. 7, California officials told counties they could vaccinate anyone in “phase 1a,” expanding beyond the first priority group of nursing homes and hospitals to nearly everyone in a health-related job. Once that wide-ranging category is finished, counties were supposed to move to “phase 1b,” which unfolds with its own set of tiers, starting with people 75 and older, educators, child care workers, providers of emergency services, and food and agricultural workers before expanding to all people 65 and older.
Mariposa and San Francisco both said they would be vaccinating people in the first 1b categories this week. That means residents will start seeing inequities among counties, said DeBurgh, noting that some counties had not yet received enough vaccine doses to cover health care workers while others are nearly finished. Stanislaus County, for example, had received approximately 16,000 first doses as of Jan. 9, but estimates it has between 35,000 and 40,000 health care workers phase 1a.
And the orders are changing yet again, forcing counties to pivot. On Tuesday, U.S. Health and Human Services Secretary Alex Azar said the Trump administration would begin releasing more of its vaccine supply, holding onto fewer vials for second doses; and he encouraged states to open up vaccinations to everyone age 65 and older. In response, California officials said Wednesday that once counties are done with phase 1a, people 65 and older are in the next group eligible for vaccines.
Some local health directors expressed dismay at the prospect, saying they welcome the influx of vaccines but need to prioritize people 75 and older who represent the bulk of hospitalizations. They also noted that states already offering broader access have had their own challenges, including flooded health department phone lines, crashed websites and fragile seniors camping out overnight in hopes of securing their place in line.
While sensible in theory, California’s phased approach to the rollout has proved cumbersome when it comes to verifying that people showing up for shots fall under the umbrella groups deemed eligible. In Stanislaus, for example, 6,600 people qualify as in-home support workers. Someone from another county department has to sit with health department staffers to verify their eligibility, since the health department doesn’t have access to official data on who is a qualified member of the group.
Complicating matters, about half the county’s in-home workers are caring for a family member, and many are bringing that person with them to get vaccinated. The county is required to turn those family members away if they don’t meet the eligibility criteria, Vaishampayan said.
A range of other hiccups hampered the rollout. Across the state, uptake of vaccination slowed to a crawl from Christmas to New Year’s. Health workers, particularly those who do not work in hospitals, were on vacation and enjoying a few days off with family after a tough year, several county officials said. Many chose not to get vaccinated during that time.
Others are choosing not to get vaccinated at all. Across the state, health care workers are declining vaccinations in large numbers. The health officer for Riverside County has said 50% of hospital workers there have declined the vaccine.
And in Los Angeles and Sonoma, officials described software challenges that prevented them from quickly enrolling doctors’ offices to receive vaccines and perform injections.
Still, statewide, officials said they were confident that the pace would pick up in the coming days, as more doses arrive, data snags get sorted out and more vaccination sites come on board. Los Angeles County announced this week it would convert Dodger Stadium and a Veterans Affairs site from mass testing sites into mass vaccination clinics. Similar plans are underway at Petco Park in San Diego and the Disneyland Resort in Orange County. Officials hope Dodger Stadium alone can handle up to 12,000 people a day.
The move solves one problem, but potentially exacerbates another: The two Los Angeles sites have been testing 87,000 people a week, according to Dr. Christina Ghaly, Los Angeles County Department of Health Services director. That will put new constraints on testing, even as covid cases in the nation’s most populous county continue to rise and hospitals are beyond capacity.
As a health care journalist in Los Angeles reporting on the pandemic, I knew exactly what I needed to do once I landed in the hospital with covid pneumonia: write my goodbye emails.
I’d seen coverage of some final covid messages during this terrible year. They were usually directed to spouses, but my No. 1 concern was how to explain my own death to my 3-year-old, Marigold, whom we call “Goldie.” How much of me would she remember, and how would she make peace with what happened to me, when I could barely believe it myself?
After the emergency room doctor confirmed pneumonia in both of my lungs on Dec. 17, I was whisked upstairs to the hospital’s covid unit, where I got a blood thinner injection, infusions of steroids and remdesivir, and continued on the supplemental oxygen they had started in the ER.
Immediately after the treatments, my mind was clearer and more focused than it had been in the nine days since my husband, daughter and I had all received positive covid results (and when my raging fevers began). As I lay in my hospital bed, my roommate’s TV blaring, I started thinking about my daughter’s understanding of death. A lapsed evangelical married to a Jewish man, I had adopted his family’s perspective on the afterlife — that discussing it wasn’t very important — but had also inadvertently abdicated the death discussion to Hollywood.
Goldie’s afterlife education began with the movie “Coco,” about the Mexican Day of the Dead, in which families put pictures of their ancestors on a home altar, or ofrenda. Then came “Over the Moon,” in 2020, about a little girl in China who loses her mom to illness and struggles to accept a new stepmother, all while her mom’s spirit visits her in the form of a crane.
That prompted her first question about my death.
“Are you going to die like Fei Fei’s mom did?” Goldie asked me in November, before I got sick. I told her at the time that no one knows when they’re going to die, but that I would love her with all of my heart for as long as I lived.
After that, Goldie would sometimes randomly declare, “I don’t think you’re going to die,” or she would ask if we could all die together, at the same time — to which I’d say, “Sure!”
My covid symptoms started Dec. 7, and we got our positive results back the next morning. Thankfully, my husband and daughter had almost no symptoms except stuffy noses and a day of low fever. But I started off with a fever that would burn me up to 104 degrees, over and over again. Tylenol and Advil could bring it down only to 100 or 101. I would cry as the painful fevers reached their peak and wondered if God had been preparing Goldie all along this year for my eventual death.
My breathing problems began eight days later. The scariest moment during that time was when I was in the middle of a shower (much needed after days of sweaty fevers) and realized I was gasping for air. I punched the shower curtains out of my way and ran to my bed, where I could lie on my stomach and get my oxygen levels up again. As I lay there, hyperventilating, soaking wet, with shampoo still in my hair, the pulse oximeter monitor registered 67, before inching back up to 92. I began thinking of what I wanted to say to Goldie in my final letter to her, but I was too weak to type it out.
Two more uterine procedures led to a successful embryo transfer, but a miscarriage put me in the ER on Oct. 8. By then, Los Angeles County had seen 278,665 cases and 6,726 deaths — horrifying numbers that I monitored and reported on as a health journalist, but data points I couldn’t, or wouldn’t, use to alter the decision-making in my own life.
With four miscarriages now under my belt and no more viable embryos left to use, my husband, Simon, and I decided we’d give in vitro fertilization one final try. I started my injections for an egg retrieval in late November, and by the time the procedure rolled around on Dec. 3, L.A. was well into its scary, almost vertical holiday season ascent, posting 7,854 new cases that day — up fivefold from a month earlier.
