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When the first American healthcare workers rolled up their sleeves for a COVID-19 vaccine, images were instantly frozen in history, marking the triumph of scientific knowledge and ingenuity. The cameras captured the first trucks leaving a warehouse in Portage, Michigan, to the applause of area workers and residents. A day later, Boston Medical Center employees, some dressed in scrubs and wearing masks, face shields and protective gowns, literally danced on the sidewalk when the doses arrived. Some have photographed themselves receiving the vaccine and posted it on social media, tagging it #MyCOVIDVax.
But the true story of the COVID-19 vaccine debut is more methodical than monumental, a celebration of teamwork rather than conquest. While the hospitals awaited their first assignment, they reviewed their carefully crafted plans. They trusted each other, traversing the usual divisions of competition and working collaboratively to share the limited offering. Their priority lists for the first vaccines included environmental service workers cleaning patient rooms and critical care physicians working to save lives.
“Healthcare workers have come together during this pandemic,” said Melanie Swift, MD, co-chair of the COVID-19 Vaccine Allocation and Distribution Task Force at Mayo Clinic in Rochester, Minnesota. “We’ve been through the darkest years relying on each other a lot,” he said. “Now we are coming together to get out of this.”
Still, a launch of this magnitude has problems. Stanford issued an apology Friday after its resident physicians protested a vaccine distribution plan that shut out nearly all of its residents and fellows, many of whom regularly treat COVID-19 patients.
There have already been more than 287,000 COVID cases and 953 deaths among healthcare workers, according to the Centers for Disease Control and Prevention (CDC). In its orientation, the agency noted that “the continued protection of them at work, at home and in the community remains a national priority.” That means vaccinating a workforce of roughly 21 million people, often the largest group of employees in a community.
“We all need to collectively vaccinate our teams to maintain that stability in our healthcare infrastructure in the Atlanta metro area,” Christy Norman, PharmD, vice president of pharmacy services at Emory Healthcare, told reporters in a briefing while the health system awaited its first delivery.
Don’t waste a dose
A fundamental imperative prevails: hospitals do not want to waste any doses. Pfizer vaccine storage requirements complicate this.
Once the vials are removed from the pizza box shaped containers in ultra cold storage and placed in a refrigerator, they should be used within 5 days. Thawed five-dose vials should be brought to room temperature before dilution and can remain at room temperature for no more than 2 hours. Once diluted with 1.8 ml of 0.9% sodium chloride injection, the vials should be used within 6 hours.
COVID-19 precautions require employees to remain physically distant while waiting their turn for vaccination, which means that the process may not reflect typical large-scale influenza immunization schedules.
To prioritize the groups, Mayo vaccination planners carried out a comprehensive risk stratification, considering the obligations of each employee. Do they work in a dedicated COVID-19 unit? Do they handle lab tests or collect swabs? Do they work in the ICU or in the emergency department?
“We have applied some principles to ensure that as we implement it, we prioritize the people who are most at risk of ongoing exposure and who are truly critical to sustaining the COVID response and other essential health services,” said Swift, who is associate. Medical Director of the Mayo Occupational Health Service.
Mayo employees who are eligible for the first few doses can sign up for appointments through the medical records system. If it seems likely that a few doses will remain at the end of the vaccination period, perhaps due to missed appointments, supervisors in high-risk areas may refer other healthcare workers. Mayo gave her first shots on Friday, but the vaccination program started in earnest this week. With the pleasant surprise that each five-dose vial actually provides six doses, 474 vials will allow the vaccination of 2,844 employees in the highest priority group. “It will expand every week or a few days as we get more and more vaccines,” Swift said.
Share roads with small rural hospitals
Minnesota is using a centralized system to give small rural hospitals access to Pfizer vaccine, even though they lack ultra-cold storage and cannot use a minimum order of 975 doses. The large hospitals, which act as centers, share their requests. (Moderna’s minimum order is 100 doses.)
In south-central Minnesota, for example, two central hospitals each have six radio hospitals. Five of the 14 hospitals are independent and the rest are part of large hospital systems, but affiliation doesn’t matter, said Eric Weller, regional coordinator for health readiness for the South Central Healthcare Coalition. “We are all working together. It doesn’t matter what system you are from,” he said. “We work for the good of the community.”
Each hospital designed a process to provide vaccine education, prioritize groups, assign appointments, register people for vaccination, obtain signed consent forms, administer vaccines in a COVID-safe manner, and provide follow-up appointments for the second dose. “We’re using some of the lessons we learned during the H1N1 flu,” Weller said, referring to vaccination during the 2009 flu pandemic. “The difference is that during H1N1, there could be lines of people.”
Coordinating appointments will be more important than ever. “One of the vaccination strategies is to group people into groups of five, so that you use one vial on those five people and you don’t waste it,” Weller said.
The logistics are somewhat different for Moderna vaccine, which will come in 10-dose vials that can be refrigerated for up to 30 days.
Both vaccines can cause mild flu-like symptoms, such as fatigue, headache, or muscle pain, especially after the second dose. That’s a sign that the immune system is reacting to the vaccine, but it’s also another consideration in vaccination plans, because healthcare workers can take a day or two off. “We’re not going to vaccinate an entire department at once. It will be staggered,” said Kevin Smith, MD, medical director of the occupational medicine program for ProMedica, a Toledo, Ohio-based health care system.
Smith said he plans to encourage employees to use V-Safe, an app created by the CDC to track adverse effects in people receiving the vaccine. He noted that a day or two of pain will be better than dealing with the symptoms of COVID-19. Some employees who have recovered from the infection still feel fatigued or have not regained their sense of taste and smell. “We are still monitoring quite a few employees to make sure they come back 100%,” he said.
Hope to end the pandemic
Public health officials have been concerned about vaccinations, including among healthcare workers, but so far, that concern seems overshadowed by enthusiasm. Smith said his department has been getting calls from employees wanting to know when they can get the vaccine. “I think everyone is relieved,” he said. “We are at the beginning of the end.”
In May, Swift is surveying staff to assess willingness to get the vaccine, but she is already excited by employees. “Sure, there are still people who doubt, but I feel a change,” he said. “I’m feeling this urge for healthcare workers to come together and want to take this vaccine, which is good, because they will be an example for their patients.”
For Colleen Kelley, MD, an infectious disease physician at Emory University in Atlanta who was a principal investigator for an Emory-affiliated Moderna clinical trial site, the past month has been very emotional. “Things looked very bleak and dark for a while, and then we started to get these efficacy results that were greater than anyone imagined,” he said.
Kelley spends time talking to journalists and educating fellow doctors and hospital employees about how the vaccine was developed so quickly and how it works. “Everybody asks me, ‘Should I get it? Will you get it?’ My answer is ‘yes’ and ‘yes’, “he said. “I am 1000% confident that the benefits of widespread vaccination outweigh the risks of ongoing COVID and an ongoing pandemic.”
Michele Cohen Marill is a freelance journalist living in Atlanta. He has written for Wired, STAT, Health Affairs, and other publications. She can be reached at [email protected].
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