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As demand for vaccines far outstrips supply, health districts try to maximize available doses

As demand for vaccines far outstrips supply, health districts try to maximize available doses

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From the moment Dr. Cynthia Morrow’s mother heard that older people were eligible to get the COVID-19 vaccine in the Roanoke Valley, she’s lobbied hard for her shot.

“My mother, every day when I come home, asks, ‘Is it my turn yet? Can’t you get me into one of those clinics?’” Morrow’s 89-year-old mother is asking the same question that hundreds, if not thousands, of elderly people in the Roanoke City and Alleghany Health Districts asked of her and her colleagues last week.

And they were just as frustrated by the answer: Just because you are eligible doesn’t mean there’s a dose waiting for you. It’s going to take time.

The districts Morrow oversees, along with the New River Health District, were among a handful in Virginia that moved to what the state calls Phase 1b last Monday. This meant vaccines that had been reserved solely for health care workers and long-term care residents could now be given to a long list of workers who are considered essential to keeping the community running — police, firefighters, teachers, factory workers, postal carriers — and to people at high risk of becoming seriously ill and dying from COVID. At the start of the week, the latter was defined as being 75 and older; by the end the week, it had shifted to anyone who’s 65 and older or who has a chronic illness.

Essentially, half of all Virginians — more than 3 million people — fall under Phase 1a and 1b.

The federal government ships just 110,000 doses to Virginia each week, and those are shared with 160 health systems and health districts. Each gets a different number of doses; each is supposed to follow a hierarchy of rules, but each also has flexibility in getting as many doses as it can into as many arms as it can.

Dr. Danny Avula, the state’s vaccine coordinator, said during a news briefing Saturday that vaccinators placed orders for three times as many doses as Virginia could send them for the coming week.

He said the federal government has told Virginia not to expect additional doses until either Pfizer and Moderna increase production or new vaccines are approved. That could occur in March or April.

In the meantime, Avula said it’s important that the most vulnerable people get the vaccination first.

“Our intent here is we would like the health districts and the health care providers to go by the phases and the prioritization list within those phases to the greatest extent they can,” said Dr. Laurie Forlano, Virginia’s deputy commissioner of population health during a phone interview Friday.

However, they also need to adapt to the logistics.

“For example, if police officers aren’t ready to be vaccinated and you can’t work it out until two weeks from now, you don’t want to wait. Perhaps you need to have two or three clinics with teachers, so you start with that,” she said.

She said speed and efficiency in vaccinating will be the most powerful factor affecting the pandemic.

“We certainly don’t want egregious deviations from our intended priority list. I understand that has happened in some areas, and we are trying to address those as we can,” she said.

In the Roanoke and New River valleys, two different approaches are being used in the vaccination campaign. Morrow and her counterpart in New River, Dr. Noelle Bissell, shared their strategies.

From civic center to vaccine clinic

On Thursday morning, members of the Virginia National Guard sat in a section of seats at the Berglund Center in Roanoke, where they were briefed on what was to take place that day. Soon, one by one, 680 people would come in. There is a cadence to the clinics: preregister, check-in, line up 6 feet apart, sit at vaccination tables two at a time, wait afterward for 15 minutes.

After three weeks of drills, the rhythm is tuned, but the tempo now must now pick up. The clinics will need to double as people come for their first doses and others return for their second.

It’s taken about a month to get the first shots to the valley’s health care workers.

Dr. Lianna Lawson, who practices family medicine in Daleville, was eligible to be vaccinated in mid-December, but her first chance to get the vaccine wasn’t until Thursday.

“I do outpatient only. I don’t do any hospital, and we are seeing all sick patients in the parking lot or by telemedicine,” she said. “I wasn’t in a huge hurry because I wanted to allow the hospitals and ERs and urgent cares where they are directly seeing sick patients to have the opportunity to get the vaccine. But I did want to get it.”

Lawson is looking forward to the day that she, too, can have vaccines in her office to give to her patients.

That’s part of Morrow’s plan.

Keeping up with changing rules

When the pandemic began in the Roanoke Valley, the health districts were without a leader. The director of the Central Shenandoah District, Dr. Laura Kornegay, was tasked with overseeing the health of 300,000 Virginians living in her district, along with the health of a like number in Roanoke, Salem, Covington and Roanoke, and Botetourt, Alleghany and Craig counties. She coaxed a former director, Dr. Molly O’Dell, out of retirement to temporarily lead the pandemic response. At the time, there were few tests available, little coordination of efforts with health care providers, governments, businesses and schools, and no local lead on educating people about the mysterious virus.

In September, Morrow was named director but was part time as she finished out other obligations, including setting up a new program at the Virginia Tech Carilion School of Medicine, and came on board full-time with the health district just this month.

When the Pfizer and Moderna vaccines were approved in December, Morrow set out to build partnerships with everyone who can and who wants to vaccinate people. Carilion Clinic and LewisGale received their own doses to vaccinate their staffs, while public health reached paramedics, EMTs and independent health care providers.

The first of the twice-weekly clinics were set up, and Morrow was ordering about 1,500 doses of vaccine a week. The orders go in on Wednesdays, though there is no guarantee of how many doses the districts will receive.