A close friend was supposed to start her IVF injections at the same time, but she decided to postpone at the last minute because covid cases were so high in our area. By that point, we were so driven in our pursuing of pregnancy that I was startled to hear her say that, as the thought had never even crossed my mind.
I have no way of knowing for sure if I was exposed to the virus sometime during this last fertility treatment. The surgical center is located on a large medical campus that also hosts a covid-19 testing drive-thru in the garage where we parked. We waited, masks on, for almost an hour outside the building, which we thought was a safer choice than the fertility clinic waiting room, but that actually put us in proximity to a lot of sick people waiting for rides home.
I also had to remove my mask just before the actual egg retrieval, because I was under anesthesia and the doctors needed quick access to my mouth in case I needed a breathing tube.
Five days after the egg retrieval, we found out we were covid-positive. I called the clinic right away to warn them; the fertility doctor told me a few days later that none of her staffers had gotten sick. And also that none of the eggs they retrieved from me had developed properly. We had no embryos to use.
Of course, as anyone who has done fertility treatments knows, all the dangers and risks we undertook would have been “worth it” if it had worked. Because it didn’t work for us, I felt defeated and foolish.
In sum, we wanted to give Goldie a sibling, but attempting to do so may have been what threatened her mother’s life. This thought haunts me and will stay with me forever, even though I’ll never know how exactly the virus entered our home.
Our nanny, who also experienced covid symptoms and tested positive three days before us, could have picked it up at the supermarket. We could have gotten it from her or while walking around our neighborhood or playing in the park. But the act of choosing, over and over again, to engage in fertility treatments as the pandemic raged on, fills me with doubt and remorse.
This was all too much to put in my goodbye letter to Goldie. Instead, this is some of what I wrote:
Around Halloween, you and I were eating breakfast together and I asked you how your life was going, and if there were any improvements I could make for you. You said, with absolute seriousness, “I’m afraid of ghosts.”
Now that I’m a ghost, I hope there’s less reason to be afraid.
Please put my picture on the ofrenda once a year. I’ll always be in your heart and in your memories. I will try to visit you too. But not in a spooky way, just a gentle way.
I will always love you. Thank you so much for being born to us. You made everything better.
After finishing my goodbye letter, I went to sleep. In the morning, I woke up, got a second infusion of steroids and remdesivir, and then was released home with oxygen tanks and an oxygen concentrator. I stayed in bed, on oxygen, for another week before my lungs were strong enough for me to stand and walk on my own. We had a wonderful Christmas morning together opening presents during a Zoom call with my family. Other than fatigue, I am now almost back to normal.
After the holidays, I sat down with Goldie for breakfast as we usually do. Feeling morose about how the year had turned out, I asked, dreading her response, if she would like to have a baby brother or sister one day.
She put her hand on my neck and pressed her forehead into mine, a face-to-face embrace that we call a “pumpkin hug.”
“No, Mom,” she said. “I want it to be just you and me, forever.”
I took a deep breath, and then sighed with relief.
Counties must figure out who falls where in the state's multitiered system for eligibility, locate vaccination sites, hire vaccinators, notify workforce groups when they are eligible, schedule appointments, verify identities, then track distribution and immunizations administered.
This article was published on Thursday, January 14, 2021 in Kaiser Health News.
In these first lumbering weeks of the largest vaccination campaign in U.S. history, Dr. Julie Vaishampayan has had a battlefront view of a daunting logistical operation.
Vaishampayan is the health officer in Stanislaus County, an almond-growing mecca in California's Central Valley that has recorded about 40,000 cases of covid-19 and lost 700 people to the illness. Her charge is to see that potentially lifesaving covid shots make it into the arms of 550,000 residents.
And like her dozens of counterparts across the state, she is improvising as she goes.
From week to week, Vaishampayan has no idea how many new doses of covid vaccines will be delivered until just days before they arrive, complicating advance planning for mass inoculation clinics. The inoculation clinics themselves can be a bureaucratic slog, as county staffers verify the identities and occupations of people coming in for shots to ensure strict compliance with the state's multitiered hierarchy of eligibility. In these early days, the county also has provided vaccines to some area hospitals so they can inoculate healthcare workers, but the state system for tracking whether and how those doses are administered has proven clumsy.
With relatively little help from the federal government, each state has built its own vaccination rollout plan. In California, where public health is largely a county-level operation, the same departments managing testing and contact tracing for an out-of-control epidemic are leading the effort. That puts an already beleaguered workforce at the helm of yet another time-consuming undertaking. A lack of resources and limited planning by the federal and state governments have made it that much harder to get operations up and running.
"We are flying the plane as we are building it," said Jason Hoppin, a spokesperson for Santa Cruz County. "All of these logistical pieces are just a huge puzzle to work out."
It's a massive enterprise. Counties must figure out who falls where in the state's multitiered system for eligibility, locate vaccination sites, hire vaccinators, notify workforce groups when they are eligible, schedule appointments, verify identities, then track distribution and immunizations administered.
Some of that burden has been eased by a federal program that is contracting with major pharmacies Walgreens and CVS to vaccinate people living in nursing homes and long-term care facilities, as well as a California mechanism that allows some large multicounty healthcare providers to order vaccines directly. As of this week, some smaller clinics and doctors' offices also can get vaccine directly from the state.
But much of the job falls on health departments, the only entities required by law to protect the health of every Californian. And they are doing it amid pressures from the state to prevent people from skipping the line and a public eager to know why the rollout isn't happening faster.
As of Monday, only a third of the nearly 2.5 million doses allocated to California counties and health systems had been administered, according to the most recent state data available. Gov. Gavin Newsom has acknowledged the rollout has "gone too slowly." Health directors counter it's the best that could be expected given the short planning timeline, limited vaccine available and other strictures.
"I would not call this rollout slow," said Kat DeBurgh, executive director of the Health Officers Association of California. "This isn't the same as a flu vaccine clinic where all you have to do is roll up your sleeve and someone gives you a shot."
It has been one month since the first vaccines arrived in California, and just over five weeks since the state first outlined priority groups for vaccinations, then passed the ball to counties to devise ways to execute the plan.
Like most states, California opened its rollout with strict rules about the order of distribution. The first phase prioritized nursing home residents and hospital staffs before expanding to other broad categories of healthcare workers. In the weeks after the vaccines first arrived, state officials made clear that providers could be penalized if they gave vaccinations to people not in those initial priority groups.
Multiple counties said there had been little in the way of line-skipping, but stray reports in the media or complaints sent directly to community officials need to be chased down, wasting precious public health resources. The same goes for reports of vaccine doses being thrown away. One of the vaccines in circulation, once removed from ultra-cold storage, must be used within five days or discarded.
State officials have since loosened their rules, telling counties and providers to do their best to adhere to the tiers, but not to waste doses. On Jan. 7, California officials told counties they could vaccinate anyone in "phase 1a," expanding beyond the first priority group of nursing homes and hospitals to nearly everyone in a health-related job. Once that wide-ranging category is finished, counties were supposed to move to "phase 1b," which unfolds with its own set of tiers, starting with people 75 and older, educators, child care workers, providers of emergency services, and food and agricultural workers before expanding to all people 65 and older.
Mariposa and San Francisco both said they would be vaccinating people in the first 1b categories this week. That means residents will start seeing inequities among counties, said DeBurgh, noting that some counties had not yet received enough vaccine doses to cover healthcare workers while others are nearly finished. Stanislaus County, for example, had received approximately 16,000 first doses as of Jan. 9, but estimates it has between 35,000 and 40,000 healthcare workers phase 1a.
And the orders are changing yet again, forcing counties to pivot. On Tuesday, U.S. Health and Human Services Secretary Alex Azar said the Trump administration would begin releasing more of its vaccine supply, holding onto fewer vials for second doses; and he encouraged states to open up vaccinations to everyone age 65 and older. In response, California officials said Wednesday that once counties are done with phase 1a, people 65 and older are in the next group eligible for vaccines.
Some local health directors expressed dismay at the prospect, saying they welcome the influx of vaccines but need to prioritize people 75 and older who represent the bulk of hospitalizations. They also noted that states already offering broader access have had their own challenges, including flooded health department phone lines, crashed websites and fragile seniors camping out overnight in hopes of securing their place in line.
While sensible in theory, California's phased approach to the rollout has proved cumbersome when it comes to verifying that people showing up for shots fall under the umbrella groups deemed eligible. In Stanislaus, for example, 6,600 people qualify as in-home support workers. Someone from another county department has to sit with health department staffers to verify their eligibility, since the health department doesn't have access to official data on who is a qualified member of the group.
Complicating matters, about half the county's in-home workers are caring for a family member, and many are bringing that person with them to get vaccinated. The county is required to turn those family members away if they don't meet the eligibility criteria, Vaishampayan said.
A range of other hiccups hampered the rollout. Across the state, uptake of vaccination slowed to a crawl from Christmas to New Year's. Health workers, particularly those who do not work in hospitals, were on vacation and enjoying a few days off with family after a tough year, several county officials said. Many chose not to get vaccinated during that time.
Others are choosing not to get vaccinated at all. Across the state, healthcare workers are declining vaccinations in large numbers. The health officer for Riverside County has said 50% of hospital workers there have declined the vaccine.
And in Los Angeles and Sonoma, officials described software challenges that prevented them from quickly enrolling doctors' offices to receive vaccines and perform injections.
Still, statewide, officials said they were confident that the pace would pick up in the coming days, as more doses arrive, data snags get sorted out and more vaccination sites come on board. Los Angeles County announced this week it would convert Dodger Stadium and a Veterans Affairs site from mass testing sites into mass vaccination clinics. Similar plans are underway at Petco Park in San Diego and the Disneyland Resort in Orange County. Officials hope Dodger Stadium alone can handle up to 12,000 people a day.
The move solves one problem, but potentially exacerbates another: The two Los Angeles sites have been testing 87,000 people a week, according to Dr. Christina Ghaly, Los Angeles County Department of Health Services director. That will put new constraints on testing, even as covid cases in the nation's most populous county continue to rise and hospitals are beyond capacity.
Frustration and confusion are rampant as states and counties begin to offer vaccines to all seniors after giving them first to front-line healthcare workers and nursing home residents.
This article was published on Thursday, January 14, 2021 in Kaiser Health News.
For weeks, doctors' phones have been ringing off the hook with anxious older patients on the other end of the line.
"When can I get a covid-19 vaccine?" these patients want to know. "And where?"
Frustration and confusion are rampant as states and counties begin to offer vaccines to all seniors after giving them first to front-line healthcare workers and nursing home residents — the groups initially given priority by state and federal authorities.
My 91-year-old mother-in-law, who lives in upstate New York, was one of those callers. She said her doctor's office told her it could be several months before she can get her first shot.
That was before New York's Gov. Andrew Cuomo announced on Friday that the state would begin offering vaccines to residents age 75 and older starting Monday. On Tuesday, the state changed vaccine policies again, this time making residents 65 and older eligible.
In this chaotic environment, with covid cases and deaths skyrocketing and distribution systems in a state of disarray, it's difficult to get up-to-date, reliable information. Many older adults don't know where to turn for help.
Since the holidays, I've heard from dozens of people frustrated by poorly informed staffers at physicians' offices, difficult-to-navigate state and county websites, and burdensome or malfunctioning sign-up arrangements. Below are some questions they posed, with answers drawn from interviews with experts and other sources, that may prove helpful.
Keep in mind that states, counties and cities have varying policies, and this is a rapidly shifting landscape with many uncertainties. Foremost among them are questions regarding vaccine supply: how many doses will become available to states and when and how those will be allocated.
Q: How can I make an appointment to get a vaccine?— James Vanderhye, 77, Denver
Vanderhye is a throat cancer survivor who suffers from sarcoidosis of the lungs and heart — an inflammatory disease.
Colorado Gov. Jared Polis announced on Dec. 30 that residents 70 and older could start getting covid vaccines, but Vanderhye wasn't sure whether he needed to sign up somewhere or whether he'd be contacted by his physicians — a common source of confusion.
UCHealth, the system where Vanderhye's doctors practice, has created a registry of patients 70 and older and is randomly selecting them for appointments, Dr. Jean Kutner, its chief medical officer told me. It's reaching out to patients through its electronic patient portal and is planning to notify those who don't respond by phone down the line. Then, it's up to patients to finalize arrangements.
Nearly 200,000 people 70 and older are patients at UCHealth's hospitals and clinics in Colorado, Wyoming and Nebraska.
TIPS: Although some health systems such as UCHealth are contacting patients, don't assume that will happen. In most cases, it appears, you will need to take the initiative.
Check with the physician's office, hospital or medical clinic where you usually receive care. Many institutions (though not all) are posting information about covid vaccines on their websites. Some have set up phone lines.