During Thursday’s clinic, Morrow said they realized that they had the capacity to expand the vaccination campaign and that’s why they moved into Phase 1b. However, the dose order had already been placed as if they were still in Phase 1a.

So while they were able to invite police and firefighters and those at the top of the priority list to the upcoming clinics, the supply was limited.

Elderly people were frustrated that there was not a way for them to get a dose.

Morrow’s strategy is for doctors, pharmacies and other health care providers to take care of individuals, while public health runs clinics for large groups of workers.

She sees that as the optimal way to reach everyone as efficiently and as safely as possible.

Carilion is expected to announce early this week its plans for vaccinating patients, and the system is using 2,000 of its doses to partner with the health department to vaccinate teachers in a mass clinic on Friday.

Morrow said last week that she expected shots would be available through doctors and drugstores in a week or two.

With Carilion and LewisGale centered in the Roanoke Valley, and both receiving their own doses, Morrow said she had been ordering as many doses as were needed to vaccinate Phase 1a health care workers outside of the large health systems.

Morrow also shares some of the districts’ vaccines with other health care providers and holds back some doses for the first clinic of each week in case the next week’s shipment doesn’t arrive in time. She ordered additional doses for the coming week — but so has every other health district.

“We order vaccine according to the rules that were in place when we ordered vaccine. The rules have changed but the vaccine supply hasn’t. That creates an unequal supply and demand,” she said.

She wants people to know that they use every vaccine they are given. They just aren’t given enough all at once to meet the demand.

As of Saturday, the Virginia Department of Health reported that 13,308 of the 300,000 people in Morrow’s districts have received at least one dose.

Building a vaccination army

Bissell has taken a different approach in her health district, where about 200,000 people live.

While Carilion and LewisGale have community hospitals in the New River Valley, Bissell has relied heavily on nontraditional partners. She has an alliance of universities, businesses and governments helping to push out the vaccines.

By Saturday, 9,223 people living in Montgomery, Pulaski, Giles and Floyd counties and Radford had received their first dose.

She credits a community task force formed at the start of the pandemic for the speed and efficiency with which her district has rolled out vaccines. The alliance of businesses, governments and universities has created a network and an army of volunteers.

“We would have never gotten our testing up and running, we would never gotten the vaccine effort up and running without the task force,” she said.

A website, NRVRoadToWellness.com, has been a centralized place to quickly push out information throughout the pandemic and to provide contact information, testing sites and registration for the vaccines. A business continuity team was also set up.

In addition, Bissell said Virginia Tech, with its testing lab and veterinary school, and Radford University, as well as students from both, have been valuable resources in allowing them to quickly reach as many people as they can.

On Monday, Bissell’s district began to give shots to anyone now eligible, including individuals 75 and older, teachers and those who deliver Meals on Wheels.

Debra Chase of Radford said she and her husband, who deliver Meals on Wheels once a week for Radford-Fairlawn Daily Bread, received an email last Sunday from the program’s director saying they were eligible. So they registered, picked up their form and showed up for their appointments the next day at Blue Ridge Church.

Chase said the clinic was very organized, with many providers giving the vaccine, and they were in and out quickly.

“I felt great. I am taking care of my dad who is 95 so I am very cautious of bringing anything to him,” she said. She’s a real estate agent and her husband is a professor at Radford, so their professions would not have qualified them under Phase 1b when they got their shots, though their ages, 67 and 68, would have made them eligible by the end of the week as the rules shifted.

Bissell said her strategy is to schedule large groups for the clinics and then to fill in any remaining slots with individuals or smaller groups.

Teachers in the New River Valley were getting vaccinated last week.

Bissell said the governor had made it clear that teachers are a priority. Asked if her clinics followed the prioritization list or were first-come, first-served, she said they followed the list.

“A lot of things are in play. It’s not perfect, and we are trying to be as equitable as we can,” she said.

Bissell said she is using all the vaccine that she is getting and is continuing to request enough to give out 1,000 doses a day. But she doesn’t know if she’ll continue to receive that amount.

She ordered and received 5,000 doses last week.

“The very first shipment we got was 600, and we went through that very quickly. So then I requested 2,500 and I was able to get that. Then we found we had a little left over, so I went down because I absolutely want to get it off the shelf,” she said during her weekly news briefing. “So I decreased my order to 1,500, and I got that. Now that the clinics are really picking up, and we are able to move a lot of people through, I requested a thousand a day, and I did get that.”

Other health districts across Virginia are moving into Phase 1b, and all are expected to be there by the end of the month. Forlano said the state has not gotten any indication that it will receive additional doses anytime soon.

As each of the districts gets more efficient in using and reporting doses, the limited supplies will be doled out based on population, Forlano said.

The districts place orders on Wednesdays but do not know for several days how many doses they will receive, or whether they will arrive on Monday or Tuesday. So there is also a juggling act to hold some of the prior week’s order in reserve to honor early-week appointments.

“Could it come to the point we don’t have the supply and have to wait? It could. Right now, at this point I have enough vaccine to go through early next week, which is enough for our teachers and day care,” Bissell said Wednesday. “Supply is obviously the key.”

The district announced Friday that while residents 65 to 74 now qualify, they would need to wait until older residents and critical workers are vaccinated as doses are limited.

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