Some health systems are willing to vaccinate anyone who signs up, not just their patients. Kaiser Permanente, which operates in California, Colorado, Georgia, Hawaii, Oregon, Washington, Washington, D.C., and parts of Virginia and Maryland, is among them, according to Dr. Craig Robbins, co-leader of its national covid vaccination program. (Within the next few weeks, it will post an online registration tool on plan websites.) Check with major hospitals or health systems in your area to see what they're doing. (KHN is not affiliated with Kaiser Permanente.)
Most places are asking people to sign up online for appointments; some sites require multiple steps and their systems may seem hard to use. If you don't have a computer or you aren't comfortable using one, ask a younger family member, friend or neighbor for help. Similarly, ask for help if you aren't fluent in English.
If you can't figure out how to sign up online, call your local county health department, Area Agency on Aging or county department on aging and ask for assistance. Every state has a covid-19 hotline; see if the hotline can direct you to a call center that's taking appointments. Be prepared for long waits; phone lines are jammed.
Q:My mother has stage 3 renal failure, high blood pressure and dementia. She's unable to take care of herself or be left alone. When can I get her vaccinated with the COVID shot?— Wendy, 61, Chandler, Arizona
Wendy had checked Maricopa County's website days before we talked on Jan. 5 and couldn't figure out when her 84-year-old mother might get a vaccine appointment. The week before, her 90-year-old father died, alone, of renal failure complicated by pneumonia in a nursing home.
Three days after our conversation, Maricopa County announced that people 75 and older could start making appointments to be vaccinated on a "first-come, first-served" basis on Monday, Jan. 11. (The state's appointment site is https://podvaccine.azdhs.gov/; callers should try 844-542-8201 or 211, according to information provided by the county.)
In Arizona, "it's up to each county to come up and execute a plan for vaccine distribution," said Dana Kennedy, state director of AARP Arizona.
Demand is high and vaccine supplies are limited, other places have found. For example, on Jan. 7, a 1,200-slot vaccine clinic in Oklahoma City for adults 65 and older filled up within four minutes, according to Molly Fleming, a public information officer at the Oklahoma City-County Health Department.
"Once we get more vaccine supplies coming more frequently, we will do more clinics," Fleming said. "The challenge we have right now is, we need the vaccine and we don't know when it's coming in."
TIPS: Consult AARP's state-by-state covid vaccine guides, focused on older adults and updated daily. (To access, go to https://www.aarp.org/coronavirus/. In the right-hand column, click on "the vaccine in your state.") More than 20 states are listed there now, but guides for all states should be available by the end of January.
Meanwhile, check local media and your county's and state's health department websites regularly for fresh information about covid vaccine distribution plans.
Be prepared to be patient as problems with distribution surface. States and counties around the country are learning from problems that have arisen in places such as Florida — crashed phone lines, long lines of older adults waiting outdoors, massive confusion. It may take some time, but vaccine rollouts should become smoother as more sites come online and supplies become more readily available.
Q: When can a 72-year-old male with chronic lymphocytic leukemia expect to be vaccinated at Kaiser Permanente in Southern California?— Barry
California last week announced that counties that have made significant progress and have adequate supplies can move toward offering vaccines to residents 75 and older.
How soon this will happen isn't clear yet; it will vary by location. But even then, Barry wouldn't qualify immediately since he's only 72 and it could take several months for vaccines to become available to people in his age group (65 to 74), said Robbins, who's helping lead Kaiser Permanente's vaccination program.
Barry is at especially high risk of doing poorly if he develops covid because of the type of cancer he has — leukemia. But, for the most part, medical conditions are not being taken into account in the initial stages of vaccine distribution around the country.
An exception is the Mayo Clinic. It's identifying patients at highest risk of getting severe infections, being hospitalized and dying from covid at the Mayo Clinic Health System, a network of physician practices, clinics and hospitals in Iowa, Minnesota and Wisconsin. When states allow older adults outside of long-term care institutions to start getting vaccines, it will offer them first to patients at highest risk, said Dr. Abinash Virk, co-chair for Mayo Clinic's vaccine rollout.
TIPS: Even if vaccines aren't available right away, production is increasing, new products are in the pipeline, and new ways of distributing vaccines — notably mass distribution sites — are being planned. If you have to wait several weeks or months, don't give up. Persistence is worth the effort, given the vaccine's benefits.
For Heather Suri, a registered nurse in Virginia, the race to vaccinate Americans against covid has thrown up some unprecedented obstacles.
The vaccines themselves are delicate and require a fair bit of focus over time. Consider Moderna's instructions for preparing its doses: Select the number of shots that will be given. Thaw the vials for 2.5 hours in a refrigerator set between 36 and 46 degrees. Then rest them at room temperature for 15 minutes. Do not refreeze. Swirl gently between each withdrawal. Do not shake. Inspect each vial for particulate matter or discoloration. Store any unused vaccine in refrigeration.
And then there's this: Once open, a vial is good for only six hours. As vaccines go, that's not very long. Some flu vaccine keeps almost a month.
"This is very different, administering this vaccine. The process, it takes a whole lot longer than any mass vaccination event that I've been involved with," said Suri, a member of the Loudoun Medical Reserve Corps who joined her first clinic Dec. 28, to vaccinate first responders.
Of the first two covid vaccines on the market, Moderna's is considered more user-friendly. Pfizer-BioNTech's shot must be stored in specialized freezers at 94 degrees below zero. Once out of deep freeze, it lasts just five days, compared with 30 days for Moderna's.
One thing the shots have in common: They last a paltry six hours once the first dose is removed from a vial. That short shelf life raises the stakes for the largest vaccination effort in U.S. history by forcing clinicians to anticipate the exact number of doses they'll need each day. If they don't get it right, precious stores of vaccine may go to waste.
During one recent clinic over several hours, Suri estimated she gave "maybe 25" shots, many fewer than the number of flu shots she's given during similar clinics over the years.
With covid, she said, "the vaccine itself slows things down."
The slow rollout has frustrated people who at Thanksgiving imagined millions of vaccines in arms by Christmas. Promises that 20 million would be vaccinated by New Year's fell well short: Just 2.8 million had the first of two required shots by the end of December, according to data from the Centers for Disease Control and Prevention.
Public health officials say many factors are at play, including a shortage of workers trained to administer shots, covid protocols that require physical distancing at clinics and vaccine allocation numbers from the federal government that fluctuate by the week.
And then there are the logistics of the first covid vaccines, which are complex and make hyper-vigilant practitioners wary of opening too many vials over the course of each day, for fear that anything unused will have to be tossed. Vaccine providers also report wasted or spoiled doses to public health authorities.
"If you get to the end of your clinic and every nurse has half a vial left, what are you going to do with that vaccine?" Suri said. "The clock is ticking. You don't want to waste those doses."
That impulse has led some health personnel to make dramatic decisions at the end of a day: calling non-front-line health workers or offering shots to whoever is at hand in, say, a grocery store, instead of scrambling to find the health workers and residents of nursing homes in the government's first tier for injections.
"We jumped and ran and got the vaccine," said Dr. Mark Hathaway, an OB-GYN in the District of Columbia who received the first dose of a Moderna vaccine on Dec. 26 along with his wife, a registered nurse specializing in nutrition. Both clinicians received vaccines faster than anticipated at a Unity Healthcare clinic when there were extra doses because fewer front-line healthcare workers than expected showed up.
"Healthcare workers have been priority 1a, so our first attempt has always been our staff," said Dr. Jessica Boyd, Unity Healthcare's chief medical officer. Since then, the community health center network has broadened its criteria for extra doses to include staff members or high-risk patients visiting a clinic, she said.
Health officials encourage using the doses to get as many Americans vaccinated as quickly as possible. Public health experts say the need to vaccinate people is especially urgent as a new and more contagious variant of the virus first detected in the United Kingdom is showing up in multiple states. Some states, including New York and California, have loosened their guidelines on who can get vaccinated after an outcry over healthcare providers throwing away doses that didn't meet officials' strict criteria.
The tiers "are simply recommendations, and they should never stand in the way of getting shots in arms instead of keeping vaccine in the freezer or wasting vaccine in the vial," Health and Human Services Secretary Alex Azar said Jan. 6, referring to CDC guidelines saying healthcare workers and residents and staff of long-term care facilities should be first in line, then people at least 75 years old. The Trump administration this week also said it would make more shots available by releasing second doses and urged states to broaden rules to allow anyone 65 or older and any resident with a serious medical condition to get a shot.
Pfizer-BioNTech's ultra-cold storage requirements have made it less ideal for local public health departments and rural areas.
Both of the available vaccines arrive in multidose vials — Pfizer-BioNTech's contains about five doses, Moderna's 10. Neither contains preservatives and they are viable for only six months frozen. By contrast, during the H1N1 pandemic roughly a decade ago, the swine flu vaccines lasted 18 weeks to 18 months, Sen. Chuck Grassley (R-Iowa) wrote in a May 2010 letter to then-HHS Secretary Kathleen Sebelius.
"We can't get the vaccine out fast enough; we have people dying. But, at the same time, we have to get it right," said Claire Hannan, executive director of the Association of Immunization Managers.
The added risk of losing doses due to quick expiration is another thing "causing angst," Hannan said. "You can't just draw it up and let it sit. It can't just sit out like that."
The Trump administration fell significantly short of its promise that 20 million Americans would be vaccinated by the end of December, partly the result of a disjointed and underfunded public health system that has received limited guidance from federal officials. As of Jan. 11, 25.5 million vaccine doses had been distributed nationwide but only 9 million administered, according to the CDC.
Federal officials have released sparse data about who is getting vaccinated, but state information has shown significant variation in vaccination rates depending on the facility. New York Gov. Andrew Cuomo on Jan. 4 said New York City's public hospital system had used only 31% of its allocated vaccines, while private health systems NewYork-Presbyterian and Northwell Health had used 99% and 62%, respectively.
"When you target a priority group, it's inefficient. When you open it up to a larger group, it's efficient … but you're not going to have enough supply," Hannan said. "You still have the challenge of getting those healthcare workers vaccinated and no matter any way you slice it, you still have limited supply. You can't please everyone."
While Pfizer's vaccine has largely been earmarked for large institutions like hospitals and nursing homes, Moderna's has been more widely distributed to smaller sites like public health departments and clinics run by volunteers. State and local officials have begun or will soon vaccinate other priority populations, including police officers, teachers and other K-12 school employees, and seniors overall.
Unlike the covid vaccines, many flu vaccines come in prefilled syringes — each syringe's cap is removed only when a shot is given, which speeds the process and eases some concerns about storage. However, relying on prefilled syringes during a pandemic has its own complications, according to Michael Watson, former president of Valera, a Moderna subsidiary: They take up more fridge space. They're more expensive. And they can't be used for frozen products, he said.
"For all these reasons, a vial was the best and only option," he said.
In Ohio, Eric Zgodzinski, health commissioner for Toledo-Lucas County, said two-thirds of first responders the county surveyed said they would get the vaccine. Still, he said, his department has encountered situations in which a covid vaccine dose is left over in an open vial and officials have turned to a waiting list to find someone who can arrive within minutes to get a jab.
His department also has an internal running list of potential vaccine takers, including health department staffers, people in congregate care settings or those who had scheduled vaccination appointments for later on.
"We're not going to open up a vial for one individual and figure out nine other people right away," said Zgodzinski, whose department planned to distribute 2,200 doses of the Moderna vaccine the week of Jan. 4.
"If I have one dose left, who can I give it to?" he added. "A shot in the arm for anybody is better than it being wasted."
San Francisco editor Arthur Allen and senior correspondent JoNel Aleccia contributed to this report.
As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people's word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.
This article was published on Wednesday, January 13, 2021 in Kaiser Health News.
By Blake Farmer, Nashville Public Radio In December, all states began vaccinating only healthcare workers and residents and staffers of nursing homes in the "phase 1A" priority group. But, since the new year began, some states have also started giving shots to — or booking appointments for — other categories of seniors and essential workers.
As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people's word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.
"We are doing everything possible to vaccinate only those 'in phase,' but we won't turn away someone who has scheduled their vaccine appointment and tells us that they are in phase if they do not have proof or ID," said Bill Christian, spokesperson for the Tennessee Department of Health.
Among the states pivoting to vaccinating all seniors, timelines and strategies vary. Tennessee started offering shots to people 75 and older on Jan. 1. So, Frank Bargatze of Murfreesboro, Tennessee, snagged an appointment online for his father — and then went ahead and put his own name in, though he's only 63.
"He's 88," Bargatze said, pointing to his father in the passenger seat after they both received their initial shots at a drive-thru vaccination site in Murfreesboro, a large city outside Nashville. "I jumped on his bandwagon," he added with a laugh. "I'm going to blame it on him."
Bargatze does work a few days a week with people in recovery from addiction, he added, so in a way, he might qualify as a healthcare worker.
Some departments are trying more than others, but overwhelmed public health departments don't have time to do much vetting.
Dr. Lorraine MacDonald is the medical examiner in Rutherford County, Tennessee, where she's been staffing the vaccination site. If people seeking the vaccine make it through the sign-up process online, MacDonald said, and show up for their appointment, health officials are not going to ask any more questions — as long as they're on the list from the online sign-up.
"That's a difficult one," MacDonald acknowledged, when asked about people just under the age cutoff joining with older family members and putting themselves down for a dose, too. "It's pretty much the honor system."
People getting vaccinated in several Tennessee counties told a reporter they did not have to show ID or proof of qualifying employment when they arrived at a vaccination site. Tennessee's health departments are generally erring on the side of simply giving the shot, even if the person is not a local resident or is not in the country legally.
The loose enforcement of the distribution phases extends to other parts of the country, including Los Angeles. In response, New York's governor is considering making line-skipping a punishable offense.
Still, many people who don't qualify on paper believe they might need the vaccine as much as those who do qualify in the initial phases.
Gayle Boyd of Murfreesboro is 74, meaning she didn't quite make the cutoff in Tennessee, which is 75. But she's also in remission from lung cancer, and so eager to get the vaccine and start getting back to a more normal life, that she joined her slightly older husband at the Murfreesboro vaccination site this week.
"Nobody's really challenged me on it," she said, noting she made sure to tell vaccination staffers about her medical issues. "Everybody's been exceptionally nice."
Technically, in the state's current vaccine plan, having a respiratory risk factor like lung cancer doesn't leapfrog anyone who doesn't otherwise qualify. But in some neighboring states such as Georgia, where the minimum age limit is 65, Boyd would qualify.
Even for those who sympathize with such situations, anecdotes about line-skipping enrage many trying to wait their turn.
"We try to be responsible," said 57-year-old Gina Kay Reid of Eagleville, Tennessee.
Reid was also at the Murfreesboro vaccination site, sitting in the back seat as she accompanied her older husband and her mother. She said she didn't think about trying to join them in getting their first doses of vaccine. "If you take one and don't necessarily need it, you're knocking out somebody else that is in that higher-risk group."
But there is a way for younger, healthier people to get the vaccine sooner than later — and not take a dose away from anyone more deserving.
A growing number of jurisdictions are realizing they have leftover doses at the end of every day. And the shots can't be stored overnight once they're thawed. So some pharmacists, such as some in Washington, D.C., are offering them to anyone nearby.
Jackson, Tennesse, has established a "rapid response" list for anyone willing to make it down to the health department within 30 minutes. Dr. Lisa Piercey, the state's health commissioner, said her own aunt and uncle received a call at 8 p.m. and rushed to the county vaccination site to get their doses.
Piercey called it a "best practice" that she hopes other jurisdictions will adopt, offering a way for people eager for the vaccine to get it, while also helping states avoid wasting precious doses.
This story is part of a partnership that include WPLN, NPR and Kaiser Health News.
The initial rollout has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.
This article was published on Wednesday, January 13, 2021 in Kaiser Health News.
Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital's board of directors and their spouses over age 65.
But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital's urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.
The move also prompted dozens of calls from donors looking to get vaccinated.
The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.
Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don't work directly with patients were included in this first round of shots.
"This was a simple way to move 40 doses very quickly" before it spoiled, she said.
She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.
Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at healthcare workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.
In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.
Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what's mattered most was who controlled the vaccine and where the vaccine distribution was handled.
Stanford Healthcare in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don't regularly see patients. (Age was the important factor in the university's algorithm.)
Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.
At least three other South Florida hospital systems — Jackson Health, Mount Sinai Medical Center and Baptist Health — have offered vaccines to donors in advance of the general public, while administering the shots to front-line employees, The Miami Herald reported.
Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.
Staffing Problems at Hospitals
An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.
In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.
That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year's weekend out of concern about side effects, he said.
The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.
"I'm happy with how it's going so far," Williams said. "I know many of our employees want to be vaccinated, but I don't see it as a panacea that they have to have it today," he said, noting that staffers already have masks and gloves to protect themselves from the virus.
The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.
As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.
Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.
"We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don't have additional staff to run the vaccine clinics," she said.
While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it's the best way to protect the entire hospital.
She noted such employees as information technology personnel who don't see patients may be around doctors and nurses who do. "Working in a hospital, almost everyone runs into patients just walking down the hallway," she said.
At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.
"Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics," said spokesperson Lee Rice.
A Non-System of Inequitable Distribution
Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.
"That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors," he said. But he acknowledged that the hospitals' vaccination systems are not always rational or equitable.
Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.
Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn't yet gotten the vaccine because his clinic had not received any doses.
Many of the community-based physicians and medical staff that aren't employed by hospitals or health systems report mixed results in getting inoculated.
This article was published on Wednesday, January 13, 2021 in Kaiser Health News.
Dr. Andrew Carroll — a family doctor in Chandler, Arizona — wants to help his patients get immunized against covid, so he paid more than $4,000 to buy an ultra-low-temperature freezer from eBay needed to store the Pfizer vaccine.
But he's not sure he'll get a chance to use it, given health officials have so far not said when private doctor's offices will get vaccine.
"I'm really angry," said Carroll.
Not only are doctors having trouble getting vaccine for patients, but many of the community-based physicians and medical staff that aren't employed by hospitals or health systems also report mixed results in getting inoculated. Some have had their shots, yet others are still waiting, even though health workers providing direct care to patients are in the Centers for Disease Control and Prevention's top-priority group.
Many of these doctors say they don't know when — or if — they will get doses for their patients, which will soon become a bigger issue as states attempt to vaccinate more people.
"The reason that's important is patients trust their doctors when it comes to the vaccine," said Carroll, who has complained on social media that his county hasn't yet released plans on how primary care doctors will be brought into the loop.
Collectively, physicians in the county could vaccinate thousands of patients a day, he said, and might draw some who would otherwise be hesitant if they had to go to a large hospital, a fairground or another central site.
His concern comes as, nationally, the rollout of the vaccine is off to a slower start than expected, lagging far behind the initial goal of giving 20 million doses before the new year.
But Dr. Jen Brull, a family practice doctor in Plainville, Kansas, said her rural area has made good progress on the first phase of vaccinations, crediting close working relationships formed well before the pandemic.
This fall, before any doses became available, the local hospital, the health department and physician offices coordinated a sign-up list for medical workers who wanted the vaccine. So, when their county, with a population of 5,000, got its first 70 doses, they were ready to go. Another 80 doses came a week later.
"We'll be able to vaccinate almost all the healthcare-associated folks who wanted it in the county" Brull said recently
Gaps in the Rollout
But that's not the case everywhere.
Dr. Jason Goldman, a family doctor in Coral Gables, Florida, said he was able to get vaccinated at a local hospital that received the bulk of vaccines in his county and oversaw distribution.
In the weeks since, however, he said several of his front-line staff members still "don't have access to the vaccine."
Additionally, "a tremendous number" of patients are calling his office because Florida has relaxed distribution guidelines to include anyone over age 65, Goldman said, asking when they can get the vaccine. He's applied to officials about distributing the vaccines through his practice but has heard nothing back.
Patients "are frustrated that they do not have clear answers and that I am not being given clear answers to provide them," he said. "We have no choice but to direct them to the health department and some of the hospital systems."
Another troubling point for Goldman, who served as a liaison between the American Academy of Family Physicians and the expert panel drawing up the CDC distribution guidelines, is the tremendous variation in how those recommendations are being implemented in the states.
The CDC recommends several phases, with front-line healthcare workers and nursing home residents and staff in the initial group. Then, in the second part of that phase, come people over 75 and non-healthcare front-line workers, which could include first responders, teachers and other designated essential workers.
States have the flexibility to design their own rollout schedule and priority groups. Florida, for example, is offering doses to anyone 65 and up. In some counties, older folks were told vaccines were available on a first-come, first-served basis, a move that has resulted in long lines.
"To say right now, 65-plus, when you haven't even appropriately vaccinated all the healthcare workers, is negating the phasing," said Goldman. "There needs to be a national standard. We have those guidelines. We need to come up with some oversight."
On Thursday, the American Hospital Association echoed that concern in a letter to Health and Human Services Secretary Alex Azar. Hospitals — along with health departments and large pharmacy chains — are doing the bulk of the vaccinations.
Calling for additional coordination by federal officials, the letter outlined what it would take to reach the goal of vaccinating 75% of Americans by the end of May: 1.8 million vaccinations every day. Noting there are 64 different rollout plans from states, cities and other jurisdictions, the letter asked whether HHS has "assessed whether these plans, taken as a whole, are capable of achieving this level of vaccination?"
Making It Work
Lack of direct national support or strategy means each county is essentially on its own, with success or failure affected by available resources and the experience of local officials. Most state and local health departments are underfunded and are under intense pressure because of the surging pandemic.
Still, the success of vaccination efforts depends on planning, preparation and clear communication.
In Lorain County, Ohio, population 310,000, local officials started practicing in October, said Mark Adams, deputy health commissioner. They set up mass vaccination clinics for influenza to study what would be needed for a covid vaccination effort. How many staff? What would the traffic flow be like? Could patients be kept 6 feet apart?
"That gave us an idea of what is good, what is bad and what needs to change," said Adams, who has had previous experience coordinating mass vaccination efforts at a county level.
So, when the county got its first shipment of 500 doses Dec. 21, Adams had his plan ready. He called the fire chiefs to invite all emergency medical technicians and affiliated personnel to an ad hoc vaccination center set up at a large entertainment venue staffed by his health department. Upon arrival, people were greeted at the door and directed to spaced-apart "lanes" where they would get their shots, then to a monitoring area where they could wait for 15 minutes to make sure they didn't have a reaction.
Right after Christmas, another 400 doses arrived — and the makeshift clinic opened again. This time, doses went to community-based physicians, dentists and other hands-on medical practitioners, 600 of whom had previously signed up. (Hospital workers and nursing home staff and residents are getting their vaccinations through their own institutions.)
As they move into the next phase — recipients include residents over 80, people with developmental disorders and school staff — the challenges will grow, he said. The county plans a multipronged approach to notify people when it's their turn, including use of a website, the local media, churches, other organizations and word-of-mouth.
Adams shares the concerns of medical providers nationwide: He gets only two days' notice of how many doses he's going to receive and, at the current pace of 400 or 500 doses a week, it's going to take a while before most residents in the county have a chance to get a shot, including the estimated 33,000 people 65 and older.
With 10 nurses, his clinic can inject about 1,200 people a day. But many other health professionals have volunteered to administer the shots if he gets more doses.
"If I were to run three clinics, five days a week, I could do 15,000 vaccinations a week," Adams said. "With all the volunteers, I could do almost six clinics, or 30,000 a week."
Still, for those in the last public group, those age 18 and up without underlying medical conditions, "it could be summer," Adams said.
While supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America's premium tobacco companies to gain market share.
This article was published on Tuesday, January 12, 2021 in Kaiser Health News. This story also ran on Fortune.
Big Tobacco did something unusual in Marlboro Country last fall: It stood aside while Colorado voters approved the state’s first tobacco tax hike in 16 years.
The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm spent more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around $6 million to help defeat South Dakota’s similar measure.
And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.
In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly approved the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.
The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.
In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, according to The Colorado Sun, citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.
The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.
Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, alleging “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request for a preliminary injunction. A spokesperson for Liggett said the company plans to appeal.
“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of Healthier Colorado and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”
Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.
“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.
Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.
Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out nationally.
Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and eventually preschool education.
The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that found every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.
“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”
There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — Measure 108 — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.
“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”
While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.
“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.
Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. At least 30% of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure increases tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.
Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has previously said it opposed Oregon’s measure.
Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.
“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.
It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.
“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”
The average state cigarette tax is $1.88 per pack, but it varies across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was defeated.
Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.
“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”
But not all voters get a say.
In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.
“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.
Miller’s recent vaping tax bill failed in the state legislature, but he’s working on a new one.
“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”
Research shows that health facilities with unions have better patient outcomes and are more likely to have inspections that can find and correct workplace hazards.
This article was published on Monday, January 12, 2021 in Kaiser Health News. This story also ran on NPR.
The nurses at Mission Hospital in Asheville, North Carolina, declared on March 6 — by filing the official paperwork — that they were ready to vote on the prospect of joining a national union. At the time, they were motivated by the desire for more nurses and support staff, and to have a voice in hospital decisions.
A week later, as the covid-19 pandemic bore down on the state, the effort was put on hold, and everyone scrambled to respond to the coronavirus. But the nurses’ long-standing concerns only became heightened during the crisis, and new issues they’d never considered suddenly became urgent problems.
Staffers struggled to find masks and other protective equipment, said nurses interviewed for this story. The hospital discouraged them from wearing masks one day and required masks 10 days later. The staff wasn’t consistently tested for covid and often not even notified when exposed to covid-positive patients. According to the nurses and a review of safety complaints made to federal regulators, the concerns persisted for months. And some nurses said the situation fueled doubts about whether hospital executives were prioritizing staff and patients, or the bottom line.
By the time the nurses held their election in September — six months after they had filed paperwork to do so — 70% voted to unionize. In a historically anti-union state with right-to-work laws and the second-least unionized workforce in the country, that margin of victory is a significant feat, said academic experts who study labor movements.
That it occurred during the pandemic is no coincidence.
For months now, front-line health workers across the country have faced a perpetual lack of personal protective equipment, or PPE, and inconsistent safety measures. Studies show they’re more likely to be infected by the coronavirus than the general population, and hundreds have died, according to reporting by KHN and The Guardian.
Many workers say employers and government systems that are meant to protect them have failed.
Research shows that health facilities with unions have betterpatient outcomes and are more likely to have inspections that can find and correct workplace hazards. One study found New York nursing homes with unionized workers had lower covid mortality rates, as well as better access to PPE and stronger infection control measures, than nonunion facilities.
Recognizing that, some workers — like the nurses at Mission Hospital — are forming new unions or thinking about organizing for the first time. Others, who already belong to a union, are taking more active leadership roles, voting to strike, launching public information campaigns and filing lawsuits against employers.
“The urgency and desperation we’ve heard from workers is at a pitch I haven’t experienced before in 20 years of this work,” said Cass Gualvez, organizing director for Service Employees International Union-United Healthcare Workers West in California. “We’ve talked to workers who said, ‘I was dead set against a union five years ago, but covid has changed that.’”
In response to union actions, many hospitals across the country have said worker safety is already their top priority, and unions are taking advantage of a difficult situation to divide staff and management, rather than working together.
Labor experts say it’s too soon to know if the outrage over working conditions will translate into an increase in union membership, but early indications suggest a small uptick. Of the approximately 1,500 petitions for union representation posted on the National Labor Relations Board website in 2020, 16% appear related to the health care field, up from 14% the previous year.
In Colorado, SEIU Local 105 health care organizing director Stephanie Felix-Sowy said her team is fielding dozens of calls a month from nonunion workers interested in joining. Not only are nurses and respiratory therapists reaching out, but dietary workers and cleaning staff are as well, including several from rural parts of the state where union representation has traditionally been low.
“The pandemic didn’t create most of the root problems they’re concerned about,” she said. “But it amplified them and the need to address them.”
A nurse for 30 years, Amy Waters had always been aware of a mostly unspoken but widespread sentiment that talking about unions could endanger her job. But after HCA Healthcare took over Mission Health in 2019, she saw nurses and support staff members being cut and she worried about the effect on patient care. Joining National Nurses United could help, she thought. During the pandemic, her fears only worsened. At times, nurses cared for seven patients at once, despite research indicating four is a reasonable number.
In a statement, Mission Health said it has adequate staffing and is aggressively recruiting nurses. “We have the beds, staffing, PPE supplies and equipment we need at this time and we are well-equipped to handle any potential surge,” spokesperson Nancy Lindell wrote. The hospital has required universal masking since March and requires staff members who test positive to stay home, she added.
Although the nurses didn’t vote to unionize until September, Waters said, they began acting collectively from the early days of the pandemic. They drafted a petition and sent a letter to administrators together. When the hospital agreed to provide advanced training on how to use PPE to protect against covid transmission, it was a small but significant victory, Waters said.
“Seeing that change brought a fair number of nurses who had still been undecided about the union to feel like, ‘Yeah, if we work together, we can make change,’” she said.
Old Concerns Heightened, New Issues Arise
Even as union membership in most industries has declined in recent years, health workers unions have remained relatively stable. Experts say it’s partly because of the focus on patient care issues, like safe staffing ratios, which resonate widely and have only grown during the pandemic.
At St. Mary Medical Center outside Philadelphia, short staffing led nurses to strike in November. Donna Halpern, a nurse on the cardiovascular and critical care unit, said staffing had been a point of negotiation with the hospital since the nurses joined the Pennsylvania Association of Staff Nurses and Allied Professionals in 2019. But with another surge of covid cases approaching, the nurses decided not to wait any longer to take action, she said.
A month later, officials with Trinity Health Mid-Atlantic, which owns the hospital, announced a tentative labor agreement with the union. The contract “gives nurses a voice in discussions on staffing while preserving the hospital’s right and authority to make all staffing decisions,” the hospital said in a statement.
In Colorado, where state inspection reports show understaffing led to a patient death at a suburban Denver hospital, SEIU Local 105 has launched a media campaign about unsafe practices by the hospital’s parent company, HealthOne. The union doesn’t represent HealthOne employees, but union leaders said they felt compelled to act after repeatedly hearing concerns.
In a statement, HealthOne said staffing levels are appropriate across its hospitals and it is continuing to recruit and hire staff members.
Covid is also raising entirely new issues for workers to organize around. At the forefront is the lack of PPE, which was noted in one-third of the health worker deaths catalogued by KHN and The Guardian.
Nurses at Albany Medical Center in New York picketed on Dec. 1 with signs demanding PPE and spoke about having to reuse N95 masks up to 20 times.
The hospital told KHN it follows federal guidelines for reprocessing masks, but intensive care nurse Jennifer Bejo said it feels unsafe.
At MultiCare Indigo Urgent Care clinics in Washington state, staff members were provided only surgical masks and face shields for months, even when performing covid tests and seeing covid patients, said Dr. Brian Fox, who works at the clinics and is a member of the Union of American Physicians and Dentists. The company agreed to provide N95 masks after staffers went on a two-day strike in November.
MultiCare said it found another vendor for N95s in early December and is in the process of distributing them.
PPE has also become a rallying point for nonunion workers. At a November event handing out PPE in El Paso, Texas, more than 60 workers showed up in the first hour, said SEIU Texas President Elsa Caballero. Many were not union members, she said, but by the end of the day, dozens had signed membership cards to join.
Small Successes, Gradual Movement
Organized labor is not a panacea, union officials admit. Their members have faced PPE shortages and high infection rates throughout the pandemic, too. But collective action can help workers push for and achieve change, they said.
National Nurses United and the National Union of Healthcare Workers said they’ve each seen an influx in calls from nonmembers, but whether that results in more union elections is yet to be seen.
David Zonderman, an expert in labor history at North Carolina State University, said safety concerns like factory fires and mine collapses have often galvanized collective action in the past, as workers felt their lives were endangered. But labor laws can make it difficult to organize, he said, and many efforts to unionize are unsuccessful.
Health care employers, in particular, are known to launch aggressive and well-funded anti-union campaigns, said Rebecca Givan, a labor studies expert at Rutgers university. Still, workers might be more motivated by what they witnessed during the pandemic, she said.
“An experience like treating patients in this pandemic will change a health care worker forever,” Givan said, “and will have an impact on their willingness to speak out, to go on strike and to unionize if needed.